What Happens If The ACA Is Repealed & You're Pregnant

Parenting is political, whether we're talking about the affordability of child care, access to paid family leave, or the controversial movement for school choice. Denying that mothers care about these issues is both incorrect — they actually care more once they have kids — and dangerous; 16 million millennial women had become mothers by January 2017, and millennial women were responsible for 82 percent of births in 2015, according to Pew Research. Removing mothers — who are also voters — from discussions about health care and education denies them a place in conversations that directly affect them and their children.

This is the first story in Romper's Swing Vote series that examines timely political issues relevant to young women with kids. Each story is approached through a bipartisan lens with the goal of investigating how the issue is relevant to mothers and what they need to know to get more involved in the systems that affect them and their children.

To say that Christine's* 2008 pregnancy was unexpected would be an understatement. She and her husband, Steven, always wanted kids, but, at the time, adding to the family wasn't in the cards. With a post-graduation move from Seattle to Austin, Texas and new job opportunities coming their way, the now mother of two tells Romper that the gauntlet of provider fees and surprise expenses she faced during her first pregnancy was enormous — mainly because, at the time, health insurers weren't required to cover maternity care.

Before she learned she was pregnant, Christine and her husband were doing everything "right." (As if there is a "right" way to do life.) He had just accepted a job with the promise of health insurance as a benefit, and she was using the NuvaRing prescription she got from Planned Parenthood in Seattle. Still, mother nature intervened, and the couple found out they were expecting their first child long before Steven’s anticipated coverage kicked in.

“I felt totally unprepared, kind of like a fish out of water,” Christine tells Romper. “I didn’t know what to do. I tried to find a job that would get me insurance, but it was 2008... jobs were not easy to get.”

Without insurance, the couple would have to find a way to cover the enormous average cost of pregnancy and childbirth in the U.S. While it varies by state, the average price tag on a normal vaginal delivery in the hospital is about $30,000, and an uncomplicated C-section about $50,000, according to a 2013 report prepared by Truven Health Analytics, which provides health care data and consulting services. These figures factor in a lot of different things: provider’s charges, the hospital’s charges, anesthesia, medications, and so on.

Still, as her pregnancy progressed, Christine looked forward to getting barebones coverage through her husband’s plan. But after their waiting period ended, getting group coverage through his employer wasn’t an easy task. According to Christine, the fear over being denied insurance for a pre-existing condition kept her from having helpful dialogue with potential insurers and kept her in the dark about how much financial responsibility she and her husband would have to take on during her pregnancy and delivery.

Christine had dealt with depression and anxiety in the past, and she knew that that could affect her potential coverage. But that wasn't her biggest concern. "I was mostly worried about trying to get insurance when they already knew I was pregnant." She didn't have a map to guide herself through the fight for coverage, often feeling that "revealing too much" — either about her previous mental illness or her pregnancy — might put her at a disadvantage.

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Once Christine and her husband were able to secure health insurance through her husband’s employer, their coverage was much like the majority of employer-backed plans at the time: coverage for basic health care but not maternity or prenatal care. In desperation to cover the coming expenses, Christine paid at least $800 to Maternity Advantage, a health discount program marketed to pregnant women who had health insurance but no maternity coverage. (The company no longer exists.)

The company promised to act as a companion to the couple’s traditional health insurance, Christine says, helping to negotiate lower lab bills and other pregnancy-related expenses. In the end, the service helped the couple secure an obstetrician, but not much else. “It was pretty much a scam,” Christine tells Romper. And because their family’s health insurance didn’t cover maternity care, she and her husband “ended up paying out of pocket for just about everything” — to the tune of $11,000. Even two years later, when her second child was born, Christine was paying off the anesthesiologist from her first delivery.

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Christine’s experience — sticker shock, deceptive third-parties, and intense negotiations over price and fretting over every single charge — might sound more typical of a car dealership than a health system. But this was the reality of maternity coverage before the Affordable Care Act.

It was not uncommon for women to find that their employer-provided or individually-purchased health insurance didn’t automatically cover maternity and childbirth. And according to a New York Times report, some 62 percent of plans purchased in the individual market didn’t cover maternity care at all. With efforts to repeal the ACA underway, lawmakers are returning to many of the old arguments concerning why coverage for pregnant women should be optional. But thousands of women and health practitioners remember what it was like to give birth without maternity coverage. And they say that going back to those days would be a disaster for the health of women and babies.

Kaiser Family Foundation fellow Karen Politz told HuffPost recently that prior to the implementation of the ACA, pregnancy, childbirth — even taking steps to begin trying to conceive — could be considered a pre-existing condition by medical insurers. So, if you were even talking to your doctor about stopping your birth control in order to conceive, you could possibly lose coverage, because trying to conceive could be considered a pre-existing condition. That’s because, through a process called medical underwriting, insurers could use patient health information to decide whether to offer coverage, according to the Kaiser Family Foundation.

How did the system come to be this way? Ironically, it involves differing ideas of choice.

When the ACA was crafted, some GOP lawmakers defended limited maternity coverage as a way of protecting choice. The argument went like this: people have the right to choose how much — or how little — insurance would fit their family's needs.

They argued that forcing people who might never get pregnant to pay for prenatal care for women who choose to have babies was a violation of basic fairness and autonomy. Former Mitt Romney adviser, Greg Mankiw, wrote at the time:

Having children is more a choice than a random act of nature. People who drive a new Porsche pay more for car insurance than those who drive an old Chevy. We consider that fair because which car you drive is a choice. Why isn't having children viewed in the same way?

It's a line of thinking that didn’t go away with the ACA's implementation. Recently, Seema Verma, Centers for Medicare and Medicaid Services Administrator under the Trump administration, said, "Some women might want maternity coverage, and some women might not want it, might not choose it, might not feel like they need that. So I think it's up to women to make the decision that best works for them and their families."

With the GOP moving to repeal the ACA — and its essential coverage mandates and pre-existing condition protections, particularly at risk — some argue that women will quickly find themselves returning to the days when “choice” meant few, if any, affordable options for maternity coverage.

What happened once an uninsured woman became pregnant?

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Several health practitioners tell Romper that before the ACA Medicaid was the first line of defense for covering uninsured pregnant women. Esme, a certified nurse midwife in the southeastern U.S., explained to Romper via Twitter that her office doesn’t treat uninsured patients. “If an established office patient loses insurance they are turned away (no appointment) & encouraged to update their coverage by applying for Medicaid,” she writes.

With the Affordable Care Act came an invitation to states to expand Medicaid coverage. And as of January 2017, the eligibility limits for pregnant women got a little higher in most states, covering more people, KFF reported.

Still, while the KFF estimates that half of all U.S. births are covered by Medicaid, it isn’t an option for all uninsured women. Even after ACA implementation, in states like Alabama, Nevada, and West Virginia, women who earned as little as $30,630 could be turned away for Medicaid coverage in January 2011, according to KFF. Workers in hourly wage jobs that didn't offer insurance could still be priced out of coverage, as could freelancers or small business owners without the ability to buy into a group plan.

The ACA mandate meant that, after 2014, many of those women were able to buy individual plans that included pregnancy and prenatal care as essential benefits. But if ACA-mandated maternity coverage disappears, so would that guarantee of maternity coverage. And since confirming a pregnancy doesn’t qualify for a special enrollment period for purchasing insurance, just buying a more comprehensive (read: expensive) plan may not even be an option for some women.

Esme tells Romper that her uninsured patients may still end up in her care, just not in her office. Instead, these patients often use the emergency room — which is required to treat them even if they can’t pay. Esme works with a service that covers obstetric patients in the emergency department if they're beyond the 20-week mark.

"In the South, given our awful Medicaid system & extremely poor access to care, most patients use ED/Urgent Care for … pregnancy confirmation or [symptoms like] cramping,” Esme explains. “Most of my patients have no idea what a primary care doctor is. They just go to [the emergency room].”

Going uninsured in pregnancy can mean forgoing early care — which can have serious implications for mother and baby.

Paying out of pocket for every prenatal visit — and the looming expense of a hospital delivery — led some uninsured patients to consider skipping appointments and early screenings — though that also carried serious risks. Kim, a mom of three in Denver, Colorado, tells Romper that when she and her husband discovered that she was pregnant in 2005, the couple was going through a brief period without insurance while her husband changed jobs.

My husband was working for his old employer and commuting for his new job. The old job was with a small employer and had a group plan, but it wasn’t great. Maternity coverage wasn’t offered. It wasn’t really an option. And we weren’t actively trying to get pregnant. We knew the new employer had great insurance, but it wasn’t crystal-clear just how long the waiting period was going to be.

The couple found out Kim was expecting and told their doctor it would take about 30 days for insurance to begin. Kim says her doctor said waiting a month for the first ultrasound would be “no big deal.”

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But it was a big deal. Kim didn't go in for another ultrasound until she hit 20 weeks. At that appointment, Kim and her doctor discovered that she was expecting twins, who were big enough that they couldn't see the placenta.

[The doctor] couldn’t tell from his machine, or his level of expertise, what risk factors the twins had. We didn’t know the location of the boys’ placenta. And we didn’t know whether they shared a placenta.

That turned out to be a critical miss in Kim’s pregnancy, as doctors later discovered that her boys had twin-to-twin transfusion, a syndrome that occurs when identical twins have a connected blood circulation through a shared placenta. According to the Twin-To-Twin Transfusion Syndrome Foundation, the complication means increased risk during delivery of blood and oxygen loss for one or both babies. The doctors told Kim that the initial ultrasound could have prevented not knowing where the placenta was.

[The doctors] told me upfront that it’s too bad we missed that initial ultrasound because we’d know where [the placenta] was, and if there was one or two. If they had known that was a risk factor, they would have taken greater care.

According to Dr. Emily Schneider, Denver OB-GYN and member of advocacy group Physicians for Reproductive Health, knowing that patients would be shouldering the finances of pregnancy and delivery themselves had real implications for how doctors delivered medical care pre-ACA, as well. And it wasn’t uncommon for finances to come front-and-center into delivery room discussions. “The first question out of my patient's’ mouth is ‘What is this gonna cost me?’," she says.

For some, it would cost a lot, leaving them to negotiate themselves. When Kim delivered her twins in 2005 at 32 weeks, she was airlifted via helicopter to the hospital. While the helicopter was medically necessary, it was not covered by her husband's new insurance. On top of long-term health expenses for one of her sons who did suffer complications from lack of oxygen at birth, Kim and her husband had a $22,000 helicopter ride to pay for.

The good news is that today the twins are doing well, Kim says, and health coverage through CHIP and Medicaid has helped the family get the needed care for her son’s cerebral palsy and seizure disorder. Kim eventually negotiated with the hospital and paid a lowered fee for the emergency helicopter ride. And once ACA was implemented, she and her husband were able to afford health insurance for themselves.

The expansion of the ACA gave us peace of mind (that if something happened to either of us we wouldn't lose everything) and the opportunity to use the money we had been putting toward that premium toward paying off debt.

This isn't the only way to approach maternal health care.

The experience of receiving multiple bills — large and small — for expenses incurred during labor and delivery was common among the women Romper spoke to, but it is not how other countries operate, as the New York Times pointed out in a report on America’s high maternity costs back in 2013. In Ireland, for example, women are guaranteed free labor and postpartum care in public hospitals. And in Switzerland, France, and the Netherlands, a combination of regulation and price setting keeps the average cost of birth at $4,000, of which mothers pay very little, the Times reported. In almost every other developed nation in the world, a flat fee is paid to providers. It’s inclusive, too: while there are limitations, a woman can pick and choose a lot of what she wants (or doesn’t want) in her birth experience.

According to the Times report, some obstetricians and hospitals in the U.S. had begun offering uninsured patients comprehensive prenatal care packages for a flat fee before the ACA mandated maternity coverage. “Making women choose during labor whether you want to pay $1,000 for an epidural, that didn’t seem right,” one obstetrics chief told the Times.

An Alabama certified nurse midwife, who preferred to remain anonymous, tells Romper that her office designed its own payment plan for uninsured, mostly Latinx patients — some of them undocumented immigrants ineligible for Medicaid — so they could focus on having a healthy baby without worrying about the cost.

With repeal of the ACA comes the threat of a return to so-called “choice.”

So far, the Republican-controlled Congress has yet to come together on an ACA replacement, and as of Tuesday Republicans didn't have enough votes of support to begin debate on the legislation they proposed. If Republicans offer a replacement for the ACA or if they repeal it, many advocates and consumers are worried that maternity coverage will disappear from the individual market. Kristin Rowe-Finkbeiner, CEO and co-founder of MomsRising — a grassroots advocacy group of more than a million mothers organized to improve public policy — tells Romper that covering maternity care is essential to leveling the playing field for women.

“Eighty-two percent of women in our nation become pregnant at some point in their lives,” Rowe-Finkbeiner says. “And we’ve all had a mother. Making pregnancy and maternity care a pre-existing condition is like saying breathing is a pre-existing condition. That’s bad for our economy, it’s bad for families, and it’s completely out of touch. It’s preposterous.”

If women are forced to bear the entire economic burden of pregnancy — as well as the physical and emotional burdens — any progress we’ve made in improving maternal health outcomes will almost certainly plummet. Not only will that put more mothers in danger, it will endangers the lives of the children they might hope to raise.

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Check out the "Swing Vote" series on Romper for more features about how politics affects motherhood.

*Only first names have been used so as not to jeopardize the source's employment or future insurance coverage.

Reporting contributed by Abby Norman.