And so President Trump's first 100 days ended with a cliffhanger in the Trumpcare saga: Will they or won't they take health insurance away from Americans who need it the most? On Tuesday, Congressman Tom MacArthur of New Jersey floated an amendment to resuscitate the once left for dead American Health Care Act, a plan that was so indifferent to human life that even Republicans who had all but sworn a blood oath to repeal Obamacare were against it. Republicans postponed a vote on the bill late Thursday night after it was clear they didn't yet have enough support.
But MacArthur's amendment dangles in front of Republicans two things they've longed for: the flexibility of states to raise costs for people with pre-existing conditions (while not outright denying them coverage so as to preserve their golly gee whaddya mean deniability) and the ability for states to skimp or totally gut the ten essential health benefits, which include prescription drugs and emergency services, that Obamacare (or the Affordable Care Act) requires insurers in the marketplace and small employers to cover.
One of the essential health benefits that's come most heavily under attack is, of all things, maternity care—and even without an Obamacare repeal, Trump and the GOP can dismantle it through regulatory changes that require zero votes, which would punish the very voters who put them in office.
Why would anyone want to make cuts to maternity coverage? After all, "it is the most common reason for hospitalization," says Usha R. Ranji, associate director for women's health policy at the Kaiser Family Foundation.
The reason the GOP opposes maternity care comes down to a basic fact: the more things insurance covers, the more expensive it is to provide. That's why virtually every part of the GOP health care plan tries to limit how much actual health care is in it and who can get it. Instead, the GOP believes people should get to choose what's in their plan, just like a burrito but with life-or-death consequences.
Conservatives have long used pregnancy and childbirth to make their a la carte insurance argument. In this case, the argument goes: why should a man or an older woman have to pay for health care they won't use? (Though, do you hear women complaining about having to pay for prostate cancer coverage?)
In 2009, during an early round of Obamacare debates, Senator Jon Kyl of Arkansas tried to dunk on Democrats with the line, "I don't need maternity care," only to be highlight-reel rejected by Senator Debbie Stabenow of Michigan: "I think your mom probably did." Still, that hasn't stopped the "To the best of your knowledge has a man ever delivered a baby?" zingers, however, or the comically hypocritical Congressman John "100% pro-life" Shimkus from taking taking issue with "men having to purchase prenatal care."
No group of people with this little knowledge of how insurance works should have all this power. "The nature of insurance is that we all pay for insurance that we hopefully aren't going to use," Ranji explains. "Hopefully, we'll never need it, but we hope that it is there if we do."
It will be even worse than before Obamacare
Before Obamacare, maternity care wasn't necessarily there when women needed it. If women didn't get health insurance through an employer, they would often need to try their luck on the individual marketplace. But, prior to the ACA, only twelve states required insurance plans sold in the individual market to cover maternity care, says Dania Palanker, assistant research professor with the Center on Health Insurance Reforms at Georgetown University. Women would often have to purchase a separate maternity care rider. That didn't usually work out so well.
For example, a woman in Topeka, Kansas, needed to pay an extra $482 per month for a rider, or nearly $5,800 a year, according to a report by the National Women's Law Center. And the riders didn't always solve the insurance problem, at least not fully. Some of them didn't kick in right away: one Arkansas option had a 12-month waiting period, one in DC was ten months. Even worse, they capped coverage at $5,000 and $3,000, respectively. This sometimes resulted in cases where women paid more than the hospital actually charged: one woman spent $9,682 for her rider and hospital charges for a delivery, but the hospital bill was only $7,488.
Things won't be this bad if the GOP takes away maternity care as an essential health benefit—no, they're likely to be much worse. "Medical costs have risen since then and the cost of riders and deductibles would likely be higher now," Palanker says.
Poor women in red states will be hit the hardest
If the AHCA were to pass with the MacArthur amendment, it would makes things worse for women who are already among the most vulnerable: that is, the poorest Americans who rely on Medicaid, government-funded insurance.
Medicaid pays for nearly half of all pregnancies in the United States. An Obamacare repeal or a zombie Trumpcare bill can't end coverage entirely, but it can affect what states are able to cover if their funding is cut through the implementation of block grants or caps on per capita spending. "Any cuts to Medicaid are going to leave states scrambling to figure out how to manage," says Tricia Brooks, associate research professor of the practice at Georgetown's McCourt School of Public Policy. "I just don't think that they can easily manage without making cuts to the program."
These cuts will be felt most severely in deep red states like Mississippi, where 60 percent of all births are covered by Medicaid. This means that the programs may be less likely to cover prenatal visits, screenings, vitamins, delivery, and postpartum care in full.
"This will affect women in rural communities," says George Saade, division chief of obstetrics & maternal-fetal medicine at the University of Texas Medical Branch. "Many of these rural communities are in red states." Yes, we're talking about Trump voters.
Maternity care can be changed without a single vote
During Obama's presidency, many assumed Republicans were the Party of No, because they despised the president. But, as the saying goes, never attribute to malice that which is adequately explained by total legislative incompetence (or something). Either way, the GOP doesn't necessarily need to pass any legislation to limit maternity care, because of the way essential health benefits provision was written.
"If you look at the law passed in 2010, it doesn't specifically outline what maternity and newborn care means," says Kathryn G. Schubert, chief advocacy officer at the Society for Maternal-Fetal Medicine. "There is a lot of discretion at [Health and Human Services] to implement that. They could, theoretically, come out with a rule that would outline the least amount of maternity care coverage possible and say that they're complying with the letter of the law."
One key element of maternity care that is particularly under threat is birth control. "Family planning and maternity care are intertwined," Ranji says. Contraception is critical for many women to ensure healthy birth spacing, which has been shown to lead to healthier babies by cutting down on the risk of preterm birth and low birth weight. But this essential health benefit also could be changed, not by a vote, but simply by being redefined by HHS head Tom Price, who said in 2012 that birth control coverage "is a trampling of religious freedom and religious liberty in this country." Just great.
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