Boston Globe | State legislators are again debating whether insurers should fully cover childbirth. Here’s why it’s different this time.

By Katie Johnston

Originally Published in the Boston Globe

Within days of the Supreme Court decision striking down the constitutional right to abortion, Massachusetts legislators expanded abortion protections in the state, including a requirement that health insurers cover the procedure without deductibles, copayments, or other out-of-pocket costs.

But childbirth itself is still subject to these costs, which can be prohibitively expensive for the growing number of people with high-deductible health insurance plans.

In 2021, nearly 43 percent of private health insurance members in Massachusetts had plans that require individuals to pay more than $1,400 out-of-pocket annually ($2,800 for families) for certain services, including childbirth, before insurance coverage kicks in, according to the Massachusetts Center for Health Information and Analysis. In 2013, only 14 percent of members had such high deductibles, reflecting efforts by employers, workers, and health plans to offset rising premiums, and health care prices, by shifting costs to members.

Families with private commercial health insurance are responsible for more than $3,000 on average for delivery costs nationwide, driven by deductibles and coinsurance, according to a 2021 study published in the American Academy of Pediatrics; for one in six families, childbirth exceeds $5,000 in out-of-pocket costs.

Now, state legislators are once again considering a bill that would address these climbing costs by requiring insurers to cover the full spectrum of pregnancy care, from prenatal to delivery to postpartum, with no financial burden on members.

This is the third legislative session in which the bill has been introduced, but the first since abortions — which were included in previous versions of the bill — were granted full coverage. A renewed focus on ensuring that everyone has access to quality, affordable care has also given the issue greater urgency. That push for equity is led by a group of local health care and business leaders who formed the Health Equity Compact in 2022 to combat racial disparities exposed by the pandemic — and introduced their own bill.

“We want our mothers to stay healthy and we want our children to be born healthy,” said state Senator Cindy Friedman, the sponsor of the pregnancy care bill, who is not aware of other states that require insurers to fully cover childbirth. “This is really putting our money where our mouth is and saying we do believe in health equity, and ... one of the things that we clearly should do is take cost out of the equation for women seeking care.”

Katie Adamek, a sexual and reproductive health researcher who lives in Medford, didn’t realize her delivery was subject to her plan’s $5,000 deductible until she got a bill for nearly $3,000 following her daughter’s birth in late 2020. She didn’t have any financial responsibilities beyond copays for prenatal visits, so she assumed it would be the same for childbirth.

Adamek, who has a master’s degree in public health and has a good understanding of health insurance and cost sharing, said that if she didn’t realize childbirth was subject to the deductible — and could cost thousands of dollars — many people probably don’t.

“It does seem a little crazy to me that Massachusetts didn’t choose to remove cost sharing for all pregnancy outcomes when they removed it for abortion,” she said.

Nationally, women ages 19-44 spend 58 percent more on health care per capita compared to men in that age range, largely due to maternity care costs, according to 2020 data from the Centers for Medicare and Medicaid Services. There are also “persistent disparities” in health care costs across income and ethnic groups, according to the Massachusetts Health Policy Commission, with nearly one in five lower-income residents paying higher out-of-pocket costs than other residents.

The latest version of the bill is before the Joint Committee on Financial Services, which must decide by Wednesday whether to advance it.

Massachusetts Citizens for Life, an antiabortion group, supports the bill, noting that it would reduce the financial burden of childbirth. “More importantly though,” president Myrna Maloney Flynn said in a statement, “this bill acknowledges and removes the discrimination against women who sought childbirth over abortion.”

But insurance companies are concerned. Eliminating cost sharing for all pregnancy care would increase insurance premiums for everyone in the state, according to the Massachusetts Association of Health Plans, due to a provision in the Affordable Care Act that dictates the ratio of premiums to consumer cost sharing.

The cost of childbirth is especially problematic for people employed by small companies, according to the Massachusetts Health Policy Commission. At organizations with fewer than 100 employees, high-deductible plans grew from nearly 35 percent of enrollment in 2012 to 72 percent in 2021, doubling out-of-pocket spending for families from $1,500 to more than $3,000 a year in that time period.

And depending on timing, some families may have to meet their annual deductible twice over the course of a pregnancy. If they haven’t paid enough medical bills to hit their deductible, some pregnancy-related services would have to be paid out-of-pocket until that amount is reached. And if the birth takes place in the insurance plan’s next year, delivery costs would have to be paid until the deductible is met again.

Katie Forde, a paralegal who lives in West Roxbury, became pregnant with twins in the summer of 2016. The twins shared a placenta, placing them in a high-risk category that required Forde to visit the doctor at least once a week throughout her pregnancy. She gave birth in February of 2017, which meant she had to meet her annual $2,500 deductible twice. All told, between the weekly doctor visits, tests, and double deductible, she had to pay $6,000 out of pocket for her pregnancy, which took her family three years to pay off while juggling the added costs of diapers, day care, and other bills for two babies.

“The biggest part of reproductive health is childbirth, and if that’s going to cause people to have debt, what’s the point of having health insurance?” she said.

Massachusetts has nearly universal health care coverage, said Claire Teylouni, director of government affairs for the Boston nonprofit Reproductive Equity Now, but the fact that women have to pay so much more than men due to pregnancy, especially as childbirth is subject to increasingly high deductibles, means that health care is not equally accessible.

“This is a really clear gender equity issue,” she said. “We can’t separate the fight for affordable and accessible abortion from affordable and accessible childbirth. It’s all pieces of the puzzle for securing true reproductive equity for everybody in the Commonwealth.”

Melissa Donahue of Ware had to pay $10,000 out of pocket for delivery and other maternity care costs when she had a baby in early 2019 — in large part due to the fact that she had to meet her $4,000 deductible twice.

When she got the bill, “I was really, really shocked,” said Donahue, who manages an Ulta Beauty store in Hadley. She also had severe postpartum depression, and paying for medicine and therapy on top of her hospital bills added to the trauma, she said. She eventually stopped going to therapy because she couldn’t afford it and put off having a second child until she had a handle on her debt, which still hasn’t been paid off.

“Do I pay this bill or do I pay to have my heat or do I pay to eat dinner?” she said. “We shouldn’t have to make choices like that.”