The text of the bill is relatively clear on some of the specifics:   It states that all group and individual health insurance policies…

“…shall insure against the expense of normal pregnancy and childbirth or provide coverage for maternity care therefor and provide coverage for contraception in the same manner as any other sickness, injury, disease, or condition is otherwise covered under the policy or contract.”

I would take that to mean that the policy out-of-pocket costs in terms of deductible, coinsurance, hospital and doctor copays, etc. would have to be met by the patient, and the rest of the costs would be covered by the insurance carrier.

The bill also states that individual policies (but not group policies) are still allowed to exclude pregnancy as a pre-existing condition:

“Individual sickness and accident insurance policies or contracts may exclude coverage for pregnancy and delivery expenses on the grounds that pregnancy was a preexisting condition.  The exclusion for the pregnancy as a preexisting condition under the policy or contract shall not apply for any subsequent pregnancies.”

But does that mean that the insurance carriers have to accept pregnant women and just exclude the pregnancy and delivery from the coverage?  Currently, no individual health insurance carrier in Colorado (or most other states) will accept any expectant parent (mother or father) at all until after the baby is born.  The pregnancy is considered a pre-existing condition, and because new babies can be added to either parent’s existing policy in the month following birth with no underwriting, health insurance carriers have all opted to deem pregnancy as an automatic decline.  As of 2014, this will no longer be the case, but I have heard nothing indicating that there will be any changes to the universal underwriting guideline that states that an expectant parent cannot get a new individual health insurance policy.

In terms of what policies will be affected, the bill states that the new requirements wills apply to policies “issued or renewed on or after the effective date of this act.”  (January 1, 2011).  My interpretation of that would be that new policies issued beginning January 1, 2011 will include maternity coverage, and that as existing policies renew throughout the year, maternity will be added to them.  So for example, the policy that Jay and I have for our family renews each year on November 1.  So I would assume that for the first 10 months of 2011 we will continue to not have maternity coverage, but then as of our renewal date in 2011, maternity will be added to our plan.

Of course my guesses in terms of how this will all work are just that – guesses.  And I have not been able to find anyone who has more concrete details at this point.  We still have several months left in 2009 for regulators and insurance companies to work out the details, and I’m sure we’ll know more by the end of the year.  When you combine this with the new Colorado law banning gender rating on health insurance policies, and the myriad of reforms coming from the federal government, I’d say that health insurance regulators in Denver are going to have their hands full for a while.

There are many reasons for the dramatic increase in c-sections over the last couple decades.  Too much medical intervention, a legal system that pushes doctors towards c-sections at the first sign of a hiccup in the birth, parental requests, ACOG’s recommendation against VBACs, etc.  Some have also pointed out that doctors make a lot more money for doing a c-section, and can do one a lot faster than it takes to wait for a laboring woman to give birth on her own.

It seems like that last one should be relatively easy to fix, if reducing the c-section rate is indeed a priority.  To make the math easy, let’s say that a surgical birth costs $20,000 and a vaginal birth costs $10,000 (these are completely random numbers.  The real numbers vary dramatically from one state to another, and from one health insurance network to another).  If we say that the goal should be no more than 15% c-sections, we can say that for 100 births there should be 85 vaginal deliveries (amounting to $850,000) and 15 c-sections (amounting to $300,000).  Add those two amounts ($1,150,000) and divide by 100 to get the average price of a delivery if we were to achieve a c-section rate of 15%:  $11,500.  In reality, the math would be much more complex than I’ve made it here, but the basics would remain the same.

Now that we have the average cost of delivery if no more than 15% of deliveries were surgical, that could become the standard payment for all births, regardless of whether a c-section were performed or not.  There would be no financial incentive for doctors to opt for c-sections, as they would no longer receive higher compensation for doing so.  The tough medical malpractice environment that OBs practice in would likely provide more than enough motivation for them to continue to do c-sections when there was a true medical emergency, despite the fact that they would know there would be no additional compensation for the birth.

The rising c-section rate is driven by a variety of factors, and obviously the problem needs to be confronted on many levels.  But it seems counter-intuitive to expect doctors to reduce their c-section rates when we’re paying them more to perform them.

The controversy surrounding homebirths (and midwives versus obstetricians) has been in the news again lately with the release of a new study that claims that homebirth is associated with a higher neonatal mortality rate than hospital births (registration required to view the Medscape article).  This has met with some fierce criticism from people who (rightly so, in my opinion) claim that the study results are politically and financially motivated.  The debate around whether births should be attended by OBs or midwives is much like the debate around health care reform.  People are very wrapped up in their own beliefs on the subject and become pretty fired up when talking about it.  It’s hard to distinguish real science and facts from hype and fear-mongering.  It’s difficult for me to consider points made by ACOG on the subject of homebirths as valid, because of their strict stance against homebirths and their obvious financial bias.   But I will readily admit that I have a bias in favor of homebirth.  Such is the way of human nature when it comes to controversial topics…. if we have opinions on them, we tend to hold tightly to them.

The US c-section rate rose by 53% from 1996 to 2007, although in Colorado and five other states the increase was a whopping 70%.  That trend doesn’t show any sign of reversing itself anytime soon.  As Jason noted in his article, there is a “cascade of interventions” in hospital birth settings that is steadily driving up the rate of surgical births.  In addition, we have a malpractice system that provides a strong incentive for doctors to perform c-sections at the first hint of a problem.  With a system like that, it’s hard to fault OBs for taking the c-section route, and intervening in general.  We can wring our hands all we want about how we need to reduce the rate of c-sections and medical interventions during childbirth, but as long as our malpractice system penalizes doctors for avoiding c-sections, we won’t make much progress.

Our own son was born at home following 45 hours of labor.  For almost nine of those hours, I had what would have been described in a hospital as “failure to progress”.  But I had competent midwives who checked our son’s heartbeat frequently, and patiently waited for me to give birth to him.  Had I been in a hospital, there is a very good chance that I would have had a c-section.  Yet our son and I both came through the birth unscathed, and a c-section would have been needless intervention.  I know it’s easy to say that in hindsight, but the problem is that when it comes to the over-medicalization of our country, we aren’t learning from our collective hindsight.

Dr. Welch also writes about late pregnancy ultrasounds doing more harm than good by finding tiny abnormalities and causing needless worry to parents when it’s far more likely that the abnormalities are nothing to worry about.  A good friend of mine went through this exact same scenario last year.  At seven months pregnant, an ultrasound revealed a problem with her son’s intestine.  She was understandably freaked out for the next two months, and was also subjected to weekly ultrasounds.  When the baby was born, he was whisked away to NICU and monitored for 24 hours (no nursing or bonding time in that first day).  The result of all that testing:  a perfectly healthy, normal baby.

I haven’t had personal experience with the over-medicalization of end of life care, but everything I’ve read about it indicates that we are doing way too much intervening there too.

Much has been said about how we need to reign in health care costs in order for health insurance to be universally affordable.   But we also need to figure out how to just use less medical care all around.  We need to find ways to support health rather than react to illness (diet is a good place to start).  And we need to question just how much we want our lives to revolve around medical intervention, pharmaceutical concoctions, and beeping machines.  As Dr. Welch noted, some medical interventions are absolutely essential and worthwhile.  But that is not the case for all medical care, and a “less is more” approach might create a healthier population and lower health care costs.

It’s true that programs like Medi-Share are exempt from the regulations established under HR3590, because they’re technically not health insurance companies.  Of course that has it’s downsides too… they are not regulated by state insurance commissioners, and they are very clear in stating that the program is not health insurance and that payments are not guaranteed.

Although regular health insurance companies do impose various limitations and restrictions on various aspects of coverage, Medi-Share does so to a greater extent.  Pregnancies to unwed mothers are not covered unless the woman can prove that she was raped.  In the event that a member has fertility treatment that results in multiple births, the program will pay up to $25,000 for complications to the mother and/or children, including the cost of the delivery.  If you’ve ever known someone who gave birth to multiples with complications, you know that $25,000 won’t go far.  I guess this is an incentive for Medi-Share members to steer clear of fertility treatments that might result in multiples (the infertility treatment itself is also not covered, but that is true of most individual health insurance policies too).  Most individual health insurance carriers in Colorado don’t offer basic maternity coverage at all right now (although that will soon be changing), but they are all required by law to cover complications of pregnancy just like any other illness.  Since medical sharing programs aren’t actually health insurance, they don’t have to abide by the rules that mandate coverage for pregnancy complications.

Pre-existing conditions aren’t covered with Medi-Share.

The mental health parity law that was passed  in 2008 has no impact on programs like Medi-Share, and mental health issues are not eligible to be shared by other members.  Neither are any conditions that stem from acts that would be considered un-Christian, such as sex outside of marriage.   HIV/AIDS treatment is only covered if the disease was contracted via transfusion, rape that was reported to law enforcement, or by a health care worker in the line of duty.  Members are not allowed to smoke, use drugs, or abuse alcohol, and conditions resulting from any of those things are not eligible to be shared with other members.

Medi-Share also does not cover routine preventive care.  In Colorado, well-child visits, mammograms and PSA testing are required by law to be covered by health insurance carriers, but since Medi-Share is not a health insurance policy, it’s exempt from the mandates.  Personally, I believe that health insurance should be more about providing a safety net to cover huge medical bills rather than focusing on small, routine, expected expenses.   But it’s something that people should be aware of if they are considering a medical sharing program… actual out of pocket medical expenses might be quite a bit higher than the “annual household portion” simply because of the things that aren’t eligible to be shared with other members.

Out of curiosity, I got quotes on the Medi-Share website for my own family.  We have no interest in joining a medical sharing program, but I was interested in seeing what the difference in price would be.  We currently have a $5000 deductible HSA qualified policy.  For a policy with a $5000 annual household portion, we’d pay about $240/month (including the discount we’d receive for being healthy).  We currently pay $336/month for our health insurance policy.  To me, the extra money we pay to have a policy that comes with written guarantees, a contract, and oversight from the division of insurance is worth it.  Medi-Share’s website states that “Health insurance comes with a contractual guarantee to pay your medical bills. For over 17 years our participants have been faithfully sharing medical bills on a non-guaranteed basis…”  For some people, that bit about no guarantee of payment might not be a concern.  But the reason I have health insurance is to protect our family in the event of a catastrophic illness or injury.  If that were to happen, I want to know that I have a real health insurance company paying my bills, and legal recourse in the event of a dispute.  I like knowing that my health insurance policy is regulated by Colorado’s Division of Insurance, and I like the fact that it doesn’t say “this is not health insurance” anywhere on my policy information.  For that peace of mind, I’ll pay an extra $96/month for my family’s coverage, which does come with preventive care coverage.

Of course the down side to HB1021 is cost.  It remains to be seen what will happen to premiums once all policies cover maternity.  Governor Ritter already signed a bill that will require equal pricing on policies for both genders, so the cost of providing maternity care will be spread to both men and women (seems fair enough, since both have a part in making babies).  In addition, the cost of providing care will be spread across every policyholder, much the way it works in the group market (all group plans in Colorado cover maternity, which means that everyone with a group policy is paying for maternity care whether they use it or not).

The few individual policies that have offered maternity riders over the years have had to price the riders based on the fact that the only people who are likely to add a maternity rider are people who are planning to use it.  Very few people add a maternity rider to an individual police “just in case” – mainly because of the cost of the coverage.  But if the cost of providing maternity care is spread across all policy holders, all the time, including those who won’t become pregnant or have already had their children, it makes sense to assume that the price increase for each person will be far lower than the cost of the riders that have been available on a case-by-case basis over the years.

I’m sure that there will be complaints that it isn’t fair to make everyone have a policy with maternity coverage when not everyone will use it.  But most people do eventually have children, and HB 1021 will make it possible for people without access to group health insurance to get coverage for maternity care (which, as I mentioned last month, is pretty close to impossible now).  I would love to see health insurance carriers expand maternity coverage to include access to midwives and home births, but providing access to maternity coverage for most women who buy their own health insurance is a good start.

Many of the other big-name insurers like Anthem Blue Cross Blue Shield, Kaiser, Humana, Aetna, and Cigna have either never offered maternity on their individual policies, or stopped doing so years ago.  All policies in Colorado cover complications of pregnancy, but getting coverage for routine pregnancy and delivery is basically now limited to one carrier.

It remains to be seen how Colorado House Bill 1021 will impact this situation.  The bill would require that starting next year, all health insurance policies in Colorado include coverage for maternity.  It passed in the House earlier this year, but it has yet to be signed by Gov. Ritter.

One of the issues that Amnesty International addressed was postpartum care.  More than half of all pregnancy-related maternal deaths occur in the six weeks following birth, and yet most women aren’t seen for a postpartum checkup until the end of that time period.  The midwife we worked with for our son’s birth provided prenatal checkups at her office during the pregnancy, but once our son was born, she came to us for postpartum checkups.  We had six postpartum checkups in the first eight weeks following the birth, and for four of those visits, she came to our house.  The first postpartum visit was two days after our son was born.  We didn’t have to leave the house to take our son for checkups until he was over a month old.

The $3,000 that our midwife charged was quite a bargain, given all the service she provided.  If there had been a complication that required surgery or emergency intervention, she would have had to refer us to a hospital, but at least the problem would have stood a better chance of being caught than if I hadn’t had any postpartum care at all for six weeks after our son was born.  But in order to get that level of care, we had to pay for it ourselves (most individual health insurance policies in Colorado don’t cover maternity care, and the ones that do offer maternity don’t cover homebirths) and seek out a midwife outside of the traditional American maternity care model.

The Amnesty International report should be an eye-opener for a lot of people.  We spend a vast amount of money in this country on maternity care, and yet our results are quite poor compared with other developed countries.  Hopefully it won’t take two more decades to get back to the level of maternal death rates that we had in the 80s.

All three of these changes sound good at first glance, but the first two are not as cut and dried as they sound.  Ending gender-based pricing in the individual market would likely result in lower premiums for women, but higher premiums for men.  In Colorado, men are more likely than women to be uninsured, and raising their prices would almost certainly mean that more of them would drop their coverage.

Adding reproductive services also sounds like a good idea, but it depends on how much it would increase premiums, as many people already struggle to afford their health insurance.  For people like me, who choose to have homebirths with midwives, would we be paying for maternity coverage and still paying out of pocket for our midwives?  Would people who choose to adopt or not have children be forced to pay for maternity coverage?  Would people who would rather have a high-deductible, HSA qualified policy still have to pay for maternity coverage?  There are a lot of questions around this topic, and I still haven’t seen any solid data indicating how much health insurance premiums would increase if reproductive services were included on all policies.  Group policies in Colorado are required to cover maternity care, and the premiums are far higher than individual policy prices.  But group policies are also guaranteed issue, and it’s hard to tell how much of the premium difference has to do with underwriting and how much has to do with things like maternity care being covered on group plans and not on individual policies.  Currently there are only a handful of individual carriers in Colorado that offer maternity coverage (Rocky Mountain Health Plans, Assurant, and United Health One), and with all of these carriers, the addition of maternity coverage makes the policy significantly more expensive.  Obviously the premium difference wouldn’t be as dramatic if the coverage price were spread across the whole population via a mandate, but I am concerned that it might not be a small rate increase.

The bill that would require standardized EOBs does have my support, as does any legislation that would make health insurance benefits and claims information easier to understand and compare.  Anything that can reduce the amount of time that medical offices and consumers spend trying to figure out benefits and claim information will ultimately make our health care system more transparent and efficient.

If you have an opinion one way or another on these or any of the other bills that were introduced this week, now is the time to contact your representative.

In Carroll’s article, she described a meeting of the Health Care Task Force where the practice of gender-based pricing in health insurance was debated.  I am amazed by the comment from Rep. Jim Kerr, who explained that “women like to shop” and we should thus do a better job of shopping for our health insurance.  And by the health insurance underwriter (a male) who said we should “blame God” for the fact that women’s parts are on the inside and men’s parts are on the outside.  Seriously?  Those comments alone make me hope for gender equality in health insurance just so that we can stop having this discussion.

Senator Carroll also noted in her article that in the individual health insurance market “the rates are already significantly higher than in the small or large group market.”  This isn’t correct – in fact, the opposite is true.  In most states, including Colorado, group health insurance premiums are more expensive than individual premiums.  This is because individual plans can exclude pre-existing conditions or decline applicants with serious health issues.  In addition, group plans have more state mandated coverage (like maternity) than individual policies.  For my own family, a group health insurance plan would be twice as expensive as our individual plan (even for a policy with much higher out of pocket exposure).

It’s a common misperception that group policies are less expensive than individual policies, likely because employers pay a chunk of the group policy premium, masking the true cost of the employee’s health insurance.  The amount that is taken out of an employee’s check is not the actual cost of the health insurance.