When people buy insurance policies through an Affordable Care Act (ACA) exchange, they have to do it during a set enrollment period unless they've just gotten out of prison, gotten married, lost previous coverage, had a baby or experienced some other "qualifying event." Being pregnant, however, isn't one of those events. "A lot of people have assumed that meant 'if I'm pregnant, I'm having a baby and I can sign up,' so we've had to do some consumer education to clarify that," said Christina Postolowski of the group Young Invinciles, which advocates for millenials.
New York state has decided that doesn't make any sense. The state legislature passed a bill late last month adding pregnancy to the list of circumstances where people can sign up for coverage outside of a designated open enrollment period, which for this year is November through January. Gov. Andrew Cuomo hasn't spoken about the bill, but if he vetoed it, it would almost certainly be overridden by a legislature that passed the bill unanimously in both the Republican-controlled Senate and the Democratically controlled Assembly.
Opponents of the bill haven't been very vocal, but health insurers in general oppose such measures, arguing they risk driving up costs for other people by allowing them to go without insurance until they need it. Making a pregnancy exception, critics argue, could lead to more and more exceptions.
Proponents, including a host of women's reproductive-health groups and others, counter that the cost to society is far worst. Prenatal care includes the screenings and procedures that help women avoid premature birth and health risks, such as preeclampsia, diabetes and heart disease.
Babies born to mothers without prenatal care are three times more likely to have a low birth weight and are five times more likely to die. A review of studies by the New York City Comptroller's office also found that prenatal care for teen mothers saves between $2,369 and $3,242 per pregnancy. Studies have estimated the annual economic burden of premature birth to society at an average of $51,600 per patient, according to a review from a California advisory group that’s analyzing a similar bill in that state. “The argument that they should pay for being late [to apply for insurance], we all pay for that—in early birth weight, developmental disabilities, [and other problems]” said Sen. Liz Krueger, who sponsored the bill in New York. “If you compare those, it’s not even close from a cost-benefit standpoint.”
Insurers try to limit enrollment to certain periods of time so they can forecast costs, set premiums and handle claims. The individual mandate in the ACA requires everyone to have insurance or pay tax penalties. The law provides subsidized or free health care for lower-income people to accomplish that. Supporters of the pregnancy bill acknowledge that, as quality coverage expands with the individual mandate, the need for a pregnancy exclusion will diminish, but for now they say it's a valuable protection.
Exactly how many people New York's and other potential bills will help isn't known, but is likely to be relatively small, considering how many people now have coverage through employers or through the ACA. About 6,000 women in New York paid pregnancy and childbirth expenses out of pocket or through an unknown source in 2013, according to state hospital data cited by Krueger's office. A number of them likely would have benefited from being able to sign up for coverage outside of enrollment periods.
More broadly, the uninsured population would benefit from changes like New York's. In California, close to a million women of child-bearing age remain uninsured. Others who benefit may include thousands of people who were able to extend individual policies that lacked full benefits with the blessing of the Obama administration after it took considerable heat for cancellations in 2013. And many plans at small firms have been grandfathered into the new health landscape and may lack pregnancy coverage.
Health-care advocates and lawmakers tried to press Health and Human Services Secretary Sylvia Mathews Burwell to add pregnancy as a qualifying event earlier this year. But she declared in April that the agency didn't have the authority to do so. Proponents found this decision questionable, given the administration’s wide latitude in shaping the health bill. Just this year the administration extended enrollment for people who would have faced tax penalties.
That refusal is leading advocates to focus on the states. California’s Assembly is already advancing a bill with overwhelming support. Young Invincibles, which has made the pregnancy issue a key platform, said there’s also interest among lawmakers in Maryland, Massachusetts and Oregon.
Insurers argue that bills like these could increase costs because they would allow people to delay getting coverage unitl it became a necessity. With the advancements of the ACA, people need to take advantage before the last minute, they argue. “We need to be careful that we are not sending a message that encourages people to ignore the requirement to get covered,” said Nicole Evans of the California Health Plan Association. “The goal is for all Americans to have coverage and if we start to provide exceptions for people to wait to get coverage until they have a need, you could be undermining the goals of the Affordable Care Act."
And they’ve got some numbers to back them up now. The California Health Benefits Review Program, which analyses legislation, said the bill there could lead to premium increases for exchange customers between about half of one percent to 1.2 percent. The lower-end figure assumes about 10 percent of women would delay signing up until they get pregnant, and the higher-end estimate assumes 25 percent of them would.
It’s unclear at this point what influence that analysis will have on debate, if any. And based on the votes so far in New York and California, it’s clear that allowing pregnant women to get insurance outside of designated enrollment times is a hard thing for policymakers to refuse.
“My sense is that, now that New York has acted quickly and decisively, there’s no reason to think other states around the country won’t follow suit in their legislative sessions,” said New York City Comptroller Scott Stringer.