Pregnancy as a preexisting condition

By Kanani E. Titchen, Esther K. Chung, and Thomas A. Klein

If you're a woman of reproductive age in Pennsylvania, you'd better make sure you have health insurance before you get pregnant. And you'd better make sure your insurance covers care related to pregnancy and delivery.

In 17 states, including New Jersey, an expectant mother can buy health insurance and get the coverage she needs for herself and her baby. In Pennsylvania, however, pregnancy can be considered a "preexisting condition," meaning a woman can be denied health insurance simply because she is pregnant. Furthermore, some insurance plans do not cover pregnancy and childbirth care.

While the Pennsylvania legislature has consistently allowed insurance companies to deny coverage to pregnant women and others, the practice is supposed to end under federal health-care reform. The law already requires insurers to cover children with preexisting conditions. And if it survives court challenges, the same mandate will apply to adults as of 2014, ensuring no one will be denied health insurance due to a preexisting condition.

Unless and until that provision goes into effect, however, those over 18 can still be denied coverage due to preexisting conditions. And in Pennsylvania, pregnancy is one such condition.

Fortunately, State Sen. Larry Farnese (D., Phila.) has introduced legislation to change that. His Senate Bill 1063 would require that small group and individual health insurance plans cover maternity.

The latest available government data show the average cost of care for a vaginal birth is $6,200, while a cesarean section with complications costs an average of $15,500. These figures exclude the costs of doctors' fees, anesthesia, and newborn care. Taking into account the cost of doctors' fees (but not of anesthesia and newborn care), the organization Childbirth Connection puts those figures at $9,617 for a vaginal delivery and $21,495 for a cesarean with complications.

Of the approximately four million American women who give birth each year, up to a third experience complications. Routine prenatal care can reduce that number through screening for gestational diabetes, high blood pressure, genetic diseases, serious infections, and other problems. Prenatal care also emphasizes proper nutrition, which can head off other complications.

This represents an opportunity for physicians and insurance companies to reduce the costs associated with pregnancy and delivery. A 2009 New England Journal of Medicine study found that the treatment of mild gestational diabetes alone reduces the risk of several complications and the likelihood of a cesarean section, which triples costs.

Uninsured women, on the other hand, are likely to head to the nearest emergency room to deliver their babies, paying fees out of pocket if they can afford them. That only shifts costs to hospitals, many of which are already struggling with shortfalls.

The Pennsylvania legislature can change this by passing S.B. 1063, which would improve care, save lives, and, in the long run, save money.