Halfway Through My Obamacare Pregnancy

Which procedures are mandatory? Which aren’t? And why is it so hard to know?

I’m almost at the halfway point of my Obamacare pregnancy, and the bills have started to arrive. As documents, these enumerations of costs—for which I am responsible for a total of $1,228 so far—have lots of comic potential and surrealist value.

For example, an ABO-blood-typing test cost $179.05, of which I am charged $152.19, though I already know my blood type and could have told anyone who asked me. Certainly it hasn’t changed since my last pregnancy four years ago.

Screenings for HIV and Hepatitis B were free (to me) while an examination of my Vitamin D levels cost $252, of which I must pay $214.20—that’s a lot of money to be told I should buy a $6 bottle of pills that, odds are, I needed to buy anyway, since pretty much everyone is Vitamin D deficient these days.

One standard, 2D ultrasound cost $500. No one at the lab mentioned that before signing me up for several. I would have had my third last week if I hadn’t finally put my foot down—or, rather, wiggled my toes in the direction of putting my foot down—by begging my midwife to help me understand what was truly necessary and what wasn’t, given the state of my health insurance.

Thanks to my midwife’s advice, which she gave cheerfully once she understood my predicament, I called the lab and canceled my scheduled 16-week appointment for more blood work and yet another night-vision-like peek into the inside of my uterus. In addition, the 16-week appointment I had been signed up for wasn’t mandatory, my midwife told me. I could skip it with no ill effects.

If only I could have known at the outset what was mandatory and what wasn’t. If only I could be sure that I will only have to experience, and pay for, what is similarly mandatory going forward. Yet I have no such confidence. Our profit-driven, opaque, and uncommunicative medical system does not allow for it.

Once a pregnancy announces itself, the expecting person is placed on what feels like an industrial assembly line. One brisk, bustling employee takes the mother-to-be’s blood, and another her urine; someone takes her blood pressure, but nobody takes the time to explain to her which procedures are crucial, which are nice, and which are superfluous but done anyway out of habit. (See ABO Blood Typing, above.)

Before the mother-to-be knows it, she has been built into a Lexus. It’s roomy and it smells luxurious. But why is a Lexus the default, when it is so fancy?

No one looks over her insurance and says, “Given your high deductible, would you prefer to pay out of pocket for the standard Lexus package or go the Honda route: safe and reliable but with fewer frills?” Perhaps that is because the thought of even offering a Honda options conjures up notions of health-care rationing and Sarah Palin’s illusory but effective “death panels.”

Nonetheless, I want Honda care, because that is what I can afford. Indeed, shouldn’t Honda care be the default, at least for healthy, uneventful gestations like mine? Otherwise, even people with full coverage will have their insurance companies charged for unnecessary and redundant procedures, the cost of which are passed along to the consumer in the form of even higher premiums.

My midwife uses a simple Doppler at each monthly check in to make sure the fetus’s heart is still beating. Why then was it necessary for the lab to also schedule an ultrasound each month? According to the American Pregnancy Association, “many healthy pregnancies will not require ultrasound” at all.  “For women with an uncomplicated pregnancy, an ultrasound is not a necessary part of prenatal care.”

“Most healthy women receive two ultrasound scans during pregnancy,” reports the Beth Israel Deaconess Medical Center and Harvard Teaching Hospital website. Despite not being high-risk in any way, I was given two in my first trimester alone. Had I not, out of desperation, intervened, I would have received, and had to pay my share of, a third.

Better safe than sorry, some will say. Still, I cannot be the only patient who would prefer to be given the chance to make an informed decision. Indeed, Katy B. Kozhimannil, associate professor at the University of Minnesota’s School of Public Health points out that I’m hardly alone in having to contend with subpar coverage: “1/5 of all American workers had high-deductible plans in 2014.” High-deductible Bronze plans are “the most common insurance product purchased on the exchanges.” In other words, there are millions of patients in some version of my situation.

Doctors, midwives, and medical professionals in general would do well to start taking us into consideration—to stop assuming that their patients want or can afford a Lexus when a Honda will do.