Why Is Maternity Care Such an Issue for Obamacare Opponents?

Opponents of the Affordable Care Act have settled on a new injustice built into the system: The law mandates that all plans cover women having babies.

Representative Renee Ellmers got the ball rolling at an October 30 House hearing where she pointedly questioned Health and Human Services Secretary Kathleen Sebelius: "As far as the essential health benefits, correct me if I'm wrong, do men not have to buy maternity coverage?" The North Carolina Republican hammered Sebelius from there, ending with, "To the best of your knowledge has a man ever delivered a baby?" Sebelius tried to defend covering maternity care, but it was too late. A "single male, age 32, does not need maternity coverage," Ellmers said.

Plenty of commentators have since argued it's unfair to make insurers cover maternity care. Fox News contributor Kirsten Powers objected in mid-November: "The idea that they think that 50-year-olds should have maternity care is very concerning to me." Writing in The New York Times, Lori Gottlieb (an Atlantic contributing editor) complained that her new individual-market policy would be more expensive and include "maternity coverage (handy for a 46-year-old)"—after she'd intentionally dumped "maternity benefits so that I didn’t have to pay for everyone else’s pregnancies." Harvard economist Greg Mankiw, a former Mitt Romney adviser, asserted: "Having children is more a choice than a random act of nature. People who drive a new Porsche pay more for car insurance than those who drive an old Chevy .... Why isn't having children viewed in the same way?"

On Thursday, Nicole Hopkins, writing in the Wall Street Journal, revived the theme, complaining of a "letter from my mother's insurer [that] promised that the more expensive plan 'conforms with the new health care law'—by covering maternity needs, newborn wellness and pediatric dental care. My mother asked: 'Do I need maternity care at 52?'"

But uninsured women of childbearing age weren't making choices between a Porsche and a Chevy in the pre-ACA world. They were trying to find a bus in sprawling towns where they had to walk while everyone else drove. According to the New York Times, in 2011, 62 percent of plans in the private market did not cover maternity care at all. The National Women's Law Center, looking at a narrower slice of the population, found that in 2009, only "13% of the health plans available to a 30-year-old woman" across the country in the individual market covered maternity care—and "in the capital cities of nearly half of the states there was not a single plan available through eHealthInsurance.com that covered maternity care." Insurers were also allowed to reject pregnant women from coverage for having a pre-existing condition (pregnancy), and to exclude women who'd had a Cesarian section from coverage entirely (since they'd be at risk of needing another if they were to have another kid). 

This was one of the critical ways the individual market differed from the employer-based one: More than half the plans in the individual market in 2010 did not meet the baseline "bronze-level" standards under the ACA, according to a 2012 study published in Health Affairs, while only 1 percent of plans in the employer-based market were similarly deficient "tin" plans. So to the extent that the ACA changes standards for insurance by adding maternity coverage, it does so almost entirely only within the individual market. Most group plans—such as the ones most employed people have—already cover maternity care. That means employed men and women have for years already been in the same situation with regard to pregnant women that people in individual-market plans will be starting in 2014.

Maternity care isn't the only women's health issue that plans are now required to cover. In fact, there are 22 types of women's health tests, visits, or prescriptions that insurers must now cover, including contraception. It just happens that besides contraception, none of them has raised the same ire as maternity care. According to a fact sheet at Healthcare.gov, "All Marketplace health plans and many other plans must cover the following list of [22] preventive services for women without charging you a copayment or coinsurance. This is true even if you haven’t met your yearly deductible" though "only when these services are delivered by an in-network provider." Including are some of the diagnostic tests used in pregnancy, though not the whole spectrum of maternity needs, where co-pays may still apply depending on the type of plan a woman picks.

One possible explanation for the unusual focus is the demographic discrepancy between who does and does not already have insurance. The majority of married people have insurance through employer-based plans. The uninsured, on the other hand, are significantly more likely to be unmarried. And the majority of births in this country to women under 30 now take place outside marriage.

Murphy Brown, the title character in a sitcom, in 1992 became a watchword for Republican discomfort with the idea of women having babies on their own after Vice President Dan Quayle criticized the show's portrayal of single motherhood. Welfare reform followed in 1994, in large measure based on the conservative argument that the government should not be in the business of supporting women who have babies on their own.

The resentment against women who have babies on their own has been part and parcel of the GOP moral argument for decades; in 2012, Mitt Romney connected gun violence to single moms.

The objection to maternity care in the individual market would appear to be an extension of this historic Republican argument. Single women—and especially single black and Hispanic women, who have been much less likely to have insurance under pre-ACA arrangements—who make too much for Medicaid but not enough to buy insurance without subsidies can now get maternity care covered through ACA-compliant exchange insurance policies.

Writing in defense of maternity coverage in The Washington Post, E.J. Dionne asked, "Who knew that supporting motherhood was suddenly controversial?"

He made the case that those who oppose abortion should hail the new coverage. But conservatives have always been ambivalent about motherhood—when it takes place outside of traditional social arrangements.