À la carte: Great for meals, not health care

Last week, the Republican repeal of Obamacare went from unlikely, to maybe, to dead. While it appears that President Obama’s signature healthcare legislation will remain in place for now, it is unlikely that the Republicans won’t try again later for another repeal. We still have another three years and nine months of Trump (but who’s counting?). Dissecting the frenzied rush to replace Obamacare last week will be crucial in future attempts to block a Republican rollback, especially when seeking to protect the kinds of things first on the chopping block.

One such example was the last-minute deal between senior Republican leaders and the House Freedom Caucus, in an attempt to draw more conservative opponents to support the rollback. The deal included eliminating the essential health benefits insurance companies under Obamacare are federally obligated to provide, such as emergency services, mental health care, rehabilitation services and maternity care. Under that plan, individual states would determine if insurance companies must provide any of those benefits. If you happen to live in a state that chooses not oblige insurers to provide things like maternity care, you could—as Trump’s budget director flippantly suggested—move or lobby your state legislature. I doubt most expecting mothers have the time to lobby their state representatives.

Before Obamacare mandated that insurance companies cover essential health benefits like maternity services, 62 percent of people who purchased their own health insurance did not have maternity services, and only 12 percent of plans on the individual market covered maternity services. While some plans offered maternity riders, which allowed people to purchase maternity care on top of their existing plan, per month fees could reach a thousand dollars. Plans had to be purchased well before an actual pregnancy, excluding any unintended pregnancies, which make up about 45 percent of total pregnancies. Those without insurance would have to pay out-of-pocket for maternity services, averaging between $30-$50 thousand dollars for pregnancy and newborn care. Childbirth could be financially disastrous.

While all ten essential benefits required under Obamacare were on the chopping block last week, the maternity care provision seemed to be singled out for special attention. Conservative congressmen expressed confusion and scoffed at the idea that men should have to pay at all for pregnancy-related care. Instead, as the Republican plan put forth, you should only have to pay for what you want.

While only paying for what you want sounds good in theory, it becomes disastrous when applied to insurance markets. Insurance works because of pooled risks; more people in the pool means more people share the risk of being in the pool, lowering individual risk for everyone. Because most people in pool will stay healthy, their payments help subsidize the costs of when a few people get sick or need some kind of coverage. Obamacare helped to create that larger pool, helping to offset the costs of requiring insurance companies to begin covering the ten essential health benefits.

Following the Republican plan to divvy up who pays for various health services completely negates the idea of a risk pool. Before Obamacare, the only people purchasing the maternity care riders were women who expected to become pregnant, meaning the entire pool was filled with people who would need the insurance, driving up insurance costs for everyone seeking maternity coverage or making the coverage cost-prohibitive. Eliminating maternity coverage would return us to pre-Obamacare days when pregnancy meant extremely costly care.

Further, the notion put forth by some conservative congressmen that men shouldn’t have to pay for “women’s care” is, to state the obvious, sexist. There appears to be no real discussion of allowing women to refrain from paying for services related to testicular cancer or Viagra. And such a move would be dangerous for the reasons listed above; when people get to choose what services they are going to pay for, any rational person is only going to pay for the services they believe they might reasonably need. Why should a young person pay for heart disease, various cancers, or high cholesterol if they remain in perfect health? The result is a classic collective action problem: individually rational actions produce collectively irrational outcomes. Paying for only what you want means that nearly everyone seeking coverage for a particular condition is likely to ultimately need coverage for that condition. That isn’t a risk pool, it’s a guaranteed illness pool—and it will drive up costs for everyone.

Finally, I would like to address the apparent conservative misconception that maternity care applies only to women expecting babies. While it’s true that the actual services provided are for expectant mothers, the benefits of these services reverberate far beyond an individual woman. An expectant mother’s spouse stands to benefit if their partner is well taken care of and their family isn’t dishing out tens of thousands of dollars to have a baby. Maternity care services and education lower the risk of infant mortality and help catch conditions in women like postpartum depression. Healthier mothers and babies mean healthier families and, ultimately, a better economy.