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Rick Bowmer, AP
Jake Martinez, 32, holds his daughter Jenny, 3, while his wife Kat, 31, holds their son Joe, 5, at their home Thursday, May 4, 2017, in Murray, Utah. Jake Martinez, who has epilepsy, is worried about health insurance as Republicans move closer to dismantling the Obama health care system, known as the Affordable Care Act, which he and his wife use. (AP Photo/Rick Bowmer)

As Mother's Day approaches, some health policy analysts are warning that motherhood could become a pre-existing condition for some women under the health care bill the House of Representatives recently passed.

The Affordable Care Act, also known as Obamacare, made maternity care one of 10 “essential benefits” that insurers must provide, even if a pregnant woman had a lapse in her coverage.

But the American Health Care Act, which is now before the Senate, would allow states to scrap Obamacare’s essential benefits and come up with their own, and some of those plans could exclude maternity coverage, Danielle Paquette of The Washington Post reported.

Refusing to pay for prenatal visits and childbirth or raising premiums for women of childbearing age may sound politically infeasible, but, in fact, such policies were commonplace before Obamacare was enacted.

Only 18 states mandated maternity coverage before 2010, Paquette wrote, citing data from the Henry J. Kaiser Family Foundation.

And insurers didn't distinguish between a normal pregnancy or one that was high-risk, said Janel George, director of federal reproductive rights and health at the National Women’s Law Center, to Paquette.

“We were penalizing women for conditions specific to women,” George said.

That's one way of looking at the issue. Another is what Seema Verma, administrator of the Centers for Medicare and Medicaid Services, said in her confirmation hearings: that maternity coverage should be optional.

Women who don't plan on having children should have the option of declining maternity coverage in exchange for a lower premium, Verma said.

However, as the Kaiser Family Foundation points out, half of all pregnancies are unintentional, and under an optional system women who had not planned on having more children could find themselves pregnant and without maternity coverage.

Childbirth in a hospital is expensive, ranging on average from $30,000 to $50,000, depending on the type of delivery. And cesarian sections, which have increased by 50 percent in the past 15 years and now account for nearly a third of births in the U.S., can result in costly complications, both at the time of birth and years later.

But no matter which side of the health care debate they’re on, every American has (or has had) a mother, and the prospect of bankrupting mothers-to-be could be a public-relations problem for Republicans as their health care bill heads to the Senate.

A condition that half of us have

One of the most contentious issues during the House debate over the American Health Care Act was how insurers should handle a pre-existing condition, which an estimated half of Americans have.

While a pre-existing condition can be something potentially fatal, such as cancer or a serious heart condition, the category also includes prevalent conditions such as high blood pressure and obesity, both of which affect about one-third of Americans.

Prior to Obamacare, some insurers maintained lists of "declinable" conditions and occupations that could result in applicants being turned down for being on the list.

Nationwide, 27 percent of non-elderly Americans had declinable pre-existing conditions in 2015, according to the report. (In Utah, the figure was among the lowest: 23 percent.)

And for those with insurance, prices could rise based on prior claims; even the number of ear infections a child had over the course of a year might affect the cost of the premiums a family had to pay, according to a 2016 report from the Kaiser Family Foundation.

"One large, national insurer would issue standard coverage if the child had fewer than five infections in the past year or ear tubes, but apply a 50 percent rate-up if there had been more than four infections in the prior year," the Kaiser report said.

Among the questions asked in the 2015 National Health Interview Survey and the same year's Behavioral Risk Factor Surveillance System was the existence of declinable conditions, which included previous stroke, heart attack or emphysema, current weak or failing kidneys or a body mass index greater than 40, and one more — "pregnant."

"Mother" wasn't among the declinable occupations, which included nuclear industry workers, professional athletes, Strongman competitors and steeplejacks.

And both Obamacare and the American Health Care Act prohibit a practice called "gender rating" — charging women more for insurance than men.

The Republican fix

The fear that pregnancy could be considered a pre-existing condition arose from an amendment proposed by Rep. Tom MacArthur, R-N.J. The measure is what allows states to apply for waivers from some parts of the Affordable Care Act, including the essential benefits.

The MacArthur amendment, which was denounced by the American Medical Association, also allows insurers to set premiums based on a person's "health status," which includes not just past and current conditions but predictions of what that status might be in the future (e.g., pregnant). Under Obamacare, insurers can only adjust premiums based on a person's age, where he or she lives, and tobacco use.

The measure isn't supposed to benefit the insurers but the overall market, Gabrielle Healy and Amy Sherman reported for Politifact. To receive a waiver, states must provide evidence that a waiver would "reduce average premiums, increase enrollment, stabilize the market, stabilize premiums for individuals with pre-existing conditions or increase the choice of health plans."

To counter complaints that the provisions unfairly burden the sick or possibly soon-to-be-sick, the House established an $8 billion fund, called a "high-risk pool," to help cover the health care costs of those with pre-existing conditions.

And even in states that receive a waiver, people who have maintained continuous health coverage wouldn't be affected. Nor would people who have insurance coverage through an employer or the government. Republicans estimate that about 7 percent of people would be affected, all of whom obtain coverage in the individual market or in small groups.

Critics counter that these are the people who need help the most.

Motherhood by the numbers

About 4 million women give birth in the U.S. every year, and pregnancy and childbirth account for about 1 out of 5 hospital discharges, according to a report co-sponsored by Childbirth Connection.

For those with employer-provided commercial insurance, out-of-pocket costs for a vaginal birth — the least costly of hospital births — average $2,244, and the mother's share of her hospital bill increased nearly fourfold between 2004 and 2010, the report said.

Among all births, out-of-pocket costs average $3,400, according to a 2013 report in The New York Times, and writer Elisabeth Rosenthal noted, "Two decades ago, women typically paid nothing other than a small fee if they opted for a private hospital room or television."

Moreover, the U.S. is unique among developed nations in what mothers pay to give birth, Rosenthal wrote.

"In most other developed countries, comprehensive maternity care is free or cheap for all, considered vital to ensuring the health of future generations," she wrote.

"Ireland, for example, guarantees free maternity care at public hospitals, though women can opt for private deliveries for a fee."

Of course, a hospital birth is free in the U.S. also if the mother is on Medicaid. About half of all births are covered by the government insurance program for low-income Americans, according to a Bloomberg report by Claire Suddath.

EMAIL: Jgraham@deseretnews.com

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