Q. I'm a middle-aged man with no intention of having children. Why should I have to pay for maternity or pediatric dental coverage?
A. I've been getting this question a lot (most recently from Dr. Sanjay Gupta during a recent appearance on his weekly program). It refers to the fact that as of 2014, all individual and small group insurance plans sold in the U.S. must cover those services as "essential health benefits." Here's why.
Health insurance, like all insurance, works by pooling risks. The healthy subsidize the sick, who could be somebody else this year and you next year. Those risks include any kind of health care a person might need from birth to death—prenatal care through hospice. No individual is likely to need all of it, but we will all need some of it eventually.
So, as a middle-aged childless man you resent having to pay for maternity care or kids' dental care. Shouldn't turnabout be fair play? Shouldn't pregnant women and kids be able to say, "Fine, but in that case why should we have to pay for your Viagra, or prostate cancer tests, or the heart attack and high blood pressure you are many times more likely to suffer from than we are?" Once you start down that road, it's hard to know where to stop. If you slice and dice risks, eventually you don't have a risk pool at all, and the whole idea of insurance falls apart.
It's worth noting that virtually all employer plans cover maternity care for exactly this reason: a unified risk pool. And no one seems to complain about that, for some reason. Moreover, we are all paying taxes to support Medicaid, which foots the bill for nearly half of all live births in the U.S.
There's another reason we know that buying insurance a la carte doesn't work: we've already tried it with maternity care. Before the new health law took effect, insurers can and did exclude maternity coverage from individual plans. In fact, in half of states you can't purchase maternity coverage on the individual market for any price. In most of the rest, you can buy a maternity rider on your policy. In many cases it costs more than the main policy itself, and you can't use it for at least a year after you buy it, and it often has a separate deductible of up to $5,000.
Why so expensive? Because the only people who buy it are, naturally, people planning to have a baby. Insurers know this and price accordingly. As a consequence, this maternity "coverage" costs just about as much as paying cash for having a baby, which means it's coverage in name only. (Thanks to the National Women's Law Center for this data, from its 2012 report entitled "Turning to Fairness.")
Also, presumably at some point you, yourself, were born. Would it have been ok for your mother not to have insurance for childbirth, which can cost as much as $30,000 for an uncomplicated delivery? The U.S. already has the highest infant mortality rate of any rich industrial democracy. Do you think it's good for society for some families not to have access to proper prenatal care? The babies thus born are going to be paying for your Social Security one day, remember.
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— Nancy Metcalf
Health reform countdown: We are doing an article a day on the new health care law until Jan. 1, 2014, when it takes full effect. (Read the previous posts in the series.) To get health insurance advice tailored to your situation, use our Health Law Helper, below.