Opinion: If you plan on having a baby under Trumpcare, you better start saving now

Seventeenth century playwright William Congreve famously wrote that hell has no fury like a woman scorned. House Republicans may feel some of that heat once their constituents find out the healthcare bill they passed could make maternity coverage vastly more expensive and harder to obtain.

It’s widely known that the House GOP’s proposed American Health Care Act would bar federal funding for Planned Parenthood, which provides many reproductive and maternal health services to lower-income women across the country. Less well understood is that an amendment to the AHCA would also allow states to lift the mandate that insurers include maternity coverage in all the policies they sell to people in the individual and small-group markets (i.e., everyone not covered by a large company health plan).

Thanks to a new analysis by the Congressional Budget Office, that particularly noxious aspect of the bill may get more attention. That is, if people ever stop talking about the CBO’s projection that the bill would leave 23 million more Americans without insurance, pushing the total higher than it was before Obamacare went into effect.

Under a compromise struck by moderate Rep. Tom MacArthur (R-N.J.) and conservative Republicans in the House Freedom Caucus, states would be permitted to waive the 10 “essential health benefits” that Obamacare required insurers to cover, and replace them with their own list. Based on prior state laws, the CBO wrote in the report released Wednesday, “maternity care, mental health and substance abuse benefits, rehabilitative and habilitative services, and pediatric dental benefits” are the most likely ones to be sacrificed.

One result, the CBO predicted, is that “out-of-pocket spending on maternity care and mental health and substance abuse services could increase by thousands of dollars in a given year” for those who need those services but aren’t covered by company plans.

The CBO is merely making a projection based on a number of debatable assumptions — it’s not conveying a mathematical certainty. But the logic underpinning its assumptions about maternity care is strong and has been echoed by numerous other healthcare analysts.

Before the adoption of the Patient Protection and Affordable Care Act in 2010, only 18 states required insurers to include maternity coverage in all policies sold in the “non-group” market. That’s because the requirement is controversial: It raises premiums for those who can’t or won’t get pregnant in order to lower them for those who can.

If Congress lets states opt out of the essential benefits requirement, the CBO predicted, at least some states would do so in an effort to lower premiums for healthier residents. Maternity coverage would be squarely in the targets of states that did not previously require it, simply because it’s so expensive to provide — the average cost is about $17,000 a year, or more than $1,400 a month, for women with private insurance coverage, the CBO said.

Those states would indeed see lower premiums, the CBO predicted, because insurers would offer less-comprehensive policies to those with fewer health problems, effectively pushing more of the cost of specific types of care onto the people who know they need it. For example, men and older women could sign up for policies without maternity coverage, concentrating the cost of that type of care onto women of child-bearing age.

In fact, mechanisms within the bill designed to stop people from gaming the system would intensify this effect. The bill would bar insurers from considering preexisting conditions unless the applicant had gone uninsured for the previous two months or more. But nothing would prevent people from switching from a limited policy to a more comprehensive one when they expect to need care, and back to a limited one afterward. So women might choose a policy with no maternity coverage until they were planning a pregnancy.

The effects wouldn’t necessarily be confined to the states that decided not to require maternity coverage. As Brookings Institution fellow Matthew Fiedler explained, there’s a potential spillover onto women across the country who get their health insurance from an employer. Under the 2010 law, employer plans cannot impose annual or lifetime caps on benefits that are classified as essential. But employers are permitted to pick any state’s definition of essential benefits — so if states were allowed to stray from the federal minimums, employer plans could start reimposing benefit caps and taking the lid off of out-of-pocket costs for certain types of care. Hello, ladies!

The CBO doesn’t expect maternity coverage to simply vanish from employer plans or in states with more limited essential health benefits. Instead, it suggested that the coverage could be sold separately as an add-on policy — but a pricey one.

“Insurers would expect most purchasers to use the benefits and would therefore price that rider at close to the average cost of maternity coverage, which could be more than $1,000 per month,” the CBO wrote in its report. “Alternatively, insurers could offer a lower-cost rider providing less-than-comprehensive coverage — with, for example, a $2,000 limit. Either type of rider would result in substantially higher out-of-pocket health care costs for pregnant women who purchased insurance in the non-group market.”

It’s in everyone’s interests to make childbirth safe and to bring children into the world healthy, just as it’s in everyone’s interests to have good public schools and safe streets. So it makes sense to spread the cost of maternity coverage broadly. The AHCA abandons this principle in its search for an easy way to slow the growth in premiums — for some Americans. On that front, the CBO says, the bill is likely to succeed, causing premiums after 2020 to be lower than they would be if Obamacare were left untouched. But the House GOP’s plan would create real winners and losers, and the latter category clearly includes women of child-bearing age.

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Twitter: @jcahealey