Penny wise

The health commissioner of Baltimore ponders what she would have faced if she had had no health insurance when she got pregnant.

Even though I’m a relatively healthy 34-year-old, I have several medical conditions that call for more frequent monitoring. My doctor recommended that I return every two weeks for a physical exam and ultrasound. Closer to delivery, I should plan to see him every week.

I didn’t hesitate to follow my doctor’s recommendations. I have excellent health insurance with no copay for doctor’s visits and a minimal cost for tests.

But what would I have done if I didn’t have insurance?

One obstetrician visit would cost $150. With an ultrasound each time, it would be $400. A Pap smear would cost $53. One set of blood tests would add another $300. All told, my prenatal care with all visits and tests included would be over $10,000. This is not counting labor and delivery, which in my area is estimated to be up to $30,000 for a vaginal birth and $50,000 for a cesarean section.

Facing these astronomical costs, would I be forced to pick and choose care based on my ability to pay, rather than the best available medical evidence? What services would I forgo, and with what consequences?

If she had no insurance, of course she would be forced to pick and choose according to what she could pay for. That’s why universal insurance should be the universal goal.

The Republican proposal to replace the Affordable Care Act would drastically cut Medicaid, which provides health coverage for women, children, seniors, and individuals with disabilities. In Baltimore, where I serve as the health commissioner, the majority of pregnant women are insured through Medicaid. Thousands of low-income women could lose coverage and have to pay out-of-pocket for services; others who have insurance may only be able to afford bare-minimum plans that don’t cover needed services.

As a physician who worked in the ER before the Affordable Care Act went into effect, I have seen what happens when patients forgo needed interventions because of cost. I have treated patients who end up in irreversible comas because they couldn’t afford seizure medications. I have treated people who died from drug overdoses because their insurance didn’t cover addiction treatment. And I have treated women who were priced out of prenatal care, whose babies suffered the consequences in the form of preventable diseases, prematurity, birth defects, and even death.

Women without prenatal care are seven times more likely give birth to premature babies, and five times more likely to have infants who die. The consequences are not only poor health, but also higher cost passed down to taxpayers. The average medical cost for a baby with problems of prematurity is $79,000, compared to $1,000 for a healthy newborn. Hospitalizations for a preemie in the first year can be upwards of $500,000; intensive care can cost in the millions.

Conversely, studies have shown that for every dollar spent on prenatal care, there are expected savings of nearly $5. Early intervention saves lives and cuts cost. Our health care system should incentivize prevention and discourage rationing of needed services.

It’s better for the people who need the care, and it’s much cheaper overall. But hey – the Republicans want to punish the poor and cut taxes for the rich, so whaddya gonna do.

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