Under current Oregon individual health insurance rules, giving birth to a baby is considered a life-changing event, one that allows a woman or her family to buy health insurance outside the open enrollment period.
But surprisingly, getting pregnant is not considered such an event, and uninsured women who get pregnant outside the November to January open enrollment window are out of luck in Oregon if they make too much money to qualify for Medicaid.
This means some families are left on the hook for medical expenses upwards of $20,000 because they lack access to insurance. Bringing babies into the world without proper prenatal care also costs the system as much as $2,400 to $3,200, even if the mothers and babies gain insurance after birth, according to Hannah Rosenau, the senior policy and access coordinator for the Oregon Foundation for Reproductive Health.
“We see women’s access to maternal care early and often as the easiest way to have better health outcomes,” Rosenau said.
Rosenau is leading a coalition of health advocates that are asking the Oregon Insurance Division to change the rules so the Division can create a special enrollment period. “It’s not going to be a lot of women, but it’s going to be extremely important for the women it does affect,” she said.
A policy switch would affect just those women whose household income was above 190 percent of poverty -- the cutoff for Medicaid -- and who became pregnant outside the open enrollment period, which runs from Nov. 1 through Jan. 31.
Although the open enrollment rules look like a shortcoming of the Affordable Care Act, under the old order, women who got pregnant but couldn’t get on the Oregon Health Plan would have had no opportunity to get health insurance year round, since pregnancy was considered a pre-existing condition that allowed insurers to refuse them coverage.
Most Uninsured Women Qualify for Medicaid
Data from the Centers for Disease Control’s Pregnancy Risk Assessment Monitoring System showed 27 percent of Oregon women were uninsured when they got pregnant in 2011, but only 1.5 percent had no insurance to pay for the delivery -- largely because the vast majority of women became eligible for the Oregon Health Plan.
The number of women in 2015 who give birth without insurance is likely to be even lower since the uninsured rate has fallen to 5 percent in Oregon. “Most people don’t wait till something happens to get insured,” Rosenau said.
Rosenau said the relatively low number of women affected by the policy change might make the change easier for the Insurance Division to adopt and for health insurers to accept. The current strategy is to persuade the state agency to create the closed enrollment exception administratively when its healthcare reform committee meets on Nov. 17.
Insurance Division spokesman Jake Sunderland said that the special enrollment discussion had not yet been added to the November agenda of the Division’s Healthcare Reform Rulemaking Committee, but the change the advocates seek could be made at the discretion of the insurance commissioner. Health insurers have not yet weighed in on the matter.
Oregon would not be the first state to add pregnancy to the list of life-changing events that allow people to shop outside open enrollment, which include job changes, adoption or birth of a child and marriage.
New York Gov. Andrew Cuomo signed a bill this summer requiring that state’s individual insurance market to sell policies to pregnant women outside of open enrollment. The California General Assembly passed similar legislation, but the California Senate blocked that change, and amended the bill to require Covered California to simply notify women of other insurance options in California.
State Could Be More Generous
California not only accepts women at a much higher income threshold -- as much as 322 percent of poverty, the state still has an active high-risk insurance pool for those who remain shut out by the Affordable Care Act.
Besides opening up the health insurance market for the remaining uninsured women, Oregon could opt to raise the number of pregnant women eligible for the Oregon Health Plan. Although the level for pregnant women -- 190 percent of poverty -- is higher than the rate for other adults -- 138 percent of poverty -- Oregon’s rate is still much stingier than other states, such as Iowa, which provides Medicaid to women up to 375 percent of poverty.
California is able to provide Medicaid to women up to 322 percent of poverty because it charges a premium equal to 1.5 percent of a woman’s income for those at the upper eligibility level.
Lesa Dixon-Gray, the women’s health systems coordinator at the Oregon Health Authority, acknowledged that the state has the discretion to set its eligibilty level higher, but was unsure whether that decision could be made by the executive or legislative branch of government, which approves the budget for the Oregon Health Plan. The state would have to contribute a matching rate for Medicaid.
“I do talk with women fairly regularly who were uninsured, weren’t eligible for OHP and became pregnant outside of open enrollment,” Dixon-Gray added. “The only thing we can do for them is to guide them to a provider who is willing to see them at a discount rate until January comes around and they can get insured. It’s a tough break for an uninsured woman, not eligible for OHP, to get pregnant in January through March, because then she has to go through labor and delivery without insurance.
“Raising the income eligibility for OHP to 300 percent or more would be a great solution. The other solution would be to have pregnancy as a legitimate life-changing event, so that anyone of any income level could shop for insurance at the time of pregnancy.”