Carrying a pregnancy to term and giving birth are some of the most high-risk activities, health-wise, that most women are likely to experience. During pregnancy, potential complications include gestational diabetes and preëclampsia (a dangerous elevation of blood pressure that can be fatal for the mother and the baby). During or shortly after childbirth, eclampsia (seizures resulting from preëclampsia), cardiomyopathy (a form of heart disease), amniotic embolism (when amniotic fluid enters the mother’s bloodstream), sepsis (an extreme response to a severe bacterial infection), and respiratory distress could occur. This is only a partial list. The risk of dying in childbirth is significant, especially in the United States, where maternal mortality rates are shamefully high: the U.S. ranks as the worst of wealthy, developed countries by this metric, and fifty-fifth out of all countries, right behind Russia.
“With the overturning of Roe and subsequent state laws outlawing abortion, we’ll see that some people will seek out abortion in different states, or through different means,” Joelle Abramowitz, an economist at the Institute for Social Research at the University of Michigan who studies how health policy affects people’s life decisions and well-being, told me. “But some people won’t. And that means we’ll see more births, and those births are going to lead to more birth-related deaths. We know that we’ll see that.”
The Supreme Court decision in Dobbs v. Jackson Women’s Health Organization, which reversed Roe v. Wade, triggered the beginning of a period of chaos, as some states rush to implement laws banning or restricting access to abortion and other states try to figure out whether they can protect a civil right that Americans have enjoyed for almost fifty years and that has provided part of the foundation for women’s full participation in society. Many of the new laws will face challenges in court, which may take years to play out. Amid great uncertainty for people who are pregnant or who may someday become pregnant and for those who care about them, as well as for health-care providers, regulators, employers and health insurers, one thing seems clear: the cost of providing health care for women is almost certain to go up.
This is partly due to the fact that some women with health complications who might have terminated a high-risk pregnancy will no longer have the option to do so. “We might see higher costs associated with caring for those pregnancies, and a greater risk that they might become fatal,” Abramowitz said. “So, we might see more complicated and risky pregnancies carried to term.” All insurance providers, whether they are private companies or government-backed plans such as Medicaid, consider factors such as age, gender, health conditions and geographical location when calculating the expected cost of insuring a particular population. Cori Uccello, an actuary and the senior health fellow at the American Academy of Actuaries, a nonpartisan organization that provides expertise on health-insurance financing to policymakers, said that, going forward, the lack of access to abortion for many women will also be a factor.
Uccello noted that it’s too early to understand what the full effects of the legal changes will be; it’s still unclear how available abortion pills will remain in places where surgical abortions are not, and whether laws prohibiting abortion will include exceptions for cases in which a woman’s life is at risk. Still, she said, she was thinking about a few different ways the Supreme Court ruling could affect the insurance market. The first was around how insurance coverage of abortion services might change. Prior to the Dobbs ruling, Uccello said, coverage of abortion was quite limited, and it varied state to state; private insurers would probably reassess their benefits going forward, but because those companies previously spent so little on abortion care, the costs to privately insured patients were unlikely to change much.
The more significant question relates to health-care spending on maternity and newborns, both of which are likely to increase. Health-insurance plans are required to cover maternity care, so any reduction in the number of abortions will lead to a rise in insurance costs, even if the insurance plan wouldn’t have covered the abortion (abortions are much less complicated, and therefore less expensive to cover, anyway, and they are statistically far safer than pregnancy and giving birth). “If they are more likely to be higher-risk pregnancies, they are likely to be higher cost. If newborns are likely to have health complications, the costs are going to be higher,” Uccello said. “We don’t know exactly how this will go, but that’s a possibility: that it will not just be more births, but more complicated births.” There could also be costs for mental-health care, physical therapy, and other services that don’t always get lumped in with pregnancy but are directly related to it.
Many insurance companies aren’t allowed to charge women more than men, so higher costs would be reflected in the premiums that everyone in the pool pays. “Premiums are probably not going to be affected right away, because the legal and regulatory environment is not going to stabilize for a while, and it will take a while for insurers to understand how those changes will evolve,” Uccello added. “But eventually, premiums may be affected by changes in health spending.”
This also has implications for taxpayers. A study by the Kaiser Family Foundation and the Peterson Center on Healthcare found that pregnancy, childbirth and postpartum care cost an average of $18,865, with Cesarean-section births costing an average of $26,280. Nearly half of the childbirths in the U.S. are covered by Medicaid, so if those costs rise, the burden on taxpayers will go up as well. “Certainly, the individuals bear some of those costs, but some are also borne by insurance, or by the actual provider, and, ultimately, they get passed on to other individuals who are insured through higher premiums. And in the case of people on Medicaid, through taxes,” Abramowitz said. “So, we’re seeing everyone bear these costs.”
Abramowitz said that a best-case scenario would have medical providers focus more on the pregnancies, deliveries, and post-natal care of high-risk patients, including making greater investments in equipment and technology. She also sees another potential silver lining: it would be great, she said, “if some people switch to more effective contraceptive methods.” ♦