No matter how you slice it, having a baby is expensive. Recent data suggests a vaginal delivery costs, on average, around $12,235 and a caesarean section (C-section) costs $17,004. With private health insurance, you'd likely still pay $1,000 to $2,500 out of pocket, but without it, your first instinct may be to panic.
That's the position of plenty of parents today: As the massive job losses from the COVID-19 pandemic added up, expecting parents have been forced to navigate the health care system after years of employer-sponsored coverage or look into federal and state insurance called Medicaid—income-based insurance that usually has no co-pays and helps those with limited income.
As of September 2020, about 77 million individuals were enrolled in some form of Medicaid—up from the some 71 million who were enrolled in 2019. (Many state marketplaces and Healthcare.gov will inform you of Medicaid eligibility; The Kaiser Family Foundation (KFF) also has a tool to help you know if you qualify.)
And while medical providers have the duty to give the same level of care to every patient they see, no matter insurance type, many expecting parents fear that free health care will be subpar—arguably for good reason: Sometimes it is.
Here, the experiences of three women who have delivered babies on both Medicaid and private insurance as well as expert insight about what to expect and how to get the care you deserve if you find yourself seeking federal or state insurance.
Having a Baby on Medicaid
First things first: Your insurance does not dictate your level of care, says Philadelphia-based health care consultant Kyana Brathwaite, R.N., who has over 20 years of experience in the medical field.
Fortunately, many women note that, overall, prenatal and labor and delivery care is similar to care received through private insurance (most basics are covered). But, anecdotally, there are differences.
For one, Brathwaite explains that some health care providers have presumptions around Medicaid. "Sometimes people look at Medicaid on your chart and treat you as if you're lazy and you're just trying to live off the government," she says. "They have no idea what your situation is." She has experienced this and witnessed it herself.
Suzanne Nelson, 48, of West Deptford, New Jersey, for one, who has had three children using both state and private insurance says that when she gave birth on Medicaid, she dealt with limited scheduling. Doctors at the Medicaid clinics also maintained private practices and gave priority to those patients over the low-income ones, she says.
When she was on Medicaid, she also notes she was asked multiple times if she wanted to have her tubes tied. "My private doctor kept asking me to have more kids, but at the Medicaid facility, I felt judged and guilty, even though I was working part-time at a doctor's office that didn't offer benefits."
It's an example of the bias that Brathwaite has pushed back against in her work.
Eunice Diaz, 34, of New York City, also notes that New Jersey's Medicaid program did not cover doula care until after she needed it.
She also discovered that she would not be able to keep her highly-rated OB-GYN when she switched from private insurance to Medicaid since the doctor did not take state insurance. Many top doctors do take Medicaid (a 2019 report found that 81 percent of OB-GYNs accept new patients on Medicaid), but even though they may take some patients, that does not mean they will take every person using state insurance. The reasoning, according to the Medicaid and Children's Health Insurance Program Payment and Access Commission is that Medicaid pays 40 percent less for care than private insurance. This can make it difficult to cover overhead fees, therefore they must maintain a balance of private and state insurance clients.
Seeking a provider who specialized in unmedicated births, Diaz says that finding a specialist through the state's database also had logistical challenges. Most of the phone numbers listed didn't take you to a particular doctor, but to a group of doctors. Many numbers were no longer in service.
In the end, she was relieved that, with Medicaid, she didn't have a $5,000 bill after giving birth to her daughter, Chloe, as she did with her first daughter, Riley. Both girls were born in the same hospital.
Sindy Lozada, a 32-year-old in Marlton, New Jersey who has given birth four times, delivered her third baby, a stillborn, at 36 weeks on Medicaid, noting that her delivering physician pushed her to deliver via C-section when she felt as though that would be more traumatic for her. Ultimately, Lozada advocated for herself and pushed her baby vaginally, but she felt as though her doctor had more of a financial focus than caring about her well-being.
C-sections are more costly than vaginal births with private insurance and Medicaid, and the U.S. performs so many C-sections (in most states, rates are over 25 percent of all of births), that the practice has drawn criticism from the World Health Organization, which says that it is only necessary for 10 to 15 percent of births.
According to the March of Dimes, C-sections should be performed primarily when the health of the mother and/or baby is at risk, for example, neither of which was the case for Lozada.
"There are several reasons for a C-section, mainly involving the health of the mother and baby, and the comfort level of the practitioner," says Brathwaite. "The one that makes me cringe is that C-sections yield more money." Though this isn't always the case, it could potentially be a way to make up for lower reimbursements from Medicaid.
The good news is that empowering yourself and being informed can help you get the best support and care possible. Here are three things to know about delivering a baby on Medicaid.
Know what\’s covered
The Kaiser Family Foundation has an extensive list of what is covered by Medicaid in each state. While coverage varies, all cover basic prenatal care, vitamins, and ultrasounds (though some require a prescription for prenatal vitamins and others may limit how many ultrasounds you can get). The Affordable Care Act also mandates that states must cover birthing centers that they license (very few cover home births) and a breast pump, though the type is up to the insurance.
Doula care is also covered in New Jersey, Minnesota, and Oregon, testing for genetic abnormalities is offered in most states—with most covering chorionic villus sampling (CVS) and amniocentesis—and nearly all states offer case management to aid mothers in getting specialty service, such as depression screenings and financial assistance (though some limit it to high-risk cases).
To ensure you're getting everything that you are entitled to, Brathwaite suggests calling your insurance company and asking questions. "You can say, 'I am this age, can you give me a breakdown of what my options are for a woman who's postpartum or prenatal or any preventative gynecological care and benefits?'" Finding the right plan for you and your particular needs can also ensure you get the care you're seeking.
Advocate for yourself
Everyone has a right to informed consent as well as a thorough explanation of benefits and risk before making a decision. For instance, before your OB-GYN decides on a particular kind of testing, ask if there are any indications that one would be necessary and if there are alternatives. Brathwaite also recommends shopping around for doctors like pediatricians, reminding parents that if you don't want to stick with the one who took care of your baby in the hospital, you don't have to. It is empowering practice to have a say in every part of your and your baby's care.
Brathwaite recommends informing your practice of any mistreatment. "In a hospital system, speak to your nurse manager on the unit. The next step is the nurse supervisor, then the director of nursing. An office manager can handle your concerns at a private office." If it isn't clear who is in charge within a hospital system, you can find the patient relations phone number and ask for the best person to handle a complaint. You can also request not to deal with someone within the practice if you have had a bad experience. The last resort: changing doctors.