The cost of giving birth in America

StellaApo Osae-Cwum and her husband did everything by the book. They went to ahospital covered by insurance, saw an obstetrician in their plan, butwhen her three sons – triplets – were born prematurely, bills startedrolling in.The hospital charged her family $877,000 in total.“Whenthe bills started coming, to be very honest, I was an emotional wreck,”said Apo Osae-Cwum. “And this is in the midst of trying to take care ofthree babies who were premature.”America is the most expensivenation in the world to give birth. When things go wrong – frompre-eclampsia to premature birth – costs can quickly spiral into thehundreds of thousands of dollars. While the data is limited, experts inmedical debt say the costs of childbirth factor into thousands of familybankruptcies in America each year.It’s nearly impossible to put aprice tag on giving birth in America, since costs vary dramatically bystate and hospital. But one 2013 study by the advocacy group ChildbirthConnection found that, on average, hospitals charged $32,093 for anuncomplicated birth and newborn care, and $51,125 for a standardcaesarean section and newborn care. Insurance typically covers a largechunk of those costs, but families are still often on the hook forthousands of dollars.Another estimate from the InternationalFederation of Health Plans put average charges for normal birth in theUS at $10,808 in 2015, but that estimate excludes newborn care and otherrelated medical services. That is quintuple the IFHP estimate foranother industrialised nation, Spain, where it costs $1,950 to deliver achild, and the cost is covered by the government.Even the luxuriousaccommodations provided to the Duchess of Cambridge for the birth ofthe royal family’s daughter Princess Charlotte – believed to have costup to $18,000 – were cheaper than many average births in America.Despitethese high costs, the US consistently ranks poorly in health outcomesfor mothers and infants. The US rate of infant mortality is 6.1 forevery 1,000 live births, higher than Slovakia and Hungary, and nearlythree times the rate of Japan and Finland. The US also has the worstrate of maternal mortality in the developed world. That means America issimultaneously the most expensive and one of the riskiestindustrialised nations in which to have children.American familiesrarely shoulder the full costs of childbirth on their own – but stillpay far more than in other industrialised nations. Nearly half ofAmerican mothers are covered by Medicaid, a programme available to lowincome households that covers nearly all birth costs. But people withprivate insurance still regularly pay thousands of dollars in co-pays,deductibles and partially reimbursed services when they give birth.Childbirth Connection put the average out of pocket childbirth costs formothers with insurance at $3,400 in 2013.In Apo Osae-Cwum’s case, private insurance covered most of the $877,000 bill, but her family was responsible for $51,000.ApoOsae-Cwum was the victim of what is called “surprise billing”. In thesecases, patients have no way of knowing whether an ambulance company,emergency room physician, anesthesiologist – or, in her case, a halfdozen neonatologists – are members of the patient’s insurance plan.Eventhough Apo Osae-Cwum went to a hospital covered by her insurance, noneof the neonatologists who attended to her sons were “in-network”.Therefore the insurance reimbursed far less of their bills.There arefew studies that estimate the number of families who go bankrupt fromthis type of unexpected expense. One of the best estimates is nowoutdated – conducted 10 years ago. But one of the authors of thatresearch, Dr Steffie Woolhandler, estimates as many as 56,000 familieseach year still go bankrupt from adding a new family member throughbirth or adoption.“Why any society should let anyone be bankruptedby medical bills is beyond me, frankly,” said Woolhandler. “It justdoesn’t happen in other western democracies.”Since Woolhandlerconducted that research in 2007, 20mn Americans gained health insurancethrough the Affordable Care Act health reform law, and consumerprotections were added for pregnant women. But Republicans and the Trumpadministration have pledged to repeal these consumer protections.“Peopleface a double whammy when they’re faced with a medical condition,” saidWoolhandler. Bankruptcy is often, “the combined effect of medical billsand the need to take time off work”.There is no nationwide law that provides paid family leave in the US, meaning most families forego income to have a child.Andalthough childbirth is one of the most common hospital procedures inthe nation, prices are completely opaque. That means Americans don’tknow how much a birth will cost in advance.Dr Renee Hsia, anemergency department physician at the University of California SanFrancisco and a health policy expert likened the experience to buying acar, but not knowing whether the dealership sells Fords or Lamborghinis.“You don’t know, are you going to have a complication that is a lotmore expensive? And is it going to be financially ruinous?”Accordingto Hsia’s 2013 study, a “California woman could be charged as little as$3,296 or as much as $37,227 for a normal delivery, and $8,312 to$70,908 for a caesarean section, depending on which hospital she wasadmitted to.”Apo Osae-Cwum and her family only found relief after aprofessional medical billing advocate agreed to take their case. MedicalCost Advocate in New Jersey, where Derek Fitteron is CEO, negotiatedwith doctors to lower the charges to $1,300.“This is why people arescared to go to the doctor, why they go bankrupt, and why they foregoother things to get care from their kids,” said Hsia. “I find itheartbreaking when patients say… ‘How much does this cost?’”