My son recently had his first birthday. He hates wearing clothes but loves eating cheese ("cheeee"). I don't know that he'd be here if it weren't for the Affordable Care Act.
Republicans are once again jockeying to repeal and replace that law — this time through a bill from Republican Sens. Lindsey Graham and Bill Cassidy. The GOP has pitched Graham-Cassidy as a friendly and fair instance of federalism — a chance to turn Obamacare's money and regulatory power over to the states.
But we know what happens when states get to do what they want with healthcare. That was the old setup, and it frustrated millions in the individual insurance market. My son's birth — and the maternity coverage that made it possible — offers a concrete example of how bad things were, how much they got better, and how bad they might become again.
My wife and I were both born and raised in Indiana, she in a working-class city, me on a farm. We both went to the University of Southern Indiana, where we met on our first day of classes. After graduation, we moved to the East Coast so she could get a job in her field, book publishing, while I worked on a PhD at Yale.
Once we were ready to start a family,we decided to return to our bland but beloved home state. (The fact that it's known for producing not presidents but vice presidents, including the current one, former Indiana Gov. Mike Pence, is Peak Indiana.) We wanted our future children to know their grandparents. We wanted to live in the Midwest.
Still, moving meant becoming full-time freelancers and sacrificing our employer-based benefits. And that meant scrounging for insurance on the individual market.
I still remember logging on to eHealthInsurance.com in early 2013, with solid maternity coverage at the top of my list. I was in for a shock. While plenty of pre-Obamacare plans covered Indiana, most of them refused to pay the costs associated with pregnancy and childbirth. Those that did required would-be moms to pay an extra monthly fee, or "rider," on top of the regular premium.
The best option I found demanded we pay a pricey rider for 12 months before even trying to conceive — and then keep paying that rider no matter how many months it took. In our case, we would have spent well over $30,000 to get this (still skimpy) coverage.
Our experience could have occurred in many states. In 2012, the National Women's Law Center analyzed more than 3,000 plans on the individual market. The center found that only 12 states required at least some insurers to offer maternity coverage. The remaining 38 states, including Indiana, were a wasteland. I guess they chose to be a wasteland, but still: Overall, a measly 6% of plans in those 38 states offered maternity coverage, and an additional 7% offered riders.
Worse, in some of those states, the center couldn't identify a single plan that included maternity coverage. Think about that for a second: If you had been self-employed and living in, say, Lindsey Graham's South Carolina, it would have been all but impossible to start a family unless you qualified for Medicaid or were willing to risk a pregnancy without insurance.
My wife and I ended up waiting until 2014 to move back to Indiana. But really we were waiting on Obamacare. By that January, we had enrolled in a plan that included the law's 10 mandatory benefits, among them maternity coverage. When my wife got pregnant the following year, she received excellent prenatal care. When our son was born four weeks premature, we didn't stress about the extra costs. Instead, we stressed about his early arrival, then celebrated when it all turned out OK.
Obamacare, in short, has been a boon to freelancers and small-business owners all over the country. It allows them to spread risks and share costs, so that a 50-year-old man helps pay for maternity coverage, just as a 30-year-old woman helps pay for prostate exams. This is how insurance works. In fact, it's the reason virtually every employer-based plan covers maternity care, that and a rather helpful bit of federal "overreach," the Pregnancy Discrimination Act of 1978.
The Graham-Cassidy bill — or any other scheme that would put states in charge of deciding what benefits are essential or whether it's OK to charge for pre-existing conditions — would surely reverse Obamacare's gains.
"Frankly, I'm really worried about the flexibility," says Paul Halverson, the dean of Indiana University's Fairbanks School of Public Health. He points to Indiana's failure to raise its tobacco tax, a proven way to cut back the state's high percentage of smokers. "We know exactly how to reduce smoking in our state," Halverson says. "But we haven't done it."
Last week, Mike Pence spoke for many Republicans when he called for applying "the American principle of federalism" to our healthcare system. Graham-Cassidy would succeed, he told CBS, by "empowering states to do what we did in the state of Indiana when I was governor."
Well, when Pence was governor, Indiana's politicians couldn't find the courage to raise the tobacco tax, much less to take care of expectant mothers.
This is what's so scary about the GOP's fetish for decentralizing and deregulating healthcare. It could mean returning to a cruel and patchy map where the state you live in determines whether you can fill a prescription, take your child to the emergency room, or even have a family at all.
Craig Fehrman is working on a book about presidents and their writings.