Published January 23, 2023
“Make Birth Free” is the new rallying cry for the pro-life movement proposed by Catherine Glenn Foster of Americans United for Life and Kristen Day of Democrats for Life. In an essay for Compact, they argue that we can and should make childbirth available with no copay or cost to parents. In their accompanying white paper, they suggest modeling a “Make Birth Free” policy after the Medicare End-Stage Renal Disease (ESRD) program, which allows anyone with end stage kidney disease to enroll for free care.
There is a lot to like in the proposal. Building a truly pro-family policy agenda for the future will require political courage and a willingness to think outside the box. It means being frank about how much financial help families need. Like them, we also want to make a big commitment to new parents and lessen the financial burden on families.
But “Make Birth Free” undersells some of the powerful programs that already exist to blunt the cost of birth. Some of the most important work involves connecting vulnerable parents with existing programs and to advocates who will fight for them. Before we embark on creating a new, universal program, we can accomplish much of the same goal by helping low income and working-class families get the aid they’re already promised on paper.
The good news is that 42% of births are already free—every mom covered by Medicaid is eligible to have all pre-, peri-, and post-natal care provided with no copays. And the Affordable Care Act ensured that for most moms on private insurance, breastfeeding support, prenatal supplements, health screening, and other preventive services are available without co-pays or co-insurance.
But one of the biggest worries for parents, regardless of insurance status, is navigating America’s healthcare bureaucracy. It’s stressful, no matter how much insurance coverage you have, to go into the hospital with no idea what you will pay for a delivery. Leah tried to get estimates from the hospital ahead of her child’s birth but never got any numbers. In contrast, when she hired out-of-network midwives and paid out of pocket, she received a clear price schedule—$6,000, all inclusive. When she needed a c-section, the midwives refunded part of their fee.
Hospitals are often cheaper due to better insurance coverage, but less transparent. The hospital bills come with gargantuan, made-up numbers at the top, but all in all, the patient responsibility averages $2,655 for vaginal delivery and $3,214 for c-sections, according to a Peterson-KFF study of births from 2018-2020. That can still be a heavy cost to bear for many families, and the uncertainty makes it worse. Both of us have had the experience of receiving bills and amendments relating to child birth a year or more after we brought our babies home.
But to make a big change for families’ financial stability, it’s a misplaced priority to focus on bringing that $2,655 (on average) down to $0. After all, many families will pay a lot more on child care and foregone wages after the baby is born. Instead, we should concentrate our efforts on making the costs of birth transparent and predictable, and giving parents support to fight for what they’re already entitled to.
Medicaid is the most powerful existing tool for lowering the cost of birth. As Patrick has written elsewhere, a major priority for pro-life activists should be expanding eligibility for prenatal Medicaid coverage to more working-class pregnant women. Currently, states are required to cover expectant mothers whose income is below 138% of the federal poverty line in Medicaid, though states can choose to go beyond that threshold. A federal push to expand a guarantee of Medicaid coverage to pregnant moms making 200% or 300% of FPL would ensure more moms who are making below the median income receive the financial support around childbirth that they need.
After delivery, moms on pregnancy-related Medicaid are eligible to stay on that coverage for 60 days post-partum. That’s not enough. The American Rescue Plan gave states the option to extend that coverage to a full year, and pro-lifers should work to get every state to opt-in: 26 states and the District of Columbia are already committed.
Provide Better Access to Patient Advocates
Expanding coverage isn’t enough if mothers can’t access the help they’re eligible for. Temporary Aid for Needy Families (TANF) is a well intentioned program that reaches only 23% of families eligible for aid. America has a pattern of funding benefits but underfunding administration, leaving those in need waiting months or years for aid. Expanding Medicaid’s promises should go hand-in-hand with expanding administrative staff and training for patient advocates who can help women navigate enrolling and who will help fight surprise or misleading hospital bills.
Bad bureaucracy is a regressive tax on the poorest and most vulnerable, who are least able to take the time to fight back or to have the confidence to threaten to sue a doctor in small claims court if erroneous bills are not corrected (as Leah did).
Inside the hospital, mothers need advocates, too. Doulas advocate for mothers during labor, standing up for women who might be ignored or taken advantage of during their most vulnerable moments. Organizations that pair Black doulas with Black mothers offer a particularly critical form of support. Just like a patient advocate constesting a bill, doulas work to get mothers what they’re entitled to on paper: lifesaving, compassionate care. Including doula fees in the “preventive care” covered by insurance would help women have safer, easier, and more humane labors.
Cap Birth Co-Pays
About half of moms have the costs of their delivery paid for by private insurance, leaving parents with some out-of-pocket expenses. The AUL proposal suggests eliminating these co-pays altogether, in the same way that the Affordable Care Act requires preventative services to be covered at no cost to the end user.
The costs of delivery in a hospital obviously far exceed the cost of a breast pump or preventative screenings. And the cost doesn’t need to be driven down to zero for all families to offer greater stability and predictability. Capping out-of-pocket expenses related to each birth at, say, $2,000 per family, would help families know what to expect without pushing the entire cost of birth into higher insurance premiums across the board.
Other small fixes to make childbirth a little less financially burdensome could include having Congress make pregnancy itself, rather than just childbirth, a qualifying life event to allow un- or under-insured moms to enroll on the ACA exchanges. States could get in on the action, too, by requiring that insurers cover home births or those attended by a certified midwife, as the AUL report correctly encourages. These births can be simpler and cheaper (in total cost) than a hospital birth, but burden parents more because they pay the fees without insurer support.
Give Cash Support to New Parents
Both of us are extremely committed to moving politics in a more pro-family direction, and each signed onto a new statement, “Building a Post-Roe Future,” which calls for reducing the “financial barriers to welcoming a new child.” Meaningful support to parents will require ambitious spending, so it’s critical to spend that money where it will do the most good.
It is true—and a moral travesty—that economic concerns remain one of the biggest reasons many women choose abortion. But the cost of childbirth per se, especially for a woman who is sufficiently low-income as to be Medicaid-eligible, is just a fraction of the overall cost of raising a child. It’s the loss of wages, the cost of child care, new expenses like diapers and formula, the increased rent for a larger space, etc. which worry parents most. The USDA estimates that a middle-class family will spend $12,680 on infant expenses in their child’s first year, and that estimate excludes foregone wages.
Parents need a policy agenda that offers sustained support more than a one-time program to make birth free. We favor programs like an expanded child tax credit, a parental benefit that offers paid leave, and/or increased child care vouchers for low-income single parents. These programs may not have a slogan as clear and compelling as “Make Birth Free,” but they are more targeted to parents’ long-term needs—and, crucially, would benefit the 42% of moms, all of whom are low-income, whose births are already free.
We admire the ambition of the “Make Birth Free” proposal and its no-apologies approach to advocating for children and their parents. No one should be forced into poverty or face a surprise five-figure hospital bill for welcoming a new life into their family. But we think there are better investments to make, which will do more to reach the poorest and most vulnerable families. We can and should expand safety-net programs around birth, but for middle- and upper-class families, ensuring predictability, rather than eliminating all out-of-pocket costs, might be a better goal.
Life starts at conception, but the financial burdens of parenthood don’t end at birth. And broader social benefits, like a baby bonus or child benefit, will ensure all parents benefit from more financial support and flexibility on how to spend what they receive.
Patrick T. Brown is a fellow at the Ethics and Public Policy Center, where his work with the Life and Family Initiative focuses on developing a robust pro-family economic agenda and supporting families as the cornerstone of a healthy and flourishing society.