I've been thinking
again about
what we'll do about health insurance if we decide to have another baby. It's complicated, because we purchased an
individual plan since we're self-employed, and the
Bill from 1972 for
Wendy Diedrich's emergency room visit for 10 stitches with local anesthesia, with no insurance and a total (and out-of-pocket) cost of $16.60 for Wendy's parents (via flickr).
individual plans in the United States where I live don't have (yet) a lot of the safeguards group health insurance plans have (the kind you get through a "real" job). Health care reform's tantalizing protection against treating pregnancy as a pre-existing condition (with a nine-month waiting period, natch)
won't go into effect for me until 2014, and we won't be waiting
that long.
We chose our current health insurance plan by virtue of its being just about the cheapest our family of three could find. It has a big deductible ($6,000) and no maternity coverage, at all. So
we pretty much just never use it, but it's there if we need it. Except, you know, if what we need it for is a pregnancy and birth.
So. Here are my options:
- Upgrade our health insurance ahead of time to a plan that includes maternity coverage.
- Pay out of pocket for all our prenatal, birth, and postpartum expenses.
Here's where I
crunch actual numbers and hope that's not too crass. I
know it's boring,
Bill from June 2010 for
Bob Bobster's colon surgery and 6-day hospital stay, with a total of $43,651.05 in expenses, offset by insurance so Bob's out-of-pocket expenses were $1,500 (via flickr).
Even acknowledging, yes, different scenarios and allowing for inflation — holy moly, what a difference!
so you can skip ahead as you wish. I wanted to write it out for my own ruminating, but I decided to post it publicly in the hope it helps someone else going through the same calculations.
Our current plan (no maternity coverage) is $256/month for the three of us. It has a $6,000 family deductible, up to $300 a year (combined for all of us) in preventive care, and it's HSA eligible, so we can (theoretically) store money away pre-tax that can be used toward medical expenses. (I say "theoretically," because our most recent HSA money disappeared when it turned out the bank managers had been embezzling, but that's neither here nor there.)
PLAN A: If we upgraded with our current insurer, it would be $516/month for the cheapest plan that includes maternity. (At least they have a choice this time — last time I checked, they had had exactly
one plan that offered maternity coverage. Now they have a whopping
two.) That's a $9,000 family deductible at $3,000 per person, $30 copays for preventive care (including well-baby) visits, 30% coinsurance after deductible for all maternity care (prenatal, delivery, postpartum).
Definition break: If you don't shop for insurance a lot, a
deductible is what you have to pay out of pocket before an insurance company will step in and pay out any benefits.
Coinsurance is the percentage you have to pay of any expenses. So, if the coinsurance is 30% and the expense is 100, we pay $30 and the insurance company pays $70 — but only if our deductible has been met.
Website plug: I'm getting all these numbers at
eHealthInsurance
.
I have no affiliation with them — I just shop for and buy my health insurance through them. (ETA: I just figured out I
can have an affiliate relationship with them when I was on their site!) The prices are legally set, and the insurance company pays whatever fees might be involved for being in their lists, so there's no extra cost to the consumer. If you're self-employed, I highly recommend it as a site to shop health insurance plans and gather quotes, and then apply through the site electronically if the plan allows. It's easier that way.
PLAN B: If we moved to a different health insurance provider, we could get cheaper maternity coverage that would be in the realm of catastrophic coverage without technically being considered that. There's a plan for $385/month that has a monstrous $22,500 family deductible! No, seriously. Ignoring that one, there's a plan for $424/month that has a $15,000 family deductible. The point of these type of plans would be that they're there if anything really, really expensive went down, like an emergency C-section and a NICU stay. Otherwise, I'd be paying everything out of pocket. Preventive care is covered at 20% coinsurance with the deductible waived. Prenatal care is $25 each for the first four visits, then subject to deductible and 20% coinsurance. Labor, delivery, and hospital stay are 20% coinsurance after deductible.
Care providers: The
midwives we used with Mikko, if someone didn't have insurance, offered a
flat cash rate of about $2,000 that covered prenatal care (hour-long office visits), labor and delivery, and postpartum care, including lactation consulting and at least two home visits. I know — nice, right? They're not currently practicing (I shed tears just thinking of this), so I don't know if whatever midwives we go with (and we will be using midwives again if all goes well) will have the same sort of deal or a more expensive one, and how much more expensive.
Our medical plans for the next pregnancy and birth: We would like to have prenatal care but nothing too fancy. Last time, we had the most highly recommended tests and skipped the rest (including ultrasounds). We would like a home birth. However, we wanted a home birth last time, and we ended up transferring to a hospital for a non-medicated vaginal birth. I still have no idea how much that cost, because we had a different health insurance plan then with $0 deductible that covered maternity (the only one then available that did). If all goes as planned and we can use a midwifery care flat-rate plan, our expenses could remain under $3,000, including lab tests.
But, we all know things do
not always go as planned, and if things went really pear-shaped, we could be out of pocket for tens of thousands of dollars in a flash. We are unfortunately (?) no longer poor enough to qualify for much or perhaps anything in the way of financial aid from a hospital, though I'm sure we could work out a long-term payment plan. That wouldn't be much consolation, though, if they took all our retirement savings and then some. According to
WSHA Hospital Pricing, the average price in Washington State for a delivery is somewhere in the range of $8,193 for uncomplicated vaginal birth to $20,224 for a complicated cesarean. That doesn't include charges for the physicians, surgeons, or anesthesiologists, or any emergency ambulance service. I'm not sure if it includes any medications used before or after birth, and I believe the newborn's hospital stay is a separate charge.
I have considered an unassisted pregnancy and birth — but more so
before Mikko's birth. There were some complications (excessive postpartum bleeding, for the most part) that made me appreciate having qualified attendants. I'm not judgmental against those who choose unassisted births, but I'm in a headspace where I'd rather have midwives present.
So here's a little chart breaking down the price difference between our current insurance, Plan A, and Plan B:
| COST | Monthly | Yearly | Difference |
| Current Plan | $256 | $3,072 | — |
| Plan A | $516 | $6,192 | $3,120 |
| Plan B | $424 | $5,088 | $2,016 |
So, if we upgrade, we're talking
at least $2,000 more a year in insurance premiums. Plus, neither plan covers
all of our increased health costs. In Plan A, we'd be paying all our prenatal care out of pocket and hit the deductible only if we had unforeseen expenses relating to prenatal care, the birth, or postpartum care. However, if we did hit a complication, it wouldn't be long till we hit the deductible, and then things would be covered at 70%. In Plan B, only four prenatal visits would be covered at $25 apiece, and even a vaginal hospital delivery would be out of pocket, with a $15,000 deductible. Only if there were more severe complications would the benefits kick in.
So:
Is $2,016 with Plan B a fair price to pay for peace of mind in the event of any catastrophic complications? Is paying $3,120 more a year for Plan A better to have less out-of-pocket worry in the case of even mild complications (like my previous, non-emergency hospital transfer for a natural vaginal birth), when with an uncomplicated pregnancy and home birth under midwifery care, we could get away with paying over $1,000 less without upgrading? Remember that we're paying the cost of prenatal, birth, and postpartum care mostly out of pocket in all three cases if it's an uncomplicated pregnancy and home birth, and we'll say that's $2,000 since that's what our old midwives charged.
Here's another chart to illustrate the options:
| MATERNITY CARE | No maternity coverage | Plan A | Plan B |
| Uncomplicated (annual cost) | $2,000 | $5,120 | $3,800 (taking off some for the first four prenatal visits being partially subsidized) |
| Complicated additional expenses (annual cost) | 100% of costs (potentially $$$$$) | $3,000 deductible, then 30% of costs | $15,000, then 20% of costs |
It's a risk-benefits game, but the potential losers are my baby and my health.
A couple other factors to keep in mind:
- Every month I've upgraded to the higher price but don't get pregnant, I lose even more of the benefit of the higher-priced insurance. Ideally, I'd time it so my coverage kicks in the month before we conceive, but I can't guarantee anything like that. Note that this also doesn't allow for any spontaneity in our planning (no let's just go for it, honey! moments), as you can see from all the dull, dull, dull, deadly dull html tables.
- Both Plan A and Plan B do not have the HSA option for paying medical expenses with pre-tax dollars. For instance, that $2,000 under our current plan would actually be $2,000 minus our tax bracket, so let's say $1,700. This is assuming no embezzling of HSA funds happens, again. Beyond that, our HSA money gets us this discount* on anything medical, including things our insurance doesn't cover, such as vision and dental care as well as prescription and over-the-counter medication. I'm just not sure how to factor this into the charts since I'm not sure what the yearly average HSA benefit is to us. (*I say "discount," but it's actually a more complicated process of getting a tax deduction after the fact. I guardedly recommend HSA-eligible plans to self-employed families who are willing to manage their own healthcare spending — just try to choose an HSA manager who's not a crook. Ha.)
- Both Plan A and Plan B offer vision coverage, and our current scheme doesn't. However, an eye exam and some glasses every couple years is not worth so very much that I throw that into the consideration.
Philosophically speaking, assuming I've lost 90% of you with all these #%*$!@ numbers,
why do I have to make decisions like this?
- Why is my baby's health and my health dependent on some number-crunchers who decided pregnancy was too much of a financial risk for them to bother making maternity coverage standard or easily obtained?
- Why is maternity care so expensive in this country, with the overzealous medicalization of prenatal care and childbirth?
- And how does even an uncomplicated hospital birth cost over $8,000?
- Does anyone think it's a teensy bit sexist not to cover a condition that half the people of childbearing age are subject to? (And you know which half I'm talking about.)
- Knowing that I am extremely privileged to be having this decision to make, how do unemployed or self-employed people without the financial resources to purchase individual health insurance and no access to group health insurance afford to give birth?
I don't understand it, and
I don't appreciate making decisions about expanding my family based on finances.
But there it is.
And this is not meant to be a political post, but I will say that I've gotten very offended when family members have talked about health care reform disparagingly, as if it's affecting
those people. Nuh-uh. It's affecting
me, and my partner and their grandchild(ren), their loved ones. This is an untenable situation for us to be put in, and I'm so conflicted about what sort of risk I'm willing to take vs. how much of my hard-earned money I want to hand over to the insurance companies.
So what would you do? Plan A, Plan B, or brave it without maternity coverage at all? Have you ever or would you ever consider forgoing insurance coverage for pregnancy and childbirth?
I wrote this last night as I was cogitating, and today I called the health insurance company just to confirm that, yes, pregnancy is a pre-existing condition on my plan, and it is. She did inform me of a few more facts:
- For pre-existing conditions, they look back six months from the date of the new plan application for any medical diagnosis, care, or treatment.
- Therefore, the "pregnancy" starts when I first seek medical care. According to that, I theoretically could buy the upgraded insurance at 8 months pregnant as long as I sought no prenatal care before then and that would be the first record that I had the condition. I'm not saying this is my plan, just that it's kind of ludicrous. I'm not sure how much to trust that, though, since I don't have it in writing. My concern was more specific: If pregnancy is dated from last menstrual period and my plan went into effect before conception but after LMP, is it covered? According to the woman on the phone, it would be.
- If I get pregnant on my current plan and upgraded, she said prenatal care would be covered under the new plan immediately but not delivery. (Big whoop, I know, but at least it's something.)
- I could upgrade just myself to an individual plan with maternity and leave the boys where they are, which would be $354/month for our family total. I know — more numbers. That actually sounds much more doable to me, but I have to look into the tax implications of that, because I thought we had to have a family plan to deduct the cost from our business taxes. It would be a blow to lose that. More thinking and researching to do!
The woman on the phone was very pleasant, but I'm still shaking. I'm thinking it must be rage.
This is another in a series of guest posts by other bloggers. Read to the end for a longer biographical note on today's guest blogger, my very own husband, Sam. Sam gives us an analogy for how we might graciously see our children: as refugees in a strange new land, needing our help and patience to adjust.
Guest post by Crackerdog Sam
There's a scene in the documentary
God Grew Tired of Us
where several Sudanese refugees get their first apartment in America, and we see these young men improvise daily life in their new, foreign setting. One of them opens a package of Ritz crackers, breaks them into a pot, and adds milk to make a thick porridge.
My initial reaction was "Eww!" But after pausing for a moment, I thought, "Well, why not?" Just because that's not the way I would have thought to combine ingredients from the store doesn't mean that it's wrong, or that it even tastes bad. It's just weird to me in the same way that America itself is weird to them.
As I watched the film, I found that the methods with which they approached simple things in daily life turned out to be
an insightful door into how they thought and processed and perceived life. They were adapting, but they weren't losing themselves in the process. The places and ways in which they held onto their own heritage and culture were extremely revelatory.
Which leads me to another scene: I was recently out talking with a friend as Mikko tagged along behind us, at his own pace, inspecting shop windows and dog bowls and stalks of grass. My friend remarked at how unusual it was to see a parent not constantly instructing his child and telling him what to do ("stay with us," "don't touch that," "watch what you're doing," etc.). I remarked that
this is Mikko's world to explore as much as it is mine.
I think I would miss out on all sorts of revelatory moments with Mikko if I were continually telling him what to do with himself, what was the proper use for things, and what should and shouldn't be done. He absorbs enough of these parameters, I've found, through observation and a desire to play along, and without too much explicit instruction. (Obviously there are exceptions, like with light sockets and crossing the street, where it is important to avoid certain things or to approach them in particular way.) For the most part, I want him to explore his world unhindered, and in doing so to reveal something about who he is and how his mind works.
I want to learn and grow from seeing Mikko's journey in the same way I learned a great deal watching the lives of the young immigrant men. I would have been saddened had these refugees succumbed to the pressure to become homogeneously and generically American. I want for Mikko what they had:
an encouragement to hold fast to and carry with them their innate pride and spirit and fortitude in crafting a new life.
Parenting in this manner becomes a two-way street. Perhaps I as the parent hold more of the cards telling me how to act and behave in a socially acceptable manner, but then again I have lost other things now only dimly remembered: the abundant curiosity and gumption and affection that we're born with. Maybe as I steer Mikko toward concepts of, say, volume control and property rights, I am able to learn lessons from him in singing with enthusiasm, and drawing beyond the paper, if I am careful to notice.
Seeing life from a different vantage point, through someone else's mental processes, can renew and restore an appreciation for what's become overly familiar and rote. We are both learning from one another, finding spaces to intersect in our lessons in maturity and in childlikeness.
The other day at a pizza restaurant, Mikko was given a cup full of crayons, but rather than draw, he made a sculpture, emptying the cup, dropping in a shaker of red pepper flakes, putting the crayons back in so they stuck over the rim of the cup like spokes, and using them to hold up a credit card we'd gotten out to pay with. I have to admit that when he started monkeying around I had to physically restrain myself from putting everything back in its proper location for its proper purpose. But then it became a beauty to watch: so unexpected, so outside the norm.
In this case he was literally arranging the world around him, just as he figuratively does it day in and day out, building and reconsidering and rebuilding his world. Social assimilation will come — I don't expect to see him making crayon sculptures in restaurants on first dates — but it's not something I need to or even want to force.
So often we are tempted to treat young children like anarchists, bent on disruption and upset, needing to be taught compliance. But most of the time young children are simply curious experimenters with no sense of time passing. Yes, they disrupt and bother and throw tantrums and
refuse us and our demands, but every time that happens, I ask myself:
Is Mikko in this situation just being curious, or focused, or lack an ability to read a watch? Beyond that, is he physically uncomfortable, having not eaten or slept enough? Nearly every time I can point to a failing on my part to provide him what he needs physically, or his being a diligent scientist who's always being interrupted by the clock people.
In other words,
I am forcing him to live in my world on my terms when he has his own priorities as a sculptor, sticker applier, truck driver, musician, and gravity tester. Problems arise mostly when we don't understand each other as two separate beings, and respect one another in those roles. When Mikko feels respected and not run-roughshod over, he is actually quite eager to engage in and play along with what I need to be doing and make space for me. (Yes, this approach takes a lot of patience, and listening, and attention.
But I've not yet heard of a method of parenting that does not try one's patience.)
It is helpful every so often to
reverse roles. Since I speak more English than Mikko, we end up with a lot of conversations with me repeating again and again what I'm trying to communicate, and he'll confirm back to me the phrases he understands or at the very least repeat what he can mimic. It's very one-way. Then one day he just started spouting a line of gibberish at me enthusiastically and, to make a joke, I imitated his gibberish back to him.
He loved this game! It was the same one he'd been playing for months but finally it was his turn to spew the nonsense and for me to repeat back words I didn't understand.
I think I enjoyed being in Mikko's shoes for awhile almost as much as he liked being in mine. (Except for the one time he started playing the game when we were out at a restaurant, and halfway into the game I noticed that the two men at the next table over actually were speaking in a foreign language, and that the two of us repeating gibberish to one another and laughing loudly might have seemed like cruel disdain for them. Whoops.)
This parenting philosophy basically comes down to my belief that
Mikko is a person: a whole person, not a wisp of a person, not a "less than" person, not a lost and confused puppy, not a pet that needs to be broken. Yes, he has fewer resources, emotional and otherwise, than an adult peer. He needs my support and strength. But he should be allowed to participate in the creation of his world as much as any other new arrival to a new land.
- I try to give him space and time to work things through emotionally as he is encountering the new and unknown, or grieving the loss of what's now ended, even though it might mean — and often does mean — grumpiness or wailing or anger. (Heck, I'm in my thirties and not beyond bouts of moodiness and despondency and frustration when going through transitions and losses.) For any adult friends going through rough times I would acknowledge and respect their feelings and not hold an outburst against them. I'd give them space, and grace, and compassion. So why not with him?
- I try to respect his body's needs and cues, allowing him to eat or not eat what he feels hungry for when I have presented a good variety of options to him. It's sometimes hard for me, as someone who still can't break free from being a member of the clean-plate club, to wrap my mind around not finishing things, but I give him that freedom to snack on a bit of this and a bit of that and not eat beyond being full, just as I never tell guests in my home to finish everything I've served them.
- I try not to stunt his process of learning by telling him the end result I'm hoping for. I would never tell an adult person "Good job!" when he's working on something, as if he were doing the task for my approval. Nor would I jump in all the time with a "No, not like that, like that!" while she tried to figure things out. Discovery is a process of exploring options and permutations, and part of the exploration is not working toward someone else's end.
The other day we were at the zoo and Mikko looked at the giant letters and said "Z—O—O—that spell 'animals'!" That is of course, incorrect, but we didn't tell him he was wrong. He was right to a particular degree, and the rest will come in time. The sense of value that a person gains from having mastered something should be the mastery itself and not having garnered praise.
- I try not to assume the worst about Mikko's intentions. When children want their own way, they are called obstinate, willful, difficult, cranky, and rambunctious. When adults want their own way (which we get a whole lot more than kids), they're called ... adults.
When Mikko wants to do his own thing, it's most often not because he wants to frustrate me but because he's in love with what he's doing or what he wants to do, just like I want to see my 
plans followed through and not constantly interrupted. I attempt to see his "stubbornness" from that point of view, and as often as I can I switch roles so that he gets to call the shots. We recently had a beautiful evening of sitting on the car trunk in a parking lot watching airplanes fly low overhead, under his direction, which was far superior to my plan to put in him his car seat, go home, and dither about before bedtime.
- I try to model for Mikko how I hope he would live. A significant insight I've learned from Lauren's research and writing is the idea that we as humans are very social creatures, and we tend to gravitate toward the norms of our families and peers and neighbors so that we'll fit in well enough to find camaraderie and acceptance. We tend not to adhere to abstract principles but concrete actions, even though we often believe it to be otherwise.
Therefore telling our children to, for instance, apologize to another kid is not going to stick as a general principle unless they also witness us as parents apologizing to one another, and to them, when we're in the wrong. When Mikko gets older, I want to be as open and up front about our financial lives, love life, emotional lives, and our friendship circles as we are able, particularly to explain why we do what we do, so that he can see firsthand what choices we've made with what resources we've had. Taught principles, without rubber-meets-the-road firsthand witnessing, have less chance of sticking.
- I try not to instill in Mikko a sense of shame. Failure is failure — it's hard enough to deal with on its own terms. But failure that is accompanied by a sense of unworthiness, of unlovableness, of shame — that's the kind of failure that keeps you from trying again. Shame is, unfortunately, an easy go-to tool in parenting. We somehow imagine that by making the stakes even higher for success ("You wouldn't want to let us down," or "No one will respect you if you're wearing that") that a child will have extra impetus to do well in whatever area.
But everyone needs the grace to look like a fool in high school as you're trying out different identities. Everyone needs the bedrock of unconditional love at home so that when you fail and stumble you haven't lost everything. And, despite the argument that it's a harsh world out there and you must prepare children with a degree of harshness oneself, I would rather hope that by maturing in an environment of grace and compassion and understanding, Mikko would seek out friends and mentors and lovers who are mature enough to give the same.
Now, obviously at some point the analogy between cultural outsider and growing child begins to break down. If I were helping an immigrant acclimate to our country I would probably not be the one to brush his teeth or lift him onto the toilet. Nor would I expect Mikko to be able to ride the bus by himself after showing him a few times. It is just for me a
helpful shorthand to think about in times of impatience and eyerolling and obsessing with completing the day's checklist tasks.
It helps me to think about the long run, about my goal to bring up a child who is not simply compliant to expectations but a full human being who has known dignity and respect. What's important is that I'm there offering up my measure of grace, my attention, my understanding, my love, my expertise, my help, and my listening ear in the process of our interrelating, all without stepping in to solve everything for him.
I am privileged to be his co-explorer in the journey of learning the world.
Crackerdog Sam (that's his hobo name) is a full-time work-from-home parent. He shares both the working and the parenting of three-year-old Mikko with Lauren of Hobo Mama.
This is his first guest post, but he's working on many more.
always inspires me. It's pretty much just exactly what I think about respecting those who are younger. The video below does not have exciting graphics (you're looking at 'em), but it allows you to listen to the song in full, and then you'll most likely want to 
children's and family personalized notecards, flat cards, invitations, birth announcements, address labels, waterproof labels, onesies, and t-shirts. Also U.S.-centric (with apologies). Enter by Aug. 19.
Off-topic, but: I have a 
I'm Lauren Wayne, writer and natural parent. I embrace attached parenting with an emphasis toward green living. 
