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Reflecting on the Dobbs Decision: Medical Debt, Pregnancy & the Shifting Reproductive Landscape

Eva Stahl

The Supreme Court’s June decision in Dobbs v. Jackson Women’s Health, overturning Roe v. Wade, ended the federal standard protecting the right to abortion and paved the way for states to determine restrictions on abortion without federal guardrails. Whether or not a person can access abortion services now depends on where they live, and the landscape is rapidly shifting as state legislatures implement trigger laws or introduce legislation to restrict or protect access to abortion. To monitor the status of state laws, see this Kaiser Family Foundation dashboard.

As an organization committed to ending medical debt, we are reflecting on how this decision will impact people accessing pregnancy-related services and the effects on their mental, physical and financial health. One of the more harmful aspects of medical debt (that we hear about from those we help), is that it prevents people from accessing care when they need it most. People fear accruing more debt or being turned away at the hospital door because of past due bills or an inability to pay for health care. The Dobbsdecision makes those fears more acute for millions of people residing in states with abortion restrictions. As a result, people’s physical, mental health and financial wellbeing will suffer. To be sure, those who are left out of our health care system will suffer most — disproportionately, Black and indigenous people women who face longstanding barriers to accessing health care.

The Dobbs decision shines a light on the financial reality of having a baby in this country. For those who have employer-sponsored insurance, the average cost of giving birth ranges from about $15,000 to almost $26,000. Notice the pink boxes below that highlight the out-of-pocket costs for the individual that exceed $3,000 for those who deliver by Cesarean and over $2,500 for vaginal delivery. We repeatedly cite the data point from several surveys that most people in this country cannot absorb a $500 unexpected bill, placing them at risk of medical debt. Even with robust planning, these high out-of-pocket costs threaten families’ financial security.

The data analysis from the Peterson-KFF Health System Tracker sheds light on health care spending on postpartum care services; these health care needs are unplanned and difficult to predict but critical. They can include services for postpartum depression, complications with delivery or other medical services required related to pregnancy. To be abundantly clear, the cost of a pregnancy is incredibly expensive even with insurance coverage and planning.

We know this from our own work in abolishing debt — take S.C.’s story:

When I had my miscarriage, it was a double blow of a loss of a pregnancy and a resulting emergency surgery to save my reproductive system. In all of this shock came the medical bills that followed. Even with a comprehensive health insurance in place, the bills poured in from everywhere. For lab work, the anesthesiologist, the doctors, the emergency room visits. What a huge relief and a surprise to see [a letter in the mail] from Undue Medical Debt. I am very grateful that there are others out there that care. That took the time out to help someone else, be it a complete stranger. This letter that brought good tidings also allowed some closure to a sad and scary time in my life. Thank you from the bottom of my heart.”

-S.C. from Florida

While the data on cost shows that it is one aspect of giving birth, the risks, particularly for Black and Indigenous women, is another important factor to consider. This country has the highest maternal death rate of any developed nation. Black and Indigenous women are more than three and two times, respectively, more likely to die from pregnancy-related complications than white women, due to systemic racism and barriers to care. Furthermore, nearly one-quarter of maternal deaths happen more than six weeks postpartum and at least one-third of maternal deaths happen following pregnancy within the first post-partum year. For all of these reasons, advocates led by reproductive justice leaders like Black Mamas Matter Alliance and the National Birth Equity Collaborative are pushing Congress to act. First, there is a need to extend post-partum coverage to one full year instead of the state standard of 60 days; currently, states have the option to extend coverage, but not all do and making it a federal standard will save lives. Second, there is consistent pressure on Congress to solve the lingering Medicaid coverage gap crisis that leaves over 2 million people without access to health insurance. Research shows that states that refuse to expand Medicaid leave people vulnerable to medical debt — those affected are disproportionately Black and brown people living in the South. As of now, these two priorities remain unresolved as states navigate a new reproductive health landscape that increases stress and risks financial insecurity for millions of people. We will continue to watch for the trends in medical debt and shine a light on their effects to inform policy change.

Eva Stahl