Madeleine James McNabb came into the world the day after Christmas 2016, bringing her parents 4 pounds, 12 ounces of joy – and thousands of dollars in a medical bill they are still paying off.
The Bryn Mawr family's insurance plan covered much of Madeleine and 31-year-old Taryn McNabb's costs, but not the $2,000 out-of-pocket responsibility the young family is meeting in $175 monthly installments.
"Miracle babies" born very prematurely, or with problems requiring high-tech interventions, get much of the cost attention, with bills that can approach and exceed seven figures.
But these days, even the routine birth of a healthy child to a woman who needs only a short time in the hospital can prove a financial surprise. As a greater share of all health-care costs shifts to consumers, new parents with already-limited savings are being saddled with medical debt just as they are facing the added cost of diapers, day care, and the many other needs of a new baby.
No one with private health insurance expects to have a baby for free, and a few thousand dollars may not sound like much compared with the extraordinary costs that many patients face. But to young families, it can be a boulder at the starting line on the expensive path of parenthood.
"It's almost like you're being punished for wanting a family," McNabb said.
Routine prenatal care is covered in full under the Affordable Care Act, with no cost-sharing. But exactly which services count as "routine" can vary from one plan to the next, leaving new mothers with thousands of dollars in medical bills for ultrasounds, genetic testing, and other services they didn't realize would not be covered in full. And when it comes to the actual birth, young adults who may never before have faced major medical issues are learning what it means to have a high-deductible health plan – spending thousands before any benefits start to kick in.
"The high-deductible plans are not made for the level of expense that occurs for childbirth in this country," said Carol Sakala, director of childbirth connection programs for the National Partnership for Women & Families.
Understanding your health plan is important, especially for people preparing for a major life — and budget — change such as a child. But it can be hard to figure out which services are covered without cost-sharing and which will lead to a bill.
Some plans may pay for two or even three ultrasounds, while others cover just one in full. Genetic testing and other screens that doctors may order if there is a family history of a particular illness are often extra, too, said Katy B. Kozhimannil, an associate professor of health policy and management at University of Minnesota's School of Public Health.
"It is so difficult to know in advance what you are on the hook for and what you're not on the hook for during pregnancy," she said.
Rubina Tahir's pregnancy was considered high risk because of her age — in the world of childbirth, 35 is deemed "advanced maternal age" — and came with additional tests and procedures that weren't covered in full by her insurance.
Tahir, 38, a chiropractor in Philadelphia, surpassed her plan's $2,000 deductible giving birth to her daughter, Viyana. And the expenses kept coming – at such a clip that even when the plan started paying a portion of her costs, she also hit her $5,000 out-of-pocket maximum. That's money she might otherwise have put in a college fund.
"It shouldn't have to be this much money to bring a child into the world," she said. "It's already hard enough."
Forty percent of Americans don't have the savings to cover even $400 in unexpected expenses, according to a May 2018 report from the Federal Reserve. Try juggling a $1,000 deductible and additional co-insurance costs of a health plan getting a workout for the first time, leave from work, and buying baby gear.
"It creates a perfect storm," said A. Mark Fendrick, director of the Center for Value-Based Insurance Design at the University of Michigan.
Taylor DiMatteo, 26, and her husband found out she was pregnant shortly after returning home from their Hawaiian honeymoon. The trip followed a wedding they'd largely paid for themselves. After learning about the pregnancy, they bought a house right away, a twin tucked up a shady hill in Havertown, to raise their daughter in a nice neighborhood.
DiMatteo didn't incur any prenatal expenses beyond what was covered in full by her health plan, but she and 4-month-old Aliyah still managed to rack up $2,500 in hospital bills when she was born in January.
"Not that I didn't think having a baby was going to be expensive, but you get home from the hospital and you have no idea what you're doing," she said. "You're confused and exhausted and every day, still, you just get seven bills a day. It's almost terrifying."
These unexpected costs can drastically alter the future that parents envisioned.
When McNabb became pregnant again just four months after giving birth, she and her husband, Connor, knew they wouldn't be able to keep up with the medical bills — on top of utilities, rent, student loans, credit card debt, and the cost of clothing and feeding two babies — without help.
So they moved from Pittsburgh to the Philadelphia area, where they live in a rental owned by Connor's parents, who live next door.
The break on rent and utilities, plus next-door child care, are lifesavers now that the McNabbs have added to their monthly bills the payment plan to cover at least $1,000 in medical expenses from their son's birth in January.
"No one should have to uproot their life to pay medical bills — especially when you have insurance," McNabb said. "How does that even happen?"
Planning for this life-giving expense, perhaps by switching to a health plan with more robust coverage, is increasingly difficult.
High deductibles have become near-ubiquitous in employer-sponsored health plans, where the vast majority of workers get health insurance.
Just over half of employees now have a deductible of at least $1,000, up from 32 percent of workers in 2012, according to the Kaiser Family Foundation, as employers cope with rising health-care costs by shifting the burden to workers.
"Fewer and fewer people have a choice," said J. Frank Wharam, an associate professor of population medicine at Harvard Medical School. "Employers are moving toward those high-deductible plans so they can keep the premiums lower and, I suspect, taking away the choice of having a plan that has a lower deductible."
And figuring out how much any given service will cost — important details to people with high-deductible plans — can be nearly impossible, even for people such as Tahir, who has years of experience dealing with insurers through her private practice.
She called her insurer before each blood test, ultrasound, and scan to see whether it would be covered and, if not, how much she would owe. It was almost impossible, she said.
"It's like this cat-and-mouse game," said Julie E. Cristol, clinical director of Lifecycle WomanCare in Philadelphia, of efforts such as Tahir's.
"We have people to a greater extent than I ever remember making decisions about, 'Should I have this test? Should I not have it?'"
Another complication: More plans have "narrow networks" of providers that can be seen at a discounted rate. So consumers need to be careful that everyone they see is in-network.
Dana Mincer, a medical resident at Lower Bucks Hospital who is now pregnant with her second child, doesn't have that option.
All Mincer's doctors will be considered out of network, because her employer's self-funded plan has no in-network obstetrician within an hour's drive of her home in Glenside, Montgomery County. And none of the three Philadelphia-area hospitals in the plan delivers babies.
She found out she was pregnant in November, a month after enrolling in the plan, and tried to switch to a plan that might offer better coverage. Mincer remembered that certain life events, such as marriage, a job change, or the birth of a baby, qualify people to switch their health plan before the year is up, so she asked.
The answer felt like a slap in the face.
"Apparently," Mincer said, "pregnancy is not considered a life-changing event."
$12,772 Pennsylvania average charge (including facility and doctor fees) for vaginal delivery in Pennsylvania in 2017
$17,677 New Jersey average charge for vaginal delivery in 2017
$12,290 National average charge for vaginal delivery in 2017
$18,486 Pennsylvania average charge for C-section in 2017
$24,941 New Jersey average charge for C-section in 2017
$16,907 National average charge for C-section in 2017
$11,450-$16,000 estimated annual cost to raise a 2-year-old in 2015
$233,610 estimated cost to raise a child through age 17 in a two-child, married-couple, middle-income household in 2015
Source: FAIR Health, United States Department of Agriculture Center for Nutrition Policy and Promotion