Before Joanna Joshua and Kyle Winning started a family, they hunted for health insurance to cover the increasingly high cost of having a baby.
The Valencia couple checked out nearly a dozen policies but came up empty, finally settling on a Blue Shield of California plan with a $5,000 deductible.
Money was tight, with her finishing her education and him starting his own appraisal business. So when their son Dylan arrived prematurely in 2007, the couple had to scramble. They took a cash advance on a credit card to cover the deductible and $5,000 more for their share of an emergency cesarean section.
"It was very tough on us financially," said Joshua, 32. "There need to be more choices."
Tens of thousands of California women find themselves in similar straits, struggling to find — and afford — maternity coverage. While many young adults are covered by employer-based insurance, motherhood can be a huge financial blow to those who are self-employed or work at businesses with no coverage for workers.
In California, health insurers are not required to provide maternity benefits to those who buy their own insurance, leaving women with limited options in a state where the average cost of delivering a baby has reached nearly $13,000.
The dearth of choices forces many would-be mothers into government insurance programs paid for by taxpayers, or to skip prenatal care that can prevent expensive medical complications for themselves and their infants.
All of this drives up costs for hospitals, insurers and consumers buying individual policies, who pay about 20% extra on average for plans that cover maternity services.
"For women who don't have access to insurance through their job or don't qualify for public programs, this is a crisis," said Brigette Courtot, senior policy analyst with the National Women's Law Center.
Women with insurance don't have it much better. Out of 295,000 California women of childbearing age who buy their own policies, 81% do not have maternity benefits. The primary reason? They can't afford the extra expense, health experts say.
"Most people don't realize that if you have insurance, you may not be covered for something as basic as being pregnant," said Susan Philip, director of the California Health Benefits Review Program, an independent research organization that analyzes the effect of health insurance mandates.
Pregnancy presents its own set of problems. Women who apply for policies in the individual marketplace after they become pregnant are often turned down by insurers, who regard pregnancy as a preexisting condition that can make applicants ineligible for coverage.
Sonia Gambaro of Los Angeles searched in vain for a policy two years ago after she and her husband learned to their surprise that she was pregnant.
The 30-year-old Gambaro, an uninsured college student at the time, wound up applying for coverage through Medi-Cal, the state's insurance program for the poor. It picked up Gambaro's maternity costs of more than $7,000, but not before she and her husband, a native Italian, considered returning to his homeland.
"I was freaking out," Gambaro recalled of that period. "I felt worried for my baby more than anything."
California lawmakers have introduced a succession of bills in recent years to expand the availability of maternity coverage by requiring it in policies.
Those efforts have met resistance from insurance industry leaders.
Anthem Blue Cross, the state's largest for-profit insurer, has argued that maternity benefits are already available to women, and that it's unfair to expect all consumers to pay for coverage they may not want or need.
The industry's trade group, the Assn. of California Life and Health Insurance Cos., pointed to a study that found the most recent maternity bill in Sacramento would drive up insurance rates as much as 28%, and would prompt more than 9,000 mostly young policyholders to give up their insurance.
"You have to weigh the benefit of mandating it on everybody against the fact that it might cause people to drop their coverage," association Vice President Anne Eowan said.
Eowan questioned whether it makes sense to compel maternity benefits for everyone before the nation's new healthcare law takes effect in 2014. That's when insurers must include maternity services in all policies sold to individuals and small businesses, and when low-income consumers will receive government subsidies to buy insurance.
Some in the industry favor more immediate action.
Blue Shield of California and Kaiser Permanente have both supported the Legislature's efforts, saying maternity care in all policies reduces the much-higher costs for individuals who need it. Blue Shield noted that just 19% of its individual and family policies now come with maternity benefits and that these plans cost 30% to 40% more than the same coverage without the services.