After reading a New York Times article about maternity care costs in the United States, I had to take a minute to untangle my brain. 

The article focuses on a couple, Renee Martin and Mark Willett, who are expecting. This joyous occasion is marked with special stress for this couple because their health plans lack maternity coverage.

Though Ms. Martin, 31, and her husband, Mark Willett, are both professionals with health insurance, her current policy does not cover maternity care. So the couple had to approach the nine months that led to the birth of their daughter in May like an extended shopping trip though the American health care bazaar, sorting through an array of maternity services that most often have no clear price and — with no insurer to haggle on their behalf — trying to negotiate discounts from hospitals and doctors.

Ok, my gut reaction (was it yours too?) is "Why doesn't this couple have maternity coverage?"  According to the article in 2011, 62 percent of women in the individual market (like Ms. Martin) didn't have maternity coverage.  When I bought my own health coverage in the individual market, I specifically opted out of maternity coverage too.  The following was a real life conversation with my dad:

"You know if you get pregnant, and you don't have maternity coverage, it could cost you thousands and thousands of dollars just to give birth in a hospital, right?

"Yes Dad. If I get pregnant, that money is the least of my worries."

See, I'm 25 and unmarried. I'm not planning on getting pregnant anytime soon. I saved money on a lower monthly premium, and I imagine that's a similar choice other women make when they are buying insurance in the individual market. But recently I got a letter in the mail from my insurer, explaining that all policies will have to cover maternity care in 2014.  My policy was changed without any say from me, and that will be the case for all plans come Jan. 1 (including Ms. Martin's plan).

But let's look at this the right way. Maternity care shouldn't be required coverage.  It is not the fact that Ms. Martin lacked insurance for this service that makes it so expensive. It's the fact that the vast majority of other mothers do use insurance to pay for their maternity expenses. Having a third-party paying the bills allows hospitals and doctors to 1) charge different prices to different consumers, depending on their coverage and 2) mostly keep consumers in the dark about prices.

It's too bad the Surgery Center of Oklahoma (an non-insurance gig) doesn't do childbirth, otherwise they'd just give you a straightforward price on their dropdown menu of services.  I couldn't find C-sections on the list, but they'll take out ovaries for $5,865.00. There are some clinics out there that have said, "To heck with insurance, we're going to shoot straight with you about prices."  But this will become harder as ObamaCare kicks in, requiring everyone to have insurance and pretty comprehensive "insurance" at that. (I put the word in quotes because at some point these health plans stop being about risk diversification and start being about socializing costs).

A Johns Hopkins expert in Public Health is featured in the NYT article, trying to help us make sense of why American health costs are so high, puts it this way:

“It’s not primarily that we get a different bundle of services when we have a baby,” said Gerard Anderson, an economist at the Johns Hopkins School of Public Health who studies international health costs. “It’s that we pay individually for each service and pay more for the services we receive."

We may pay for each individual service, but we do not pay as individuals. We pay as groups – insurance pools – and therein lies the problem. We always pay more when we pay together.

Most American women may not get a different bundle of services in the United States than in other countries, because most births are straightforward and healthy.  But I'd like to hear Mr. Anderson's take on infant viability in the United States. We have more NICU units per capita than any other country, and we work hard to save every life, even babies born at low weight or to high-risk mothers (see American obesity, teen pregnancy, or drug abuse).  That's expensive.  And we all pay for it together.  Also, we Americans get litigation-happy, sue like crazy, and this too raises health care costs.

The Times sums things up this way:

"From 2004 to 2010, the prices that insurers paid for childbirth — one of the most universal medical encounters — rose 49 percent for vaginal births and 41 percent for Caesarean sections in the United States, with average out-of-pocket costs rising fourfold, according to a recent report by Truven that was commissioned by three health care groups. The average total price charged for pregnancy and newborn care was about $30,000 for a vaginal delivery and $50,000 for a C-section, with commercial insurers paying out an average of $18,329 and $27,866, the report found.

"Women with insurance pay out of pocket an average of $3,400, according to a survey by Childbirth Connection, one of the groups behind the maternity costs report."

Let me tell you, price inflation to the tune of 49 percent is not the mark of a free market. Even before ObamaCare, government controlled about 1 out of every 2 health care dollars in the United States.  

So how should we solve the costs problem? With less insurance coverage, not more.  I'd like to have coverage for catastrophic pregnancy complications, because I know there's always a risk of something going wrong.  And quite frankly, there's nowhere I'd rather be with a sick or low-weight newborn than these United States.

But I shouldn't need my insurer to pay for every ultrasound.  People are right to use the analogy: You don't pay for an oil change with your auto insurance.  If we did, oil changes would be much more expensive.

Any American woman who wants to give birth overseas, happy traveling. Remember, all's well in socialized medicine, until somebody gets sick.