They're middle-class and insured. Childbirth still left them with crippling debt.

Jessica Hurley eyed the stack of medical bills in her purse as she held one of her twin babies, blue from lack of oxygen, in the neonatal intensive care unit. 

She prayed that the boys, Perry and Kinser — born prematurely at 32 weeks — would survive. 

About a month had passed since a traumatic delivery in which she’d given birth to Kinser naturally, then Perry via cesarean section. She and her husband, Jimmy, had two other children, ages 2 and 13, to care for. On top of that was another source of dread: How would they afford the mounting costs of the birth? And why were the bills already so high when they had insurance?

“I was getting bills from the lab, I was getting bills from the hospital, I was getting bills from the medical group, I was getting bills from radiology,” Jessica said. “It was a full-time job trying to figure it out, and I’m trying to keep my babies alive.”

The Hurleys’ income was too high to qualify for Medicaid in Illinois, where they live. But their insurance plan — provided through Jimmy’s union — has an out-of-pocket maximum of $28,500 for in-network services. 

That put them in a vulnerable category of middle-class families: those who earn too much for Medicaid but can’t afford or access insurance plans that sufficiently cover costly births.

That group has been left behind by the major health care reforms of the last few years. Expansions to Medicaid for new parents that many states have enacted since 2022 don’t apply to them. The No Surprises Act, which took effect the same year, hasn’t entirely prevented surprise bills. And the Affordable Care Act still allows for high out-of-pocket costs.

In interviews, more than 20 experts on medical debt, insurance and health care policy pointed to systemic failures in the private insurance system that cause families like the Hurleys to acquire giant bills after childbirth. High deductibles — the amount people have to pay before their insurance starts to cover a share of their medical costs — are a primary issue. More than half of private-sector workers with insurance through their jobs had high deductibles last year (at least $3,200 for a family, under the IRS definition), compared with just over a third in 2014, according to the Bureau of Labor Statistics. 

The risk of accumulating medical debt during childbirth is therefore high for such families, especially if complications arise. By nature, pregnancy is both common and risky. Pregnant patients generally see multiple providers over nine months, during which time deductibles often reset. Delivery and postnatal care come with charges for parent and baby. And in the first weeks of a newborn’s life, parents have little time or energy to pore over insurance statements or dispute charges.

“The people who really get hit with the highest out-of-pocket costs relative to their incomes are low- and middle-income people in private insurance,” said Dr. Nora Becker, a health economist at the University of Michigan.

Kinser Hurley was discharged from the NICU at 40 days old in January 2023, followed by Perry at 68 days the next month. But that was just the beginning of the Hurleys’ fight to lower their medical bills — a challenge that continues to plague them nearly two years later.

The amount Jessica owed various providers for her pregnancy and delivery and the twins’ NICU stay totaled nearly $38,000 — close to a quarter of her family’s income.

“I just felt like this isn’t fair. I’m going to have to file bankruptcy. They were trying to tell me I had to pay all this in a year, which there’s no way,” she said.

The Hurleys are one of several families who spoke to NBC News about the medical debt they faced after childbirth, even though they had private insurance. The families shared more than 180 documents that detailed a maze of bills and claims. They all found it nearly impossible to be certain of what they owed and why.

Debt has threatened their ability to stay afloat, putting strain on their marriages, making it difficult to afford clothing and toys and encouraging them to avoid medical visits.

“It prevents me from going to the doctor because I’m afraid of what bills I might get,” Jessica said. “I go if I absolutely need to.”

When the ACA doesn’t protect you

Jessica works as a dental hygienist and Jimmy as a superintendent for an asphalt company. Their house in Springfield, Illinois, is adorned with family portraits and messages like “Today I Will Be Thankful and Make Memories.”

On a recent afternoon when the kids were still at school and day care, Jessica crossed her legs on the couch and cried.

“I feel guilty for having the twins, and then I feel guilty for feeling guilty because I love them,” she said. “You’re like, ‘What if it just didn’t all happen, these horrible things?’ But then I’m like, ‘I have these beautiful boys, and they’ve made my 4-year-old so happy.’ But yeah, I can see why people wouldn’t want to have children.” 

The Hurleys’ bills were eventually reprocessed and they were granted some financial assistance from the hospital. But they were still left responsible for nearly $11,500, of which they have paid around $3,300. 

The family’s high medical bills stemmed, in part, from the nature of their insurance plan, which had a low deductible of $375 but an unusually high out-of-pocket maximum — the total amount a family has to pay in a year before its plan covers medical costs at 100%. After a deductible is met, an insurance company usually pays a part of subsequent medical claims (known as coinsurance) until that maximum is reached.  

The Affordable Care Act mandates that insurers cover maternity care and caps the in-network out-of-pocket maximum for a family at $18,900. But that limit doesn’t apply to plans that are short-term or considered “grandfathered” because they existed before the bill was passed. 

The Hurleys’ plan fell into that last category.

The ACA also doesn’t prevent insurance companies from denying coverage for services they deem unnecessary, though patients can appeal. Jessica’s insurance provider, Central Laborers’ Welfare Fund, denied coverage for a costly service that helped the twins transition from feeding tubes to bottles in the NICU. The fund said it doesn’t respond to media inquiries as a matter of policy. 

On top of that, Kinser and Perry were born at the end of 2022, so the family’s annual coverage began anew while the twins were receiving care. According to a June study, patients whose pregnancies, deliveries or hospital stays span two years pay $1,310 more, on average, than they would have had all costs been within the same year.

Hospital Sisters Health System, which operates the hospital where Jessica gave birth, said it doesn’t comment on specific patients but is “committed to transparency and accuracy in our billing practices.”

SIU Medicine, a medical provider that partners with the hospital, reduced Jessica’s bills by around $3,700 after NBC News reached out. SIU said the discount was awarded to match the rate of financial assistance Jessica got from the hospital. 

“Patients may qualify for financial assistance, whether or not they’re insured, and eligibility is based on household income and family size,” Lauren Crocks, SUI Medicine’s communications director, said in an email.

To defray their medical expenses, the cost of day care and Jessica’s reduced income from being out of work at the end of pregnancy, the Hurleys started making minimum payments on their credit cards, which has led them to incur around $18,000 in credit card debt since the twins were born.

Better off on Medicaid

People with insurance through their employers pay around $3,600 out of pocket, on average, for prenatal, delivery and postpartum services, according to data provided to NBC News by the Health Care Cost Institute. But for around a quarter of the births analyzed, costs exceed $5,000.

Those on Medicaid, by contrast, generally have no out-of-pocket costs, since the program prohibits cost-sharing, including deductibles, for pregnancy-related services through 60 days postpartum.

Pregnant people nationwide qualify for Medicaid if their incomes are at or below 138% of the poverty level — up to $36,000 annually for a family of three. But 34 states and Washington, D.C., have set the threshold for coverage through Medicaid or the Children’s Health Insurance Program at or above 200%, according to KFF, a nonprofit health think tank. And all but two states have adopted Medicaid coverage lasting for a year after birth.

Becky Munge, a mother of three in Morton, Illinois, was on Medicaid when she gave birth to her first two children and doesn’t recall paying a single bill for the health care she received then. 

But that wasn’t the case when she had her daughter Jovie in 2021. Following a life-threatening delivery, Becky went into cardiac arrest and suffered internal bleeding after the removal of her placenta, which had been lodged to her uterine wall. She was intubated and underwent several operations. As her organs began to fail, doctors asked her husband, Cole, and older children, Gavin and Ava, to say their goodbyes. 

Jovie was in the NICU, but doctors allowed her to see her mother.  

“They wanted her to at least be able to do skin-to-skin if I were to pass away,” Becky said.

Becky recovered, and she and Jovie were discharged within a day of each other. But while she was in the hospital, Becky contracted a bone infection that would ultimately require nine arm operations.

The Munges pay $1,300-per-month premiums for an insurance plan with a $3,000 in-network deductible and a $12,500 out-of-pocket maximum.

For the complicated delivery and Jovie’s NICU stay, they wound up paying $8,000, after insurance covered around $1 million in medical expenses. 

They still owe nearly $4,000 for treatment for Becky’s bone infection at the Mayo Clinic in Rochester, Minnesota, having paid around $1,000 so far.

The Mayo Clinic said it doesn’t have authority over insurance coverage decisions. In a statement, Blue Cross and Blue Shield of Illinois, the couple’s insurance provider, said, “we work directly with members and don’t comment publicly about their cases.”

In prioritizing their medical expenses over other costs, the Munges have amassed around $55,000 in credit card debt and drained their retirement accounts.

“If we cannot control the debt, as of right now, we’re going to have to file bankruptcy,” Becky said. “That’s a huge threat over our shoulders.”

Like the Hurleys, the Munges are solidly middle-class. Cole is a self-employed insurance agent. Before her health issues prevented her from working, Becky was an orthodontic assistant. The family lives in a three-bedroom, ranch-style home. 

“We’re not in poverty, but we’re not rich by any means, and we’re still struggling,” Becky said. “I wish I’d make less money so that I can get more benefits, because I’m actually more in debt now.”

The challenge of a high deductible

Of all the reasons a family can face medical debt from childbirth, high deductibles are among the most common.

“Many workers used to have zero-deductible health care plans, but that’s less true today. The majority of employer-provided private health insurance plans do have a general deductible,” said Dr. Adam Gaffney, a critical care physician at the Cambridge Health Alliance in Massachusetts who researches medical debt. In the early 1980s, his research shows, just 30% of private insurance plans had deductibles for hospital stays.

Wesley Bruce and Ashley Perez’s insurance plan had a $7,000 deductible and a $13,000 out-of-pocket limit when she got pregnant. They knew childbirth would be expensive, so they set aside money in a health savings account.

But they couldn’t anticipate how complicated their medical needs would be. Their twin girls, Isla and Juno, were born prematurely in June, each with a hole in her heart, and spent roughly a month in the NICU. The couple's insurance didn’t cover some specialty care during Perez's pregnancy, and they wound up on the hook for more than $10,000 in total. 

Bruce, a mental health counselor, and Perez, a Ph.D. candidate in clinical psychology, are still paying off student loans. 

“I just kind of said: ‘What can we do? We don’t have a choice,’” Perez said. “I’m never going to pay off all of our debt, so add on the hospital debt to it. I don’t even know, just pile it on.”

The couple drained their health savings account and solicited donations from family members to pay their medical expenses. 

But then in September, a stroke of luck: Perez qualified for financial aid from the hospital system, Sanford Health, and their balance dropped to zero. NBC News reached out to Sanford Health this month, and the couple was subsequently refunded around $7,000 that they'd already paid.

“We are committed to ensuring patients receive high-quality care regardless of their ability to pay and providing financial assistance to those who need it most,” Nick Olson, Sanford Health’s chief financial officer, said in a statement. 

Nonprofit hospitals like the ones operated by Sanford Health are required by law to provide “charity care” in the form of discounted or waived costs. Eligibility varies by hospital, but many mandate that patients have incomes at or below 400% of the poverty level. Since some of those patients are on Medicaid, it’s unclear how many people benefit from the policies.

Becker referred to the system as the “Wild West.”

Instituting a federal requirement for hospitals to provide a minimum threshold of financial assistance could make childbirth more affordable, she said. Another policy on her wish list: requiring employers to offer insurance plans with varying coverage based on people’s incomes. 

“Fundamentally, we could fix this problem if we as a society decided that this was a problem that we wanted to fix,” she said. 

But other changes, like getting rid of deductibles altogether or even instituting universal health care, feel impractical, if not impossible. And any changes would come too late for families already overwhelmed with debt.

Jessica Hurley’s medical debt is something she had tried all her life to avoid — her own mother struggled to pay off medical bills after Jessica’s father died in a car accident. Despite her best efforts, she said, “I found myself in a similar situation.” 

She’s terrified that another medical emergency will land one of her family members in the hospital. Already, she said, her debt has led her to delay addressing health issues that aren’t emergencies. 

Jessica has been canceling her own physical therapy appointments for hip pain from her delivery. Last week, she waited several days to take Kinser to urgent care after he developed a rash on his face and coldlike symptoms. Meanwhile, the doctor’s office keeps calling to schedule a follow-up appointment for eczema on Perry’s feet, but Jessica is trying to manage it herself by applying a cream and keeping his socks on. 

“Every doctor appointment — I worry every single one — what’s going to be covered? What’s going to be adjusted?” she said. “Am I going to get another bill?” 

This article was produced in collaboration with the USC Annenberg Center for Health Journalism’s 2024 National Fellowship Fund for Reporting on Child Well-being.

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