Out-of-Pocket Healthcare Spending Higher for Pregnant People

Pregnant people were more likely to experience high out-of-pocket healthcare spending, but Medicaid and public health insurance coverage helped minimize costs compared to private insurance, a study published in Obstetrics & Gynecology found.

Although the Affordable Care Act (ACA) cemented provisions prohibiting coverage denials based on pregnancy and introduced coverage eligibility expansions, pregnant people still face significant out-of-pocket expenditures during their delivery year.

To understand how insurance coverage, employment, and pregnancy status impact catastrophic out-of-pocket healthcare spending, researchers from Mount Sinai gathered data from the Medical Expenditure Panel Survey between 2008 and 2016. Out-of-pocket expenditure is considered catastrophic when it exceeds 10 percent of a family’s income in a given year.

The researchers identified just over 4,000 birth parents and nearly 8,000 women of reproductive age who were not pregnant to use as a control cohort.

Out-of-pocket delivery costs varied depending on the birth parent’s coverage. For example, parents with private coverage spent between $699 and $863, and uninsured parents spent between $540 and $1,013. Meanwhile, parents who had Medicaid coverage spent between $25 and $106 out-of-pocket.

Birth parents had higher enrollment in Medicaid compared to their non-pregnant counterparts.

While birth parents were less likely to be uninsured than the control cohort during their delivery month, 27.6 percent reported uninsurance in at least one month of their delivery year. Pregnant people were also more likely to change insurance, with the change typically being a loss of insurance.

This churn particularly impacted pregnant people enrolled in Medicaid. They were more likely to gain and lose Medicaid coverage than the control cohort. However, birth parents were less likely to gain or lose private insurance coverage.

For the 524 newborns that experienced extended hospitalization, the average total cost for each extended stay was $19,500. However, patients typically only paid 2.4 percent of the total cost, or $470, out-of-pocket. Parents with newborn extended stays were more likely to have catastrophic healthcare spending by expenses alone compared to other parents, the study found.

Birth parents faced higher risks of catastrophic healthcare spending than the control cohort. Almost 10 percent of birth parents had family healthcare expenses, not including premiums, that exceeded ten percent of their family income compared to 6.8 percent of the control group. After including out-of-pocket spending on premiums, the birth parent percentage increased to 21.3 percent.

Nearly 25 percent of parents making 250 percent or less of the federal poverty level incurred expenses exceeding five percent of their income.

Certain factors put birth parents at a higher risk of experiencing catastrophic spending. People in families making less than 138 percent of the federal poverty level were more likely to be at risk for high healthcare spending.

Additionally, low-income birth parents who were unemployed had an increased risk of catastrophic spending. Birth parents were more likely to experience unemployment for at least part of their delivery year or the whole year than the control cohort.

Researchers found that for low-income birth parents, receiving coverage from public insurance was associated with a lower risk of catastrophic health spending compared to those on private insurance.

Low-income parents with Medicaid and public insurance had an 18.8 percent risk of catastrophic expenditure, including premiums, during the delivery year. In contrast, the risk for low-income parents with private insurance was 67.9 percent.

The study results may help convince policymakers to consider public health reforms, such as Medicaid expansion.

“Given the association between pregnancy, delivery and catastrophic health expenditure—as well as the protective effects of public insurance—it is imperative that we create policies that not only ensure insurance coverage for pregnant people, but also make it affordable,” Jessica Peterson, MD, corresponding study author, said in a press release.

“Possible avenues to improve access to affordable health insurance include Medicaid expansion, as well as regulation of insurance cost-sharing and benefit designs.”