High-Deductible Health Plans Spur Maternity Out-of-Pocket Spending

The rise in high-deductible health plans due to the ACA’s lack of cost-sharing restrictions in some areas may be leading to high maternity out-of-pocket spending, researchers have discovered.

The Health Affairs study looked at the fully adjudicated and paid claims of nearly 660,000 women, covering over 804,000 deliveries.

“Our findings suggest that women with employer-based insurance continue to have substantial out-of-pocket spending for maternity care after implementation of the ACA,” the researchers state. “Trends may worsen with the potential reemergence of short-term plans, which are not subject to the ACA’s essential health benefits provisions.”

Looking at data from the Clinformatics Data Mart Database between 2008 to 2015, researchers found that out-of-pocket healthcare spending in employer sponsored maternity care was high. Between 90 and 100 percent of women with employer sponsored maternity care reported some kind of out-of-pocket healthcare spending for maternity care throughout this study. Over time, that number rose by 4.5 percent.

The overall mean out-of-pocket healthcare spending also rose from $3,069 in 2008 to $4,569 in 2015. But it wasn’t the cost of care that drove this increase, the researchers found.

It might come as a surprising twist that the cost of maternity care was stable. It hovered between $29,100 and $29,700 from 2008 to 2015.

Instead, women were taking on a greater share of the cost, leading to higher out-of-pocket spending.

In 2008, for instance, women were responsible for approximately 13.6 percent of the cost of a vaginal birth. By 2015, however, they would face a bill that was 21.7 percent of the maternity care cost.

Mothers who had cesarean births in 2015 were taking care of 4.6 percent more of the overall cost (14.6 percent) than mothers in 2008 (10 percent).

The key factor that boosted maternity out-of-pocket healthcare spending was high deductibles.

Vaginal births cost less than cesarean births. However, both procedures saw a huge leap in out-of-pocket costs from 2008 to 2015, brought on by high deductibles.

For vaginal birth, the mean out-of-pocket healthcare spending was $4,314 by 2015, rising over $1,400 in 7 years. For cesarean, the mean rose nearly $1,800 from $3,364 to $5,161.

These costs were driven by rising deductibles. For vaginal births, the mean deductible increased by 62.3 percent to $2,625 in 2015. For cesarean, the mean deductible spiked from $1,532 to $2,640, or 72.3 percent.

Consistently from 2008 through 2015, a woman who had an HRA or HSA saw higher and more rapidly escalating costs, especially if she also had deductibles to pay. An increasing number of women chose to use an HRA or HSA over the course of the study.

Meanwhile, for those who did not have an HRA or HSA, deductible payments were rising faster than any other type of payment. However, mean coinsurance payments produced the highest spending for women without an HRA or HSA.

According to the researchers, the ACA is at the heart of this issue. It is both the cause of high maternity out-of-pocket healthcare spending and the defense against even higher costs.

The ACA allows for cost-sharing for certain maternity services including preventive services. This lenience could be enabling high deductibles and high out-of-pocket healthcare spending.

But the ACA also has restrictions for cost sharing, something the researchers say has addressed price disparities between high- and low-income women.

The study found that women who were 400 percent of the federal poverty line or below tended to have higher cost-sharing.In 2014, the spending trend took a turn. Climbing mean cost-sharing for women with lower incomes slowed. 

However, the mean cost-sharing continued to increase for women with higher incomes. By 2015, there was no real difference in cost-sharing expectations between the two demographics.

While the ACA may have decreased the demographic distinction, the cost for both camps is still extreme and escalating.

Payers have a strong incentive for lowering these out-of-pocket healthcare spending costs for their consumers.

These high costs put mothers and infants at risk, according to the researchers.

“Financial burdens place women at risk for delaying or deferring maternity care. Indeed, prior work suggests that burdensome cost sharing is associated with delayed breast cancer care. Late or insufficient prenatal care increases the risk of maternity complications, including prematurity and stillbirth,” the researchers explain.

And when women delay this care, they run the risk of incurring even higher bills for themselves and their payers.

The researchers recommend that policymakers limit cost-sharing for maternity care. 

Since this study ended, however, some things have changed.

Short-term healthcare plans are on the rise. The researchers found short-term healthcare plans particularly concerning because many do not cover any maternity care.

More positively, in more recent years under employer sponsored coverage, maternity benefits increased by 15 percent, according to an Optum study. 

And some payers are starting to take notice and use value-based care to reduce maternity care costs. In 2018, Humana established a bundled payment program for maternity care. The program covers prenatal, labor and delivery, and post-delivery care for pregnancies that are low to moderate risk.