Differences in out-of-pocket spending for maternity care by race and ethnicity
Faculty Associate Rebecca Gourevitch and colleages assert that stark differences in maternal health outcomes by race and ethnicity exist in the US, including severe maternal morbidity, stillbirth, and preterm birth. Black and Hispanic birthing individuals have lower rates of adequate prenatal care and are more likely than White individuals to deliver their babies at lower-quality hospitals. Half of childbirths in the US are covered by commercial insurance plans. While the Affordable Care Act made prenatal visits and some preventive services exempt from cost sharing, several important prenatal services (blood tests, ultrasonography, fetal surveillance) and delivery hospitalizations are not exempt. From 2018-2020, birthing individuals paid an average of $3070 out-of-pocket during the prenatal and delivery periods. Despite evidence of high and increasing out-of-pocket costs, little is known about whether such costs for maternity care vary by race and ethnicity. In this study, Gourevitch and colleagues describe the differences in out-of-pocket spending during maternity episodes by birthing peoples’ race and ethnicity.
Administrative data from Blue Cross Blue Shield of Massachusetts from 2018 to 2022 was used for analysis. The analysis was conducted at the maternity episode level. For estimation on whether racial and ethnic differences in out-of-pocket spending during the maternity episode persist after controlling for covariates that impact health care utilization, regression analyses using multiple imputation were conducted. Linear regression models were used due to estimated coefficients being interpreted as differences in mean spending, which the authors believed to be the policy-relevant parameter.
Gourevitch and colleagues ultimately found that those who were Asian, Black, or Hispanic had higher out-of-pocket spending overall and as a proportion of median household income in their census block than White birthing people. Differences in benefit design were associated with spending differences. Such out-of-pocket expenditure differences are another way in which individuals of different races and ethnicities experience maternity care differently in the US. The authors conclude by stating that “changes to benefit design could reduce out-of-pocket spending and differences across racial and ethnic groups.”
Gourevitch RACohen JLShakley T, et al. (2025). "Racial and Ethnic Differences in Out-of-Pocket Spending for Maternity Care". JAMA Health Forum. 6(2):e245565. doi:10.1001/jamahealthforum.2024.5565.
