Racial and Ethnic Differences in Out-of-Pocket Spending for Maternity Care

Rising out-of-pocket costs of maternal health care for people with commercial insurance may affect use of health care and outcomes. There are stark racial and ethnic disparities in outcomes, but little is known about differences in spending.

To measure differences in out-of-pocket spending for maternity care by race and ethnicity.

This retrospective cross-sectional study used administrative data from Blue Cross Blue Shield of Massachusetts from January 1, 2018, through December 31, 2022, for pregnancies, deliveries, and 42-day postpartum care. Participants were continuously enrolled during pregnancy, delivery, and 42 days post partum (collectively termed maternity episode).

The primary characteristic of interest was the birthing person's race and ethnicity.

The primary outcome was total out-of-pocket spending during the maternity episode. Out-of-pocket spending was measured separately for the pregnancy period, prenatal services, and delivery, by type of cost sharing, and as a percentage of the median household income in the patient's census tract (using American Community Survey data). Race and ethnicity were measured via self-report and imputation.

The analytic sample included 87 253 maternity episodes among 76 826 unique birthing persons (mean [SD] age, 32.4 [4.7] years; 99.8% female) between 2018 and 2022; among maternity episodes, 8572 birthing persons (9.8%) were Asian, 3331 (3.8%) were Black, 6872 (7.9%) were Hispanic, and 68 478 (78.5%) were White. Mean out-of-pocket spending for the maternity episode was highest among Black birthing people ($2398 [$426]), followed by Hispanic ($2300 [$572]), Asian ($2202 [$603]), and White ($2036 [$1547]) birthing people (P < .001). These differences remained statistically significant after adjusting for health and demographic characteristics. The differences were largest in the prenatal period and for coinsurance payments. Black (1003 [30.1%]) and Hispanic (2302 [33.5%]) birthing people were more likely than Asian (1569 [18.3%]) and White (12 600 [18.4%]) birthing people to be enrolled in plans with high coinsurance, but not plans with high deductibles (3317 [38.7%] for Asian, 1232 [37.0%] for Black, 2350 [34.2%] for Hispanic, and 24 515 [35.8%] for White birthing people).

In this study, differences in out-of-pocket maternity spending among the commercially insured were associated with differences in coinsurance rates. These costs could lead people to forgo needed health care or other basic needs that support health (eg, food or housing). Changes to health plan benefit design could improve equity in out-of-pocket maternity spending and its consequences.