Coinsurance, not deductibles, drives racial gaps in maternity costs

Listen to this article

Black and Hispanic patients with private insurance pay more out of pocket for maternity care than white patients, according to a February 2025 study in JAMA Health Forum.

Although the analysis focused on Massachusetts, researchers say the disparities reflect a national trend — one that Maryland regulators are beginning to confront as they examine how insurance design, particularly coinsurance, affects what families pay to give birth.

Lead researcher Rebecca Gourevitch, Ph.D., an assistant health policy and management professor at the University of Maryland School of Public Health, said the study fills a gap in understanding who bears the hidden costs of childbirth.

“There’s been clear evidence for a while that the out-of-pocket costs people face for childbirth are rising and really high,” Gourevitch said. “What we haven’t known is who is most affected, who bears the burden.”

RELATED: vNOTES provides women with a scarless option for fibroid surgery

Her analysis found that Black patients paid about 18% more and Hispanic patients 13% more than white patients for maternity care, even with similar insurance coverage. Gourevitch said those differences appear to stem less from health factors and more from plan design.

“It’s actually the types of health insurance plans that seem to be really different across these racial and ethnic groups,” she said. “Black and Hispanic people are more likely to be in plans with really high coinsurance, and we think that may be one of the things really driving these differences in spending.”

Mark Friedberg, senior vice president for performance measurement and improvement at Blue Cross Blue Shield of Massachusetts — which provided the data used in the study — said the insurer’s records helped reveal how cost-sharing structures quietly reinforce inequities.

He explained that coinsurance — the percentage patients pay even after meeting their deductible — can vary widely depending on the insurance plan and a hospital’s negotiated prices.

“Even within the same insurance plan, costs can vary dramatically depending on where someone gives birth,” he said. “If one hospital charges $1,000 and another charges $3,000 for the same service, the percentage a patient pays doesn’t change, but the bill does.”

Blue Cross Blue Shield of Massachusetts has begun testing new plan designs to reduce those out-of-pocket costs, including options that eliminate patient payments for childbirth. Friedberg said the insurer also supports legislation that would standardize costs statewide.

“A change in the law will, of course, really force everybody’s hands,” he said, “but even under current law, employers can choose plans that eliminate out-of-pocket costs for childbirth.”

RELATED: UMMS launches first-of-its-kind remote fetal monitoring center on East Coast

He said the company will evaluate whether the new plans will gain traction and whether policy changes can accelerate adoption.

Friedberg noted that while insurers can design lower-cost maternity products, employers ultimately decide which health plans to offer their workers.

“They have a lot on their plates,” he said. “It’s one among many considerations — but employers who choose plans with less cost-sharing can make a real difference for families.”

That choice, he added, often determines whether employees face steep coinsurance bills or have full coverage for childbirth.

In Maryland, state regulators and lawmakers have started examining how benefit design — particularly coinsurance — shapes the financial burden of childbirth.

A 2023 Maryland Health Care Commission analysis found that eliminating cost-sharing for labor and delivery services could save families with private insurance roughly $1.50 per member per month, while raising premiums by less than 25 cents. The report concluded that removing cost-sharing for maternity care “would have a minimal effect on premiums but a meaningful effect on affordability for patients.”

Following that analysis, legislators proposed several measures to address maternal health costs. Senate Bill 535 (2024) would have required insurers to cover labor and delivery without deductibles, copays, or coinsurance, but the bill did not advance. In 2025, Senate Bill 411 was enacted to expand coverage for postpartum depression screening beginning in 2026, and Senate Bill 965 directed the Maryland Department of Health to publish annual reports on delivery and postpartum spending.

While none of the measures eliminate coinsurance for childbirth, they represent the state’s ongoing consideration of how insurance design influences maternal care affordability.

At the national level, the Supporting Healthy Moms and Babies Act, introduced in Congress earlier this year, would prohibit cost-sharing for prenatal, delivery, and postpartum care in private insurance plans. Maryland advocates, including researchers at the University of Maryland School of Public Health, have testified in support of the proposal.

Gourevitch said her team continues to study how financial differences shape care after childbirth.

“The concern,” Gourevitch said, “is that high medical expenses influence the way people make decisions about future healthcare utilization.”