The staggering financial burden of giving birth — even with insurance

The burden of high health care costs and medical debt in the U.S. is no secret. Medical debt affects one in five adults in the U.S., with an average burden of more than $20,000 for each medical debtor. As primary care physicians, we frequently witness the effects of these financial burdens, particularly for our older or sicker patients with expensive medical conditions.

However, new research we published recently in the Journal of General Internal Medicine shows that medical debt is also common in one younger and healthier population: women who have just had a baby.

In a sample of more than 12,000 women, we found that having a baby in the past year is associated with a 31% increased risk of having medical debt, and one in five postpartum women carries medical debt. This finding, surprisingly, even holds true for women with private health insurance, the type covering most insured working-age Americans. The findings remain the same when we adjusted for women’s age, income, and other factors. Among new mothers without insurance or with chronic medical conditions such as asthma or gestational diabetes, rates of medical debt were more than doubled.

Accumulating medical debt during the most formative years of a newborn’s life can have harmful consequences. Research has already shown that medical financial hardship in families is associated with poor health outcomes and a decrease in health care use for the children. In addition to the typical stress and worry that comes with a newborn child, saddling families with medical debt deters necessary medical care at a critical developmental time, and forces some to forgo necessities such as food, safe housing, and enriching activities.

Why are new mothers going into medical debt? Some women lack any health coverage and are unable to cover the average childbirth-associated costs of nearly $19,000. However, even for many with insurance, the cost of prenatal, hospital childbirth, and follow-up care are simply unaffordable. Many privately insured families are burdened by high copays, insurance deductibles, uncovered services, or costs for out-of-network care. In fact, privately insured families pay on average about $3,000 for maternal and newborn hospitalizations. Complicating matters is that up to 20% of young people who have health insurance at any particular moment are at risk of losing it as their eligibility for various plans change.

All of us want America to be a place that values women and families. In order to live up to those aspirations, policymakers will need to ensure that health insurance plans cover all medically necessary care related to childbirth.

Fortunately, federal law dictates that pregnant women who live at or below 133% of the poverty level (around $40,000 income for a family of four) are eligible for Medicaid, which has few out-of-pocket expenses — though after 60 days, this coverage is not mandated to continue. This can leave people uninsured or scrambling for insurance options while their medical expenses accrue, and potentially at risk for the health complications and poor outcomes associated with being uninsured. While the federal government allowed states to expand this Medicaid coverage to 12 months postpartum during the Covid-19 state of emergency, 15 states have not yet done so, leaving many women without expanded access. If we want to give low-income mothers the best chance of avoiding medical debt caused by pregnancy-related care, all states should permanently extend Medicaid coverage to mothers for a full 12 months after birth.

Women and families in other wealthy, developed countries are not subject to debt-inducing financial burdens from the medical system at the time of their child’s birth. America saddles pregnant and postpartum individuals with financial burdens whether publicly insured, privately insured, or uninsured. Our findings carry particular weight after the Supreme Court’s recent Dobbs decision undoing abortion rights and recent attempts to reverse the FDA’s 20-year-old approval of mifepristone for abortions. Our results also suggest that limiting an individual’s reproductive freedom and forcing the continuation of unwanted pregnancies can also inflict financial harm.

It is past time for policymakers and health care leaders to prioritize the financial well-being of postpartum women and their families by expanding Medicaid and mandating full comprehensive childbirth coverage, allowing new mothers to focus on the joys of raising a child, rather than the stress of paying off medical debt.

Aaron Birnbaum is an internal medicine resident physician at Cambridge Health Alliance interested in improving the affordability of health care. Matthew Makansi is an internal medicine resident physician at Cambridge Health Alliance interested in improving health care access to underserved populations.