Paying for Maternity Care in the United States

Introduction Giving birth to a child is an almost universal human experience, a process associated in the minds of most people with joy and fulfillment. Pregnancy and childbirth are not, however, without risks-risks that are sometimes serious and, occasionally, even fatal. Medical monitoring and the provision of nutritional, educational and other support services and health care before, during and after the birth are, therefore, essential to ensure the best possible outcome for the mother and her baby. Not all Americans, however, can take high-quality maternity care for granted. In some parts of the country, distance from a doctor or hospital is a problem; in others, medical personnel are in short supply. Some physicians are unwilling to accept high-risk patients, out of fear of expensive malpractice suits. Other doctors are reluctant to accept poor patients if they anticipate that their bills will not be paid, or that they will receive inadequate reimbursement from public insurance programs. Not all the shortcomings in maternity care are attributable to the service delivery system. But clearly, one important factor that contributes to the inability of many expectant mothers to obtain appropriate maternity care in a timely manner is the cost of having a baby. Even if the pregnancy and birth are uneventful, the charges are high, and if there are complications, a young couple without health insurance can be faced with bills amounting to more than they earn in an entire year. Although most people have insurance that covers the costs of maternity care, many people do not have any insurance coverage, or their coverage is inadequate. Maternity care, like general health care in the United States, is paid for by a mix of private health insurance, public financing systems and out-of-pocket payments by the patient and the patient's family. Coverage, however, is by no means universal. Some 35 million Americans under age 65 in 1984 had no health insurance of any kind, and that number is rising.' In the late 1970s, 13-14 percent of those under age 65 had no insurance; by 1984, that fraction had increased to 17 percent.2