
What are the effects of cost exemption during pregnancy?
What economic, social, and health consequences arise from cost-sharing during pregnancy, and how much do costs increase when cost-sharing is eliminated? Answering these questions enables a targeted use of cost-sharing as a regulatory instrument in the healthcare system.
In Switzerland, women are entirely exempt from cost-sharing in basic health insurance before and after childbirth. This exemption stems from several parliamentary motions that ultimately led to a legislative amendment in 2013, which came into effect on March 1, 2014. Since then, all services covered by basic insurance are exempt from cost-sharing from the beginning of the 13th week of pregnancy until eight weeks after delivery (first chart). This represents an expansion of insurance coverage during pregnancy. The aim of the legislative amendment was to prevent pregnant women with complications from paying more than those without complications. The focus was thus on fairness and reducing inequality among pregnant women, rather than cost considerations. This is also evident in the fact that Parliament did not expect a cost increase due to higher demand. Our research examines whether Parliament’s expectations were accurate and provides insights into the health and social implications of this cost-sharing exemption.
Comparison of pregnancy weeks
Our study is based on data from CSS for the period between 2012 and 2019, covering an average of nearly 13,500 births per year. For our statistical analysis, we leverage data on pregnancies not yet exempt from cost-sharing, i.e., pregnancies with deliveries before March 1, 2014. Additionally, services during the first 12 weeks of pregnancy remained subject to cost-sharing even after the legislative change. This allows us to compare pregnancy weeks over time, as well as with and without cost-sharing. We employ a difference-in-differences model to quantify the effects of the cost-sharing exemption.
Increased demand for physiotherapy and laboratory services
Our analysis reveals that eliminating cost-sharing led to a slight increase in overall expenses, contrary to the lawmakers' original expectations of no increase in demand. The cost effect is particularly evident in specific services. Physiotherapy services increased by 30%, and demand for laboratory services rose by 5%. As expected, we found no demand effect for inpatient services, where cost-sharing has minimal influence on the decision to seek care.

Low-income groups benefit
A central finding of our research is that the effects of the legislative change are entirely concentrated in low-income groups (below the median income). For this group, overall services increased by around 5%, while physiotherapy and laboratory services rose by 50% and 10%, respectively (second chart). Consequently, we observe a convergence in service utilization between low- and high-income groups during pregnancy, reducing inequality.

Health outcomes for newborns
In the final part of our analysis, we examine whether the legislative amendment resulted in positive health effects for newborns. We take advantage of the fact that low-income individuals increased their demand for services, while high-income groups did not. Comparing the trends in average newborn morbidity by income level, we conclude that eliminating cost-sharing positively impacted the health of newborns in low-income families. Our research suggests a slight improvement in the health of newborns from lower-income households, possibly due to the increased utilization of healthcare services during pregnancy.
Conclusion and outlook
The elimination of cost-sharing reduced the financial burden on expectant mothers and addressed the politically undesirable situation in which women with pregnancy complications paid more than those without. Our research demonstrates, however, that the regulatory change had additional effects on costs, inequality, and health. Specifically, we show that lower-income groups benefit the most, with a potential positive impact on newborn health.
We estimate these additional costs at CHF 150 per pregnancy or, extrapolated to Switzerland, CHF 6 - 7 million per year. In addition, there is a shift in healthcare costs from pregnant women to the health insurance companies, i.e. to the premium payers, totalling CHF 40 - 50 million per year.
Our study illustrates the trade-off in determining cost-sharing levels: Lowering cost-sharing increases demand and costs but reduces inequality and may even improve health outcomes. Conversely, raising cost-sharing has the opposite effects. Through a differentiated approach, such as the one applied to expectant mothers, this trade-off can be mitigated to some extent.