The Ethical Problem of Inequality in Access to Infertility Treatments may have Economic Solutions
YASH KULKARNI, BS (Bioengineering) is a writer and designer of THE REPRODUCTIVE TIMES
September 4, 2024. Revised from the CHR VOICE
BRIEFING: The astounding price of fertility treatment, the lack of coverage by both government and private health insurance, and the growing financial burden that children represent, to a degree reserve the right to procreate for privileged social classes. Medicaid exemplifies some of the most flagrant inequalities when it comes to fertility treatment, while private insurers often use religious and bureaucratic excuses to withhold coverage. Coverage of LGBTQ+ people has often been withheld based on federal and state laws. Some state mandates have allowed for progress, but too slowly, leading Americans to go abroad for cheaper treatments.
Among myriad factors, the unmanageable financial burden of parenthood on young people increasingly appears to contribute to people having fewer or no children. Recent inflation in the U.S. and across the world also doesn’t help. As costs of living surge and companies often restrict health coverage, more women choose careers over building families. This decision can then pose fertility challenges and has greatly increased the demand for fertility preservation through prophylactic egg-freezing. The lack of affordability of treatments such as this, however, creates escalating challenges, exacerbated by lagging government health plans and private insurance coverage.
America has a lengthy history of unjust reproductive legislation, manifested most blatantly in the eugenics movement, which sought to improve humanity through policies like forced sterilization to prevent “unfit” individuals from having children. And “fitness” was, of course, defined by race, ethnicity, and other demographic factors. While the injustices of eugenics reached their peak in Nazi Germany, plenty of revered Americans were proponents of the movement here at home.
Politicians like Woodrow Wilson, scientists like Alexander Graham Bell, and even many physicians believed that eugenics was a moral and ethical obligation of medicine. One of the more prominent figures was Margaret Sanger, a birth control activist and sex educator who founded Planned Parenthood. Her association with Planned Parenthood allowed some to define the organization to this day as a sinister force of racism.
Even in current medicine, eugenic concepts are still present, especially when it comes to management of genetic abnormalities, cognitive impairments, and physical disabilities, of which Sanger said, “the most urgent problem today is how to limit and discourage the over-fertility of the mentally and physically defective.”
Though our healthcare system has made much progress, it is not surprising that current state and federal healthcare programs still leave plenty of room for systemic failures that affect the most vulnerable. While the World Health Organization (WHO) defines infertility as a disease, government healthcare does not cover infertility. Many private health plans decline to cover fertility treatments, and state laws requiring coverage are often greatly influenced by powerful insurance companies.
The greatest problem is with Medicaid, which only provides fertility coverage in two states and only covers small portions of treatment. For people with incomes low enough to qualify for Medicaid, the up to $20,000 price tag of a single cycle makes IVF unattainable, not even considering that conceptions in a first cycle attempt occur in only a small minority of cases. Arguments often heard especially from the political right against expanding IVF coverage include the fallacy that those who can’t pay for fertility treatments likely would be unable to afford raising children anyway, exposing an obvious failure of the U.S. health care system for this vulnerable population and creating a sentiment of superiority for those with the financial freedom of having children in comparison to those who cannot afford it.
A map of the United States showcasing which states cover IVF coverage, fertility preservation coverage and infertility coverage.
Quoting noted reproductive endocrinologist and fifth Dean of Medicine and Biological Sciences at Brown University, Eli Adashi, MD, these policies “stand out as a sore thumb in a nation that would like to claim that it cares for the less fortunate”.
According to a 2022 Duke University study, the cost of IVF remains the greatest barrier to infertility care. Private insurers have used the same excuses as the government to deny coverage, but states have the ability to mandate some coverage under laws that define infertility as a disease. So far, 21 states have passed mandates, with 14 including limited IVF treatment. While still in Chicago in 1991, THE REPRODUCTIVE TIMES’s founder, Norbert Gleicher, MD was intimately involved in passing the second such state law in Illinois, called the Family Building Act. More recently, insurers have developed additional motivations for offering coverage for fertility services, as employers are asking from them since their employees increasingly demand them as part of comprehensive health insurance packages.
Of course, insurers have found a variety of convenient objections, from the religious doctrine cited by Providence Health Plan in Oregon to Sanford Health Plan in the upper Midwest using obscure North Dakota laws to inflate premiums and create red tape. Bills in Oregon, North Dakota, Illinois, Wisconsin, Connecticut, Washington, New York, and other states failed to pass in 2023. North Dakota State Representative Mike Brandenburg (R) has thrice unsuccessfully attempted to pass a bill mandating coverage and says he will keep trying. Wisconsin Governor Tony Evers (D) added a mandate to the budget in 2023 which was shot down by the legislature.
Interestingly, these issues are clearly not partisan, but the insurers’ bottom line continues to prevail. Despite the difficulty in passing legislation, infertility coverage could and should be rather inexpensive. Financially, it makes little sense for a company not to provide coverage for their employees, as an overwhelming majority of employees will not need the services.
Patients with fertility coverage are, of course, more likely to receive fertility services than the non-insured. But they also will experience fewer complications in pregnancy, ultimately reducing overall expenses for employees and employers. The costs of more expensive fertility treatments can also become tax deductible. Taxpayer Publication 502 includes possible deductions for medical and dental expenses, including fertility enhancement procedures. Such deductions, however, only apply if the expenses are more than the taxpayer’s adjusted gross income and cannot include the cost of gestational carriers (surrogates).
This area of the law is still quite murky and gets increasingly uncertain for non-heterosexual patients. The US Center for Disease Control and Prevention (CDC) defines infertility as “not being able to conceive after one year of unprotected sex,” which obviously excludes same-sex couples. While the lead of the CDC’s Assisted Reproductive Technology Surveillance and Research Team clarifies that the language is “not intended to guide any recommendations about the provision of fertility care services,” many insurance providers still use similar language in their policies. One of these, Blue Cross Blue Shield of Illinois, was sued last year on the basis that it openly discriminates against LGBTQ couples.
While there are exceptions, insurance coverage for infertility in general kicks in only after a couple has attempted spontaneous conception for one full year. Under the aforementioned Illinois Blue Cross Blue Shield plan, infertile couples who could not conceive because of their sexual orientations, therefore, had to pay out of pocket for a full year of assisted conception (mostly insemination cycles) before coverage from the insurance company kicked in with IVF.
According to Patience Crozier, the Director of Family Advocacy at GLAD (GLBTQ Legal Advocates and Defenders), there is legislation in the works to address this issue, though hundreds of anti-LGBTQ bills introduced just this year in various state legislatures have stalled progress. House Bill 6617, introduced in Connecticut last year, would have required private insurance companies to offer fertility coverage to LGBTQ and single people, but was tabled for the legislative session.
While change through legislation is gradual by design, political pushback in recent years has not helped. Crozier worries especially for the LGBTQ community about the impact of the 2022 Supreme Court overturn of Roe v. Wade and relegation of this issue to state laws.
In response to these developments, increasing numbers of American women are going abroad in search of significantly lower treatment costs. In Colombia, for example, they pay around $7,000 for a round of IVF. In Barbados, that cycle costs about $6,500; in Spain, $6,000; and in Mexico, $5,800, according to a recent Axios report. Of course, this does not include travel costs.
International options, therefore, may also be out of reach for many lower- and middle-class Americans. Among the interests of legislatures, insurers, employers, employees, fertility clinics, and the general public, there must lie a solution somewhere, but it is unlikely that one single solution will fulfill everyone’s needs. Any real solution must make access for fertility treatment available for everybody who needs it, and this appears urgent, considering the worldwide birthrate crisis.
Simply because its citizens cannot afford it, the U.S.—supposedly the most prosperous country in the world—does fewer IVF cycles per capita than almost any other developed nation, yet it hosts some of the largest and most sophisticated health insurance companies. What appears to be lacking is a consensus on where infertility ranks as a problem in the national psyche. Considering the slowing national birthrate, this should be a high priority, because economies shrink with falling birth rates and an aging population ends up supporting rapidly growing numbers of citizens aging out of the workforce.
Maybe the mistake made thus far has been to present this issue as primarily one of equality and equity. Explained as a potential economic time bomb rather than a moral problem, the issue may find a better reception.