To: Bob Cook-Deegan
From: Amber Johnson
Date: February 8, 2000
Re: Federal Mandate for Infertility Treatment Coverage by
Statement of Issue: 6 million Americans currently
suffer from a medical disorder resulting in infertility. Because
only 14%-17% of insurance companies provide coverage for fertility services,
including assisted reproductive technologies, access to treatment is restricted
to the affluent who pay high out-of-pocket expenses. Without
insurance coverage, costs are spread across a small fraction of the population,
increasing per capita rates for treatment and encouraging physicians to
favor quicker and cheaper practices that compromise quality of care and
raise health care costs.
Reproduction is a “major life activity” according to the Supreme
Court. By denying access to effective treatment for most socioeconomic
groups, current policy violates the Americans with Disabilities Act.
Costs of infertility treatments without insurance coverage are a significant
barrier to access. An infertile couple will pay an average of
$59,484 in medical expenses per live delivery with assisted reproductive
Premium increases to provide insurance coverage for infertility treatments
are low. The monthly cost of providing infertility treatment
in Massachusetts, which mandates coverage, is approximately $0.26 per person.
Exclusion of infertility coverage increases multiple gestation, the
main cause of neonatal morbidity in IVF patients. With
financial and time pressure from patients with limited funds, doctors have
incentives to maximize pregnancy outcomes that may negatively affect maternal
and neonatal health and increase hospital costs.
Policy Recommendation: With rising usage rates of infertility
treatment, along with rising rates of multiple gestation, quick reform
is necessary to ensure patients have access to cost-effective, quality
care. Although state reform has worked in some areas, the time needed
for broad implementation in states without current initiatives hurts the
health of patients. A federal mandate without significant restrictions,
streamlining care and providing consistency between states, will increase
access to many people in a short amount of time. While this option
costs money, individual burden will be very minimal. Additionally,
the costs of infertility treatments and ART have been steadily falling
with rising use, suggesting that infertility treatments will be more affordable
as the market grows through expanded insurance coverage.
A federal mandate for annualized case rate packages, would require all
insurance companies to provide infertility treatment. Local provider
communities would decide on specific treatment algorithms and base their
one-year case rates of unlimited services on these algorithms. Patients
would receive treatment at designated centers. Supported by infertility
interest groups such as RESOLVE and many women’s groups.
Advantages: Provides coverage to all patients, reducing
per capita costs and allowing insurance companies to negotiate discounts
for services. Resolves ethical issue of discrimination under ADA.
Eliminates incentives for couples to seek premature ART, reducing the risk
of multiple gestation and limiting related health care costs. Eliminates
discrepancies between states.
Disadvantages: Increases premiums for all payers, most
without infertility problems. Encourages more people to seek treatment,
increasing costs. Reluctance to increase premiums and payments from
providers, who argue that infertility is not a life-threatening disease.
Mixed support from reproductive specialists, who will either benefit or
lose business through designation of treatment centers.
A restricted federal mandate, similar to the above option in structure,
would limit coverage only to those with higher probability of success,
such as younger women with no male-factor infertility. Limits could
also be placed on the number of treatment cycles performed.
Advantages: Less costly than a full federal mandate.
Provides coverage for couples with best chances of success, limiting costs.
May encourage couples with little hope of conceiving to consider adoption.
Insurance company support more likely for limited mandate.
Disadvantages: Limits on treatment will encourage overuse
of ART and incidence of multiple gestation. Would not fully resolve
discrimination issue, because clear restrictions are difficult to set.
Consumer savings from reduced benefits would be small relative to total
Optional state mandates, already successful in areas such as Illinois and
Massachusetts, would leave discretion to state legislatures. As already
reflected in current legislation, the scope and restrictions of the initiatives
would vary considerably, and the federal government would make no requirement
stipulating mandatory coverage.
Advantages: Doctors, providers, and patients could
be encouraged to limit costs without government intervention. More
individualized policies depending on state demographics. Less opposition
from national insurance providers.
Disadvantages: Many current state policies have significant
restrictions on coverage. Variety in state policies could not address
problem of multiple gestation and overuse of ART as effectively.
Insurance companies who provide coverage in states without mandate will
pay disproportionately high costs as more people enroll in their plans.
“RESOLVE: Inform Congress about Infertility.” http://www.resolve.org/advltr1.htm.
Netscape Navigator, Feb. 6, 2000.
Neumann, Peter. “Should Health Insurance Cover IVF?” Journal
of Health Politics, Policy and Law. Vol. 22, No. 5,
Gleicher, Norbert. “Strategies to improve insurance coverage
for infertility services.” Fertility and Sterility.
Vol. 70, No. 6,
Griffen, Martha and William F. Panak. “The economic cost of infertility-related
services: an examination of the Massachusetts
insurance mandate.” Fertility and Sterility. Vol. 70,
No. 1, July 1998.
Faber, Kenneth. “IVF in the US: multiple gestation, economic
competition, and the necessity of excess.”