Who Are the Players in the National Coverage Debate?


Infertility Lobby
Case Study: RESOLVE

The Supreme Court

Although the judicial branch is not formally involved in the formulation of medical policy, recent decisions by high court and lower branches provide legal support for the coverage of infertility services.  These rulings give credibility to the insurance reform lobby and may bolster the views of medical ethicists who support insurance coverage on the basis of equal access to treatment.

Cost Analyists

Infertility specific healthcare represents a very nominal proportion of insurance plans' total health care costs.  Research demonstrates that for health plans offering infertility services, infertility-specific costs account for as little as one percent of total health care costs.  Infertility coverage can be obtained at a minimal cost to the health plan as well as to the consumer, ranging from $0.33 to $0.86 per member per month in increased premiums.  Most infertile couples receive low cost, conventional services, such as drugs used to treat ovulatory disorders.  Research findings show that 50 percent of infertile couples seek treatment, while only ten percent will undergo an assisted reproduction cycle.
Studies also show that even when treatment utilization rates and the maximum benefit per member are increased, no significant increase in the cost of infertility care or total health care is documented.  What increases in maximum benefit per member and utilization rates do accomplish, however, are more individuals receiving treatment independent of their income levels.  This is an essential point because although infertility is equally distributed among the population, income is not.  Currently, only couples who can afford high out-of-pocket expenses, unless they are residents in a state with mandated coverage, are receiving services.  More infertile couples will certainly pursue treatment if all insurance plans cover infertility; yet, the cost of increased consumer utilization will be curbed by provider arrangements and capitation agreements between infertility clinics and HMOs, as demonstrated by Massachusetts data, where access to infertility services has been mandated since 1989.

Health Care Providers

Some providers of fertility services argue that without insurance coverage of infertility treatment, the quality of care goes down.  Reproductive endocrinologists, who are most closely involved with the medical aspects of treatment, may feel constrained by economic limits which compromise their abilities to treat patients.  Infertile women with a limited amount to spend on fertility services will place pressure on the physician to ensure success (pregnancy) in the shortest time possible, therefore minimizing costs.  However, quick success does not necessarily ensure the highest overall health benefits for mother and baby.

Physicians may implant high numbers of embryos into the uterus with each treatment cycle in an attempt to maximize success rates.  This practice drives up the incidence of multiple gestation, which is both financially costly and medically risky.  The hospital expense of delivering triplets is ten times that of a single birth, and twins and triplets have significantly higher risks of congenital anomalies and serious disabling conditions such as cerebral palsy and mental retardation.  Insurance companies, who deny coverage for infertility treatment, are instead responsible for the significantly higher costs of long-term care for chronically ill infants.

Doctors who choose not to implant high numbers of embryos are inadvertently punished by the current policies regarding infertility treatment coverage.  Although clinics that implant fewer embryos may have better overall outcomes in terms of health, "success" rates may be lower.  Because many infertile couples use statistical comparisons of pregnancy rates to choose a care provider, the more cautious and conscientious infertility clinics receive fewer patients than their less careful competitors.  For this reason, many health care providers feel that an insurance mandate would raise the overall quality of reproductive care.  However, not all members of the medical community support mandatory coverage (see below).

Medical Ethicists

While certainly not unanimous, many medical ethicists support increased access for infertility services through the use of a national insurance mandate.  Using the principles of justice and beneficence, ethicists argue that a system which discourages equal access to treatment is discriminatory and results in marginal care for those of lower socioeconomic status.  When treatment is available and effective for a medical disorder, it is not "just" to prevent some members of society from obtaining it.  However, some medical ethicists use the same principle of justice to dispute the necessity of mandatory insurance coverage (see below).


Insurance Providers
Insurance providers generally oppose the idea of a mandate for infertility coverage for economic reasons. Any increase in patient benefits translates into increased expenses, which conflicts with the provider's goal of maximizing profit margins.  Insurance companies employ a number of arguments to justify their stance on the infertility coverage debate.

One argument frequently advanced is that infertility is not an illness and, furthermore, the treatment of infertility is not a medical necessity.  In fact, infertility is an established illness of the reproductive system for which legitimate and effective treatments exist.  The treatment of infertility falls within the definition of "medical necessity," that is, "medically required and medically appropriate for diagnosis and treatment of an illness under professionally recognized standards of health care."

Another argument often presented against mandating infertility coverage is that many infertility services are experimental. Since the late 1980s, the most widely used treatments for infertility have not been considered experimental by the American Medical Association.  Finally, groups against mandated coverage reason that the definition of "infertility" is too broad and that the scope of services needs to be tightened before coverage can be provided. These arguments have little logic and are fundamentally inconsistent with how other complicated, broad illnesses have been successfully covered by insurance providers.

Health Care Providers
Some health care providers oppose a federal mandate for insurance coverage because profit margins may be reduced.  As was the case in Massachusetts, where coverage is guaranteed to all policy holders, insurance companies would set limits on treatment costs and implement a capitation system for payment, reducing profits to clinics and physicians.  Smaller infertility clinics may also oppose the mandate because the larger providers will likely be favored in the selection of care providers by insurance companies.

Medical Ethicists
The principle of justice addresses the question of fair distribution of scarce resources and the management of competing needs, rights and obligations.  The case of an infertility treatment mandate brings up ethical dilemmas because many other diseases and conditions do not have special coverage by insurance companies.  Oral contraceptives, which are used by many more women than those seeking infertility treatment, are not universally covered.  Some ethicists argue that although infertility treatment is a justifiable cause, other more widespread and serious conditions should receive insurance priority when deciding where to expend limited resources.

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