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The journey to conception is a long, difficult road...
Q: Should health insurers be forced to pay for infertility treatments?
Insight on the News, Feb 8, 1999 v15 i5 p24(1)
DIANE D. ARONSON; MERRILL JR. MATTHEWS.
Abstract: The executive director of Resolve believes that infertility should be covered by medical
insurance since it is a disability like any other. The vice president of domestic policy at the National
Center for Policy Analysis believes that the cost of treating infertile women would be unfairly passed
on all premium-payers.
Full Text: COPYRIGHT 1999 News World Communications, Inc.
Yes: Infertility is a medical disability like any other and should be covered as a disability.
What is the most important concern in your life.? For many people, the answer would be family. If
you are a couple with a vision of building a family, the condition of infertility can interrupt this basic
human desire. Infertility is a life-changing crisis that affects more than 10 percent of the
reproductive-age population in the United States. Having children and raising a family, which comes
easily to many couples, can be a heartbreaking challenge for those afflicted with infertility.
Infertility is a disease of the reproductive system which affects both men and women; it is not elective
or selective. It strikes people in all walks of life, and it crosses racial, ethnic, religious and
socioeconomic boundaries. Couples who experience infertility most often have to pay out of pocket
for their diagnoses and treatments. Health-insurance coverage usually either is nonexistent or minimal.
For many couples, only medical treatment can enable them to become pregnant and have children.
While adoption is an option for many, the costs can reach $30,000, and there are not enough babies
available in the United States to meet the need. Proven medical treatments are available, and insurance
coverage should be provided as it is for other diseases. Insurance covers the maternal and neonatal
costs for fertile couples who are able to have children. Individuals with infertility pay into the
insurance plans that cover those costs, even though they often cannot access care to bear children.
Couples who need medical assistance should not be denied the opportunity to become pregnant and
have children.
In any given month, a normally fertile couple has a 22 percent chance of becoming pregnant. Nearly
two-thirds of couples receiving infertility treatments have successful pregnancies. Most who
successfully obtain medical assistance for infertility are able to do so through relatively low-cost ($500
to $2,000) and noninvasive treatments such as medication or intrauterine insemination.
Approximately 5 percent of couples who seek treatment undergo assisted reproductive technology, or
ART, such as in vitro fertilization, which costs approximately $12,000 per attempt. When the woman
has blocked fallopian tubes or the man has a low sperm count, ART treatment may be the only
method by which a couple can become pregnant. Another treatment option is surgery, which usually
costs more than ART but often is covered by insurance plans. Because of this coverage, couples may
undergo multiple surgical procedures, even if ART would be the best and most cost-effective option.
Such partial coverage encourages inefficiency and, at times, incorrect treatment choices. Insurance
coverage of the range of treatments would allow for better management of care, as physicians and
patients could then better determine the most effective treatment path.
Infertility insurance coverage also would help to manage the rate of multiple births that result from
some treatments. The multiple-birth rate among those who obtain infertility treatments is higher than
among the general population. The neonatal costs following multiple births are high, as are the health
risks to the mother and the babies. (The neonatal costs of the Chukwu octuplet births in Houston on
Dec. 20, 1998, are estimated to be more than $2 million.)
When couples are straggling to have a child and do not have insurance coverage, they may be more
willing to take risks in treatment that increase their chances of having a pregnancy but also could
increase the chances of having a multiple birth. When paying out of pocket, knowing that they will not
be able to afford more than a certain number of treatments affects their decisions and their willingness
to take risks. Insurance coverage would remove that incentive. Further, insurance coverage would
bring about additional oversight and management of care from the insurance company, which could in
turn reduce the rate of multiple births. A 1998 study, led by physician David Frankfurter of Beth Israel
Deaconess Medical Center in Boston, found that in states with mandated infertility-insurance coverage
the average number of embryos transferred in an in vitro fertilization attempt was lower and the
multiple-birth rate per attempt was lower than in states without mandates. The study's authors
concluded that this lower rate of multiple births may be a result of less pressure from patients to
maximize the chance of pregnancy and increased pressure from insurers to minimize the likelihood of
multiple births.
Couples who experience infertility ride an emotional roller coaster -- from diagnosis through treatment
-- a very difficult experience. The physical and emotional struggles are further exacerbated when
couples face financial hurdles because of a lack of insurance coverage. Alice D. Domar of the
Mind/Body Institute at Beth Israel Deaconess Medical Center led a study of women with chronic
diseases which found that the psychological effect of experiencing infertility was similar to that of
cancer and heart disease. Compounding the emotional distress is the stigma of infertility and the
difficulty that many couples have in telling their family and friends.
What is fair when it comes to insurance coverage? The Supreme Court strengthened the arguments in
favor of infertility-insurance coverage when it issued a ruling in June 1998 that demonstrated the
importance of reproduction and the ability to have children. In Bragdon vs. Abbott the high court ruled
that reproduction is a major life activity under the Americans with Disabilities Act, or ADA. According
to the ADA, an individual is disabled if he or she has a mental or physical impairment that substantially
limits one or more major life activities. Therefore, those who are impaired in their ability to reproduce
may qualify for protection from discrimination based on that disability. This ruling allows those
experiencing infertility to make claims of discrimination when employers specifically exclude infertility
treatment from insurance plans. A number of lawsuits have arisen in the wake of that decision.
While Bragdon was not a case involving infertility (the plaintiff was an HIV-positive woman who was
denied dental care), lower courts have ruled in cases specific to infertility that it qualifies as a disability
under the ADA. In Bielicki vs. The City of Chicago, police officers Anita and Vince Bielicki sued the
city of Chicago for excluding infertility treatment from their health plans. After the U.S. District Court
for the Northern District of Illinois ruled that reproduction is a major life activity and that the Bielickis'
lawsuit could go forward, the city decided to settle. Most infertility-treatment costs incurred by
employees in the previous 10 years were reimbursed, and city health-insurance plans now include
infertility coverage. The precedents set by this case and the Supreme Court ruling, and the prospect of
further lawsuits, have brought infertility-insurance coverage to the attention of a growing number of
employers and legislators.
William M. Mercer, a benefits consulting firm, published a report in 1997 which disclosed that
approximately 25 percent of employers provide some infertility insurance coverage. Another
consulting firm, the Segal Co., issued an August 1998 report which found that only 7 percent of
employer plans cover infertility treatment, and about 14 percent of plans cover the costs of infertility
diagnosis. Most of those plans that cover treatment do not cover all infertility services.
The costs of including infertility coverage in an insurance plan are low. Studies cited by the Mercer
report found that the cost of in vitro fertilization coverage is approximately $2.50 per member per
year. Another study, by Martha Griffin and William F. Panak, published in the July 1998 issue of
Fertility and Sterility, found that the cost of comprehensive infertility coverage is $1.71 per family plan
per month. Isn't it worth the cost of a monthly cup of coffee to ensure that couples who are
struggling to build much-wanted families are afforded the option?
Several state legislatures have responded to the needs of their constituents and recognized the
importance of supporting couples who are striving to build their families. Thirteen states enacted
infertility insurance laws after they determined that such financial assistance is in the best interest of
their residents. The mandates are quite different in scope and substance. Ten states have a mandate to
provide some level of infertility insurance. Three states have a mandate to offer under which insurance
companies must have infertility insurance available for purchase, but employers do not have to choose
to provide that coverage to their employees.
A number of state legislatures considered infertility-insurance laws in the 1997-98 legislative session,
and new legislation is being drafted for introduction in 1999. Mandates may be introduced in Florida,
Indiana, Michigan, Nevada, New Hampshire, New Jersey, New York, Pennsylvania, Tennessee and
Texas. Infertility patients, providers and others who understand the need for insurance coverage are
working to gather support for mandates, and a number of legislators have committed to assist.
The existing infertility-insurance mandates have allowed many couples to obtain needed medical
treatments and to build their families. However, even in states with mandates, many employees still do
not have insurance coverage because of the Employee Retirement Income Security Act, or ERISA.
Employers who self-insure are exempt from any state health-insurance mandates, including infertility
mandates. In some states, more than 50 percent of employees work for exempted employers.
Self-insured employers sometimes do choose to follow the state's policy lead and provide infertility
coverage to their employees. A federal infertility insurance mandate, a long-term goal of the infertility
community, would cover all employers and make coverage consistent across states.
Legislators and employers are beginning to recognize that helping couples who are struggling to build
much-wanted families is the right thing to do. In a country that places great value in family, it is
salutary that insurance coverage for couples with infertility is just around the corner.
Aronson is executive director of RESOLVE, the National Infertility Association, a nonprofit
consumer-advocacy and patient-support organization in Somerville, Mass.
No: The high cost of these treatments would be unfairly passed on to all premium-payers.
When miracles happen on a regular basis, they no longer are miracles -- and they may even be seen as
problems. That's what has happened with the miracle of multiple births.
Geraldine Brodrick, 29, of Sydney, Australia, performed a miracle in 1971 when she gave birth to nine
babies. All died. But 30 years of advances in infertility treatments and neonatology have made multiple
births almost common and fairly safe. Bobbi McCaughey of Carlisle, Iowa, also 29, gave birth to
septuplets in 1997, all of whom survived. And now Nkem Chukwu of Houston has given birth to
octuplets, one of whom died. There also are nonscientific reasons for the increase in the frequency of
multiple births. One is that health insurers often are willing or required to pay for infertility treatments.
As a result, an increasing number of infertile couples seeks counseling and medical help in having a
baby.
According to the Centers for Disease Control and Prevention, 1.2 million women (about 2 percent) of
reproductive age visited a medical professional about infertility in 1995. And 9.3 million women (15
percent) had used some kind of fertility service at one time in their lives, compared with 6.8 million
(12 percent) who had done so in 1988.
Most women who pursue treatment need only moderate medical intervention, such as counseling or
drug therapy. Others need more aggressive or invasive care, such as surgery or assisted reproductive
technology, or ART. ART includes such procedures as in vitro fertilization, in which eggs and sperm
are taken from the couple, fertilized outside the womb and then implanted in the uterus.
While moderate medical intervention for infertility can be relatively affordable for most couples --
$500 to $2,000 -- more aggressive therapy can cost as much as $12,000. And in vitro fertilization can
be expensive -- $10,000 to $15,000 per attempt. It often takes several attempts before a prospective
mother is successfully impregnated -- which can drive up the cost significantly.
According to a 1994 New England Journal of Medicine study by Peter J. Neumann et al., the
estimated cost per live delivery for in vitro fertilization ranged between $66,667 in the first cycle to
$114,286 by the sixth cycle. A July 1998 study by Martha Griffin and William F. Panak, published in
Fertility and Sterility, found the cost of ART per live delivery in 1993 was $59,484.
Because some infertility treatments can be prohibitively expensive for middle- and lower-income
families, advocacy groups have lobbied legislators to require insurance to cover the treatments -- and
many have listened. For years state legislatures have passed laws -- "mandates" -- that require insurers
to cover providers such as chiropractors and podiatrists or for services such as drug and
alcohol-abuse treatments. In 1965 there were only eight mandates nationwide. Today there are more
than 1,000. And one mandate that has been gaining popularity -- especially among politicians who
want to be perceived as sympathetic to women's needs -- requires health insurers to cover infertility
treatments.
While these mandates make insurance coverage more comprehensive, they also make it more
expensive because people use insurance for services they previously paid for out of pocket. For
example, consider a patient who was spending $50 a month out of pocket to visit a chiropractor. If
the government requires insurers to cover 80 percent of his cost, the patient then is out only $10 a
month. If he believes he benefits from the chiropractic care, he may double the frequency of his visits
and still spend less than he spent before the mandate was passed. While the patient's personal
health-care costs have gone down, total costs to the system have doubled -- from $50 to $100 a
month. If many patients do the same, insurers eventually will have to increase their rates to make up
for the additional costs.
So while it may be true that chiropractors charge less per service than medical doctors and may in
certain circumstances provide better care, the additional utilization increases overall health-care costs.
Of course, special interests who push for insurance coverage of their particular specialty may believe
that such action will improve the quality of care. But they also know that providers will get more visits
and therefore more money. That's one of the reasons they work so hard to get legislators to mandate
coverage of their specialty. And that's also why they search for data and justifications that will "prove"
their assertions.
For example, Griffin, a doctoral candidate in the College of Nursing at the University of Rhode Island,
and Panak, a psychologist at the University of Northern Iowa, believe that insurance should cover
infertility treatments and produced a study to justify their beliefs. Their examination of the
Massachusetts infertility mandate led them to claim that "limiting the number of ART attempts could
motivate clinics to maintain policies of transferring numerous embryos as a way of increasing success
rates for couples who cannot afford numerous ART attempts. Thus, limits on ART cycles
inadvertently could maintain high rates of multiple births and the associated medical complications and
economic costs of these births."
In other words, if cost were not a factor, infertility clinics and patients might be less aggressive in
their attempts to ensure pregnancy on the first attempt by implanting numerous embryos. If true, that
could decrease the number of multiple births and costs would go down.
The problem is that mandates also increase total utilization of health care. If insurance is required to
cover infertility treatments, more women will get the treatments. The attempt to remove or destroy
some of the fertilized embryos, a process known as selective reduction, is seen by many couples as
abortion, a broader social issue that many people oppose. Chukwu was offered selective reduction and
declined for religious reasons. Indeed, because some women are reluctant to have embryos removed,
there is a debate within the medical community about whether such women should even be offered
fertility drugs. Thus, multiple births will not go down as the authors suggest.
Proponents of infertility mandates also assert that the cost of adding the coverage is minimal and
would have little impact on premiums. In support, they cite various studies that project a premium
increase of between $0.40 and $2.50 per family per month.
There are several problems with these projections. First, they seldom take into consideration other
factors. For example, Chukwu's medical bills for her octuplets will reach an estimated $2 million. She
is covered by insurance, so the family will not have to bear most of the cost; the insurer will. But
insurance is just a pass-through mechanism. That is, insurers pass expenses on to all the people who
pay the premiums. Thus policyholders pay higher premiums for the infertility treatments of others and
eventually bear the costs of postnatal care.
Actuaries take these collateral effects into consideration when calculating the costs of mandates. For
example, when Milliman & Robertson, one of the leading actuarial firms in the country, did a cost
analysis of a typical infertility mandate adopted by state legislatures, it estimated the mandate would
increase the cost of a health-insurance policy 3 to 5 percent per year, or $105 to $175 a year for a
basic health-insurance policy that had no other mandates included.
Which brings us to a second problem. Even if proponents of insurance coverage for infertility were
correct in asserting that a mandate would be relatively inexpensive, the larger problem is the total
number of mandates. Most states have adopted 30 to 40 health-insurance mandates. While the
Milliman & Robertson study makes it clear that most of these mandates are inexpensive -- adding less
than 1 percent to the cost of a policy -- the sum of their costs can make a health-insurance policy
prohibitively expensive, boosting premiums by 40 percent to 50 percent in most states.
A third problem is fairness. Thirteen states have adopted some form of infertility mandate. In some
cases the legislation requires insurers to cover infertility treatments; in other cases it requires only that
coverage be offered. Some states limit how much money insurers are required to spend on treatments
(say, to $15,000), while other states exempt very small employers (those with, say, fewer than 25
employees).
However, state-insurance laws primarily affect only small employers and individuals such as the
self-employed who purchase private insurance for themselves and their families. That's because most
large employers self-insure under the Employee Retirement Income Security Act, or ERISA, a federal
law that supersedes state laws. Companies that insure their employees under ERISA avoid state
mandates completely.
Thus state mandates affect only a small segment of those with private insurance, and the costs of
those mandates fall on a relatively small number of people. As a result, premium increases in the small
group and individual health-insurance markets grow much faster than in the large group market.
Ironically, it is in the small group and individual markets where people are least able to afford the
premium increases.
Of course, many large companies that self-insure voluntarily cover infertility treatments. But that's a
choice the companies have made, not one imposed by government. It's those governmental
impositions that can lead a business or a family to decide to cancel coverage. Which leads us to the
real question: Do we want to put an increasing number of low-income families at risk of lacking basic
health insurance so that infertile couples can have their treatments paid for by somebody else?
At a time when health-insurance premiums are projected to increase significantly during the next few
years and demographers are worried about world population growth, it simply makes no sense for the
government to force insurers to subsidize infertility treatments. Those who have the income to pay for
the treatments or who are disciplined enough to save the money to pay for them should have that
option. But since it is their choice, it should be their responsibility, not a financial burden that others
must bear.
Matthews is a medical ethicist and a vice president of domestic policy at the National Center for Policy
Analysis, a nonpartisan, nonprofit research institute in Dallas.
Insight on the News, Feb 8, 1999 v15 i5 p24(1)
DIANE D. ARONSON; MERRILL JR. MATTHEWS.
Abstract: The executive director of Resolve believes that infertility should be covered by medical
insurance since it is a disability like any other. The vice president of domestic policy at the National
Center for Policy Analysis believes that the cost of treating infertile women would be unfairly passed
on all premium-payers.
Full Text: COPYRIGHT 1999 News World Communications, Inc.
Yes: Infertility is a medical disability like any other and should be covered as a disability.
What is the most important concern in your life.? For many people, the answer would be family. If
you are a couple with a vision of building a family, the condition of infertility can interrupt this basic
human desire. Infertility is a life-changing crisis that affects more than 10 percent of the
reproductive-age population in the United States. Having children and raising a family, which comes
easily to many couples, can be a heartbreaking challenge for those afflicted with infertility.
Infertility is a disease of the reproductive system which affects both men and women; it is not elective
or selective. It strikes people in all walks of life, and it crosses racial, ethnic, religious and
socioeconomic boundaries. Couples who experience infertility most often have to pay out of pocket
for their diagnoses and treatments. Health-insurance coverage usually either is nonexistent or minimal.
For many couples, only medical treatment can enable them to become pregnant and have children.
While adoption is an option for many, the costs can reach $30,000, and there are not enough babies
available in the United States to meet the need. Proven medical treatments are available, and insurance
coverage should be provided as it is for other diseases. Insurance covers the maternal and neonatal
costs for fertile couples who are able to have children. Individuals with infertility pay into the
insurance plans that cover those costs, even though they often cannot access care to bear children.
Couples who need medical assistance should not be denied the opportunity to become pregnant and
have children.
In any given month, a normally fertile couple has a 22 percent chance of becoming pregnant. Nearly
two-thirds of couples receiving infertility treatments have successful pregnancies. Most who
successfully obtain medical assistance for infertility are able to do so through relatively low-cost ($500
to $2,000) and noninvasive treatments such as medication or intrauterine insemination.
Approximately 5 percent of couples who seek treatment undergo assisted reproductive technology, or
ART, such as in vitro fertilization, which costs approximately $12,000 per attempt. When the woman
has blocked fallopian tubes or the man has a low sperm count, ART treatment may be the only
method by which a couple can become pregnant. Another treatment option is surgery, which usually
costs more than ART but often is covered by insurance plans. Because of this coverage, couples may
undergo multiple surgical procedures, even if ART would be the best and most cost-effective option.
Such partial coverage encourages inefficiency and, at times, incorrect treatment choices. Insurance
coverage of the range of treatments would allow for better management of care, as physicians and
patients could then better determine the most effective treatment path.
Infertility insurance coverage also would help to manage the rate of multiple births that result from
some treatments. The multiple-birth rate among those who obtain infertility treatments is higher than
among the general population. The neonatal costs following multiple births are high, as are the health
risks to the mother and the babies. (The neonatal costs of the Chukwu octuplet births in Houston on
Dec. 20, 1998, are estimated to be more than $2 million.)
When couples are straggling to have a child and do not have insurance coverage, they may be more
willing to take risks in treatment that increase their chances of having a pregnancy but also could
increase the chances of having a multiple birth. When paying out of pocket, knowing that they will not
be able to afford more than a certain number of treatments affects their decisions and their willingness
to take risks. Insurance coverage would remove that incentive. Further, insurance coverage would
bring about additional oversight and management of care from the insurance company, which could in
turn reduce the rate of multiple births. A 1998 study, led by physician David Frankfurter of Beth Israel
Deaconess Medical Center in Boston, found that in states with mandated infertility-insurance coverage
the average number of embryos transferred in an in vitro fertilization attempt was lower and the
multiple-birth rate per attempt was lower than in states without mandates. The study's authors
concluded that this lower rate of multiple births may be a result of less pressure from patients to
maximize the chance of pregnancy and increased pressure from insurers to minimize the likelihood of
multiple births.
Couples who experience infertility ride an emotional roller coaster -- from diagnosis through treatment
-- a very difficult experience. The physical and emotional struggles are further exacerbated when
couples face financial hurdles because of a lack of insurance coverage. Alice D. Domar of the
Mind/Body Institute at Beth Israel Deaconess Medical Center led a study of women with chronic
diseases which found that the psychological effect of experiencing infertility was similar to that of
cancer and heart disease. Compounding the emotional distress is the stigma of infertility and the
difficulty that many couples have in telling their family and friends.
What is fair when it comes to insurance coverage? The Supreme Court strengthened the arguments in
favor of infertility-insurance coverage when it issued a ruling in June 1998 that demonstrated the
importance of reproduction and the ability to have children. In Bragdon vs. Abbott the high court ruled
that reproduction is a major life activity under the Americans with Disabilities Act, or ADA. According
to the ADA, an individual is disabled if he or she has a mental or physical impairment that substantially
limits one or more major life activities. Therefore, those who are impaired in their ability to reproduce
may qualify for protection from discrimination based on that disability. This ruling allows those
experiencing infertility to make claims of discrimination when employers specifically exclude infertility
treatment from insurance plans. A number of lawsuits have arisen in the wake of that decision.
While Bragdon was not a case involving infertility (the plaintiff was an HIV-positive woman who was
denied dental care), lower courts have ruled in cases specific to infertility that it qualifies as a disability
under the ADA. In Bielicki vs. The City of Chicago, police officers Anita and Vince Bielicki sued the
city of Chicago for excluding infertility treatment from their health plans. After the U.S. District Court
for the Northern District of Illinois ruled that reproduction is a major life activity and that the Bielickis'
lawsuit could go forward, the city decided to settle. Most infertility-treatment costs incurred by
employees in the previous 10 years were reimbursed, and city health-insurance plans now include
infertility coverage. The precedents set by this case and the Supreme Court ruling, and the prospect of
further lawsuits, have brought infertility-insurance coverage to the attention of a growing number of
employers and legislators.
William M. Mercer, a benefits consulting firm, published a report in 1997 which disclosed that
approximately 25 percent of employers provide some infertility insurance coverage. Another
consulting firm, the Segal Co., issued an August 1998 report which found that only 7 percent of
employer plans cover infertility treatment, and about 14 percent of plans cover the costs of infertility
diagnosis. Most of those plans that cover treatment do not cover all infertility services.
The costs of including infertility coverage in an insurance plan are low. Studies cited by the Mercer
report found that the cost of in vitro fertilization coverage is approximately $2.50 per member per
year. Another study, by Martha Griffin and William F. Panak, published in the July 1998 issue of
Fertility and Sterility, found that the cost of comprehensive infertility coverage is $1.71 per family plan
per month. Isn't it worth the cost of a monthly cup of coffee to ensure that couples who are
struggling to build much-wanted families are afforded the option?
Several state legislatures have responded to the needs of their constituents and recognized the
importance of supporting couples who are striving to build their families. Thirteen states enacted
infertility insurance laws after they determined that such financial assistance is in the best interest of
their residents. The mandates are quite different in scope and substance. Ten states have a mandate to
provide some level of infertility insurance. Three states have a mandate to offer under which insurance
companies must have infertility insurance available for purchase, but employers do not have to choose
to provide that coverage to their employees.
A number of state legislatures considered infertility-insurance laws in the 1997-98 legislative session,
and new legislation is being drafted for introduction in 1999. Mandates may be introduced in Florida,
Indiana, Michigan, Nevada, New Hampshire, New Jersey, New York, Pennsylvania, Tennessee and
Texas. Infertility patients, providers and others who understand the need for insurance coverage are
working to gather support for mandates, and a number of legislators have committed to assist.
The existing infertility-insurance mandates have allowed many couples to obtain needed medical
treatments and to build their families. However, even in states with mandates, many employees still do
not have insurance coverage because of the Employee Retirement Income Security Act, or ERISA.
Employers who self-insure are exempt from any state health-insurance mandates, including infertility
mandates. In some states, more than 50 percent of employees work for exempted employers.
Self-insured employers sometimes do choose to follow the state's policy lead and provide infertility
coverage to their employees. A federal infertility insurance mandate, a long-term goal of the infertility
community, would cover all employers and make coverage consistent across states.
Legislators and employers are beginning to recognize that helping couples who are struggling to build
much-wanted families is the right thing to do. In a country that places great value in family, it is
salutary that insurance coverage for couples with infertility is just around the corner.
Aronson is executive director of RESOLVE, the National Infertility Association, a nonprofit
consumer-advocacy and patient-support organization in Somerville, Mass.
No: The high cost of these treatments would be unfairly passed on to all premium-payers.
When miracles happen on a regular basis, they no longer are miracles -- and they may even be seen as
problems. That's what has happened with the miracle of multiple births.
Geraldine Brodrick, 29, of Sydney, Australia, performed a miracle in 1971 when she gave birth to nine
babies. All died. But 30 years of advances in infertility treatments and neonatology have made multiple
births almost common and fairly safe. Bobbi McCaughey of Carlisle, Iowa, also 29, gave birth to
septuplets in 1997, all of whom survived. And now Nkem Chukwu of Houston has given birth to
octuplets, one of whom died. There also are nonscientific reasons for the increase in the frequency of
multiple births. One is that health insurers often are willing or required to pay for infertility treatments.
As a result, an increasing number of infertile couples seeks counseling and medical help in having a
baby.
According to the Centers for Disease Control and Prevention, 1.2 million women (about 2 percent) of
reproductive age visited a medical professional about infertility in 1995. And 9.3 million women (15
percent) had used some kind of fertility service at one time in their lives, compared with 6.8 million
(12 percent) who had done so in 1988.
Most women who pursue treatment need only moderate medical intervention, such as counseling or
drug therapy. Others need more aggressive or invasive care, such as surgery or assisted reproductive
technology, or ART. ART includes such procedures as in vitro fertilization, in which eggs and sperm
are taken from the couple, fertilized outside the womb and then implanted in the uterus.
While moderate medical intervention for infertility can be relatively affordable for most couples --
$500 to $2,000 -- more aggressive therapy can cost as much as $12,000. And in vitro fertilization can
be expensive -- $10,000 to $15,000 per attempt. It often takes several attempts before a prospective
mother is successfully impregnated -- which can drive up the cost significantly.
According to a 1994 New England Journal of Medicine study by Peter J. Neumann et al., the
estimated cost per live delivery for in vitro fertilization ranged between $66,667 in the first cycle to
$114,286 by the sixth cycle. A July 1998 study by Martha Griffin and William F. Panak, published in
Fertility and Sterility, found the cost of ART per live delivery in 1993 was $59,484.
Because some infertility treatments can be prohibitively expensive for middle- and lower-income
families, advocacy groups have lobbied legislators to require insurance to cover the treatments -- and
many have listened. For years state legislatures have passed laws -- "mandates" -- that require insurers
to cover providers such as chiropractors and podiatrists or for services such as drug and
alcohol-abuse treatments. In 1965 there were only eight mandates nationwide. Today there are more
than 1,000. And one mandate that has been gaining popularity -- especially among politicians who
want to be perceived as sympathetic to women's needs -- requires health insurers to cover infertility
treatments.
While these mandates make insurance coverage more comprehensive, they also make it more
expensive because people use insurance for services they previously paid for out of pocket. For
example, consider a patient who was spending $50 a month out of pocket to visit a chiropractor. If
the government requires insurers to cover 80 percent of his cost, the patient then is out only $10 a
month. If he believes he benefits from the chiropractic care, he may double the frequency of his visits
and still spend less than he spent before the mandate was passed. While the patient's personal
health-care costs have gone down, total costs to the system have doubled -- from $50 to $100 a
month. If many patients do the same, insurers eventually will have to increase their rates to make up
for the additional costs.
So while it may be true that chiropractors charge less per service than medical doctors and may in
certain circumstances provide better care, the additional utilization increases overall health-care costs.
Of course, special interests who push for insurance coverage of their particular specialty may believe
that such action will improve the quality of care. But they also know that providers will get more visits
and therefore more money. That's one of the reasons they work so hard to get legislators to mandate
coverage of their specialty. And that's also why they search for data and justifications that will "prove"
their assertions.
For example, Griffin, a doctoral candidate in the College of Nursing at the University of Rhode Island,
and Panak, a psychologist at the University of Northern Iowa, believe that insurance should cover
infertility treatments and produced a study to justify their beliefs. Their examination of the
Massachusetts infertility mandate led them to claim that "limiting the number of ART attempts could
motivate clinics to maintain policies of transferring numerous embryos as a way of increasing success
rates for couples who cannot afford numerous ART attempts. Thus, limits on ART cycles
inadvertently could maintain high rates of multiple births and the associated medical complications and
economic costs of these births."
In other words, if cost were not a factor, infertility clinics and patients might be less aggressive in
their attempts to ensure pregnancy on the first attempt by implanting numerous embryos. If true, that
could decrease the number of multiple births and costs would go down.
The problem is that mandates also increase total utilization of health care. If insurance is required to
cover infertility treatments, more women will get the treatments. The attempt to remove or destroy
some of the fertilized embryos, a process known as selective reduction, is seen by many couples as
abortion, a broader social issue that many people oppose. Chukwu was offered selective reduction and
declined for religious reasons. Indeed, because some women are reluctant to have embryos removed,
there is a debate within the medical community about whether such women should even be offered
fertility drugs. Thus, multiple births will not go down as the authors suggest.
Proponents of infertility mandates also assert that the cost of adding the coverage is minimal and
would have little impact on premiums. In support, they cite various studies that project a premium
increase of between $0.40 and $2.50 per family per month.
There are several problems with these projections. First, they seldom take into consideration other
factors. For example, Chukwu's medical bills for her octuplets will reach an estimated $2 million. She
is covered by insurance, so the family will not have to bear most of the cost; the insurer will. But
insurance is just a pass-through mechanism. That is, insurers pass expenses on to all the people who
pay the premiums. Thus policyholders pay higher premiums for the infertility treatments of others and
eventually bear the costs of postnatal care.
Actuaries take these collateral effects into consideration when calculating the costs of mandates. For
example, when Milliman & Robertson, one of the leading actuarial firms in the country, did a cost
analysis of a typical infertility mandate adopted by state legislatures, it estimated the mandate would
increase the cost of a health-insurance policy 3 to 5 percent per year, or $105 to $175 a year for a
basic health-insurance policy that had no other mandates included.
Which brings us to a second problem. Even if proponents of insurance coverage for infertility were
correct in asserting that a mandate would be relatively inexpensive, the larger problem is the total
number of mandates. Most states have adopted 30 to 40 health-insurance mandates. While the
Milliman & Robertson study makes it clear that most of these mandates are inexpensive -- adding less
than 1 percent to the cost of a policy -- the sum of their costs can make a health-insurance policy
prohibitively expensive, boosting premiums by 40 percent to 50 percent in most states.
A third problem is fairness. Thirteen states have adopted some form of infertility mandate. In some
cases the legislation requires insurers to cover infertility treatments; in other cases it requires only that
coverage be offered. Some states limit how much money insurers are required to spend on treatments
(say, to $15,000), while other states exempt very small employers (those with, say, fewer than 25
employees).
However, state-insurance laws primarily affect only small employers and individuals such as the
self-employed who purchase private insurance for themselves and their families. That's because most
large employers self-insure under the Employee Retirement Income Security Act, or ERISA, a federal
law that supersedes state laws. Companies that insure their employees under ERISA avoid state
mandates completely.
Thus state mandates affect only a small segment of those with private insurance, and the costs of
those mandates fall on a relatively small number of people. As a result, premium increases in the small
group and individual health-insurance markets grow much faster than in the large group market.
Ironically, it is in the small group and individual markets where people are least able to afford the
premium increases.
Of course, many large companies that self-insure voluntarily cover infertility treatments. But that's a
choice the companies have made, not one imposed by government. It's those governmental
impositions that can lead a business or a family to decide to cancel coverage. Which leads us to the
real question: Do we want to put an increasing number of low-income families at risk of lacking basic
health insurance so that infertile couples can have their treatments paid for by somebody else?
At a time when health-insurance premiums are projected to increase significantly during the next few
years and demographers are worried about world population growth, it simply makes no sense for the
government to force insurers to subsidize infertility treatments. Those who have the income to pay for
the treatments or who are disciplined enough to save the money to pay for them should have that
option. But since it is their choice, it should be their responsibility, not a financial burden that others
must bear.
Matthews is a medical ethicist and a vice president of domestic policy at the National Center for Policy
Analysis, a nonpartisan, nonprofit research institute in Dallas.