Infertile Couples Wrestle With Insurance Coverage

Sixteen years ago, infertile couples and their doctors achieved a victory they thought would be the first of many.

Maryland had passed a law requiring health insurers to pay for infertility treatments, including in vitro fertilization, and advocates believed that other states would quickly follow suit.

Instead, although two states passed laws this year mandating insurance coverage, the total number of states with such laws is now only 12--far fewer than advocates had hoped.

Three other states, including California, require health plans to offer policies covering infertility treatments. Employers are free to choose policies without coverage, however.

Infertile couples, their doctors and their advocates acknowledge that progress has been halting and difficult. Many people--including health insurers and employers--oppose the co-verage of infertility treatments given the already high cost of health. Opponents argue that infertility isn’t a disease or illness.

States that have passed laws tend to have lawmakers especially sympathetic to the issue.

In many of the states with mandatory coverage, laws were passed because high-ranking lawmakers, or their family members or friends, were personally affected by infertility, says Kate Doyle, director of government affairs for Resolve: The National Infertility Assn.

“It’s a very time-consuming process,” Doyle says. “The majority of these laws take four to eight years to get passed, depending on who the sponsors are.”

Last month, New Jersey became the most recent state to implement mandatory coverage. That effort began six years ago when an infertile woman wrote a letter to her state representative seeking help.

But, says Doyle, “it took 2,500 people in New Jersey being relentless to get this passed.”

According to the National Center for Health Statistics, about 5.4 million couples experience infertility each year, although fewer than 2 million seek medical treatment.

According to Dr. David Adamson, a Palo Alto-based infertility expert, hundreds of thousands of other couples receive a diagnosis of infertility but do not follow through with treatment because of the financial costs.

“It’s clear they wanted babies, because they went for treatment,” he says. “It also seems pretty obvious that many could have proceeded with treatment if they could have afforded it.”

Advocates for infertile couples charge that it’s simply not fair that infertile couples pay premiums for health insurance that covers a host of other conditions but not the condition that affects them.

The issue of fairness in health insurance coverage is a persistent one. Women’s advocacy groups have harshly criticized insurance plans that pay for Viagra but not birth control pills, for example.

And the lack of coverage for cutting-edge and experimental cancer therapies has long stirred dissent. But there is perhaps no more controversial insurance coverage issue than that of infertility.

Here the argument resides on the dilemma of whether having a baby is a health-care right. Opponents of infertility coverage suggest that couples who have postponed pregnancy until their 30s or 40s, when they are less fertile and have lower odds of conceiving naturally, may have forgone their right to a slice of the insurance pie.

Some question whether such non-lifesaving therapies are even affordable for a nation struggling to cope with high numbers of uninsured people. One IVF cycle costs from $7,000 to $12,000, according to current estimates.

“I think many people see pregnancy as a lifestyle choice,” says Adamson, founder of a network of infertility doctors called Advanced Reproductive Care Inc. “But if you don’t have children and want them, then infertility becomes a real disease.”

Insurers, however, say infertility coverage increases premiums for a large number of people while only a small number benefit. They also say success rates--the birth rate per treatment--are too low to justify the services.

“We are typically opposed to any form of mandate,” adds Bobby Pena, a spokesman for the California Assn. of Health Plans. “It takes the option away from employers.”

Resolve leaders say that experience in states such as Massachusetts, which has had mandatory coverage since 1987, show that costs can be minimized.

Many states bar the use of donor sperm and limit the number of costly high-tech treatments, allowing them only if other less expensive treatments have failed. Other states specify that covered treatments must take place at facilities that conform to standards set by the American Society for Reproductive Medicine or the American College of Obstetricians and Gynecologists.

Proponents argue that infertile couples with health insurance pay premiums for health benefits they are unable to use, such as maternity services.

Ultimately, infertility patients and their doctors say, infertility is a disease--and should be treated as such.

“Infertility is a physical problem that can be corrected by medical treatments,” Doyle says. “Everyone should have the right and the ability to have a family. But some people need assistance in having a family.” Several states continue to make incremental progress on legislation, including New York, Connecticut and Pennsylvania. And four federal bills regarding various aspects of infertility coverage have been submitted in the House and Senate.

But pessimism over government assistance has led patients and doctors to look for other ways to cope with the costs of infertility treatments. Some private physicians and doctors’ groups are offering financial packages to patients that include refunds when patients are still unable to have a baby after treatment.

Adamson launched his company, Advanced Reproductive Care, in 1997 to offer an “economic solution” to couples who can’t afford treatment. With a network of 250 doctors in 37 states, the company offers financial plans to couples that, Adamson says, help them manage the financial risk.

Adamson says a goal of the program is to persuade couples to enter infertility treatment at younger ages. Couples who encounter difficulties conceiving but are still in their 20s or early 30s often lack the money to pay for treatment.

“We’re trying to move the demographic toward the 30-year-old,” Adamson says. “Forty-year-olds often have the money to pay for treatment but have much lower chances of becoming pregnant.”