Note: Please excuse the weirdness with the comments. Those before Oct. 16 belong to a related post that I moved to another location. I placed this post here because other websites refer to this permalink. If you commented on the original post, I may have temporarily unpublished it to streamline a new conversation.
Also, please feel free to use this post in your own battle for insurance coverage.
Statcounter tells me many recent visitors to this blog are arriving via posts to the Health Business Blog and InsureBlog, the result of lengthy comments I left on the Health Business Blog’s post on IVF (in vitro fertilization) and its relationship to twin, triplet, and higher order pregnancies. In those comments, hgstern (the owner of the InsureBlog) and I had a vigorous debate as to whether infertility treatment should be covered by medical insurance. Jenn, a nurse who formerly worked at an insurance company, also joined the debate and has an excellent post on her blog.
Here’s my position paper on the issue:
Executive Summary / Abstract (since this is a really long post)
Medical insurance should cover infertility treatment because:
- For most, infertility is a treatable medical condition
- Treatment meets the criteria for "medically necessity"
- Infertility is akin to other serious, life-limiting medical problems and not at all similar to having male pattern baldness or being less than endowed in the chest area.
- Providing coverage for infertility costs less that $2.50 per year per member
- It is indeed fair and right for other health plan members to subsidize infertility treatment, just as the infertile subsidize the child birth and pregnancy costs of more fecund members
- Not providing coverage for infertility treatment does not make macroeconomic sense; it costs the overall healthcare system more due to less effective surgical procedures and self-paid IVF cycles that result in multiple gestations.
1) Infertility is a treatable medical condition, and therefore should be covered
Infertility is a medical condition. 95-100% of the time one or more specific medical causes can be identified. Some causes are structural abnormalities in the reproductive tract, such as a hydrosalpinx, a septated uterus, or a varicocele. Other causes are disease or endocrine disorders, such as endometriosis, cancer, PCOS (polycystic ovarian syndrome), and amenorrhea. As such, infertility has much in common with other medical conditions that are caused by structural abnormalities, disease, or hormonal imbalances.
Not only is infertility a bona fide medical condition from a medical point of view, it is from a legal one as well. The Americans with Disabilities Act and the US Supreme Court have confirmed that the ability to reproduce is a “major life activity,” akin to seeing, walking, working, and caring for one’s self. With that context, a disability is defined as a physical condition that prevents someone from participating in a major life activity.
For the majority of infertile couples, infertility is a treatable medical condition, for which non-experimental, minimally invasive procedures, such as IVF and artificial insemination are very effective. In fact, in some instances, it is the only way for a couple to conceive. In my case, for example, I no longer have fallopian tubes due to two ruptured ectopic pregnancies, probably caused by in utero exposure to DES (yes, I was appropriately monitored, but was just very unlucky). The only way for me to conceive is through IVF, which bypasses the tubes.
2) Infertility treatment is “medically necessary," and therefore should be covered
What is “medically necessary?” Well, on this point, hgstern and I seem to disagree. So, I did a little research.
Medicare defines “medically necessary treatment” as:
- safe and effective
- not experimental
I have no problem with this definition, and treatment of infertility with IVF clearly meets all three criteria.
IVF is safer, more effective, and less costly to the health care system than alternative surgical procedures (for tubal reconstruction, removing endometriosis, etc), even though -- ironically -- these more expensive, less effective surgical procedures are often covered under medical insurance where IVF is not.
IVF is not experimental. It has been around for 27 years and is recognized by the American College of Obstetricians and Gynecologists and the American Society for Reproductive Medicine.
Finally, because it is less invasive, less risky and more successful than alternate surgical approaches, it is often the most appropriate treatment. In fact, sometimes it's the only treatment if you have tubal problems (like me), recurrent miscarriages, or sperm quality issues.
I’ve also seen stricter definitions of “medically necessary” that require that the medical condition be likely to get worse if left untreated. Infertility treatment meets this criterion as well, since fertility declines as time goes on for both men and women.
3) Infertility treatment is not “lifestyle medicine,” and therefore it should be covered
Some people (hgstern included) argue that medical treatment for infertility is “lifestyle medicine,” akin to dental veneers, breast implants, and hair replacement. As such, they argue against infertility treatment by saying it is not fair to ask other health plan members (or the government, via tax breaks) to subsidize treatment for the infertile.
First, the lifestyle claim. This one really pisses me off because:
- No one should compare the importance of children to the importance of breast implants or hair plugs. Seriously, think about the absurdity of that argument.
- The medical inability to have children has been proven to cause as much stress as a having a terminal disease such as cancer or heart disease. Many scholarly publications compare the impact of the loss to losing one's arm or leg. Sure, you can live without an arm or leg, but is it really a "lifestyle" choice to seek medical treatment for it?
In fact, let’s take a much lesser condition as an example: a knee injury. Say you play sports, twist your knee and require surgery on your knee ligaments. Now, you won't die if you don't have the surgery, but you might limp around for the rest of your life. Most people, myself included, would say ABSOLUTELY that health insurance should cover the surgery:
- …EVEN THOUGH you won’t die without the surgery
- …EVEN THOUGH your desire to walk without a limp might be considered “vanity” or merely supporting a "lifestyle" by some
- …EVEN THOUGH you might have contributed to your own problems by playing a sport when you were perhaps too old and too out of shape
If you don’t support insurance-covered infertility treatment, where do you stand? Do you think insurance should cover the knee repair?
Because, I'll tell you what. I personally would take a permanent limp over never ever having children any day of the week. And I’m sure many (most?) infertile couples feel the same way. And besides that, your knee surgery is likely more expensive to the the health care system than my IVF procedure.
So, where do you stand on treatment for other illnesses and conditions that are not life threatening but can limit your life in ways both more and less insignificantly than infertility? For example: epidural anesthesia, medication for migraine headaches, sports medicine surgeries, treatment for eye disease, artificial limbs, hearing aids, treatment for skin rashes, surgery for back pain, treatment for Alzheimer's, normal vaginal childbirth, etc… If you accept that infertility is a treatable medical condition, you cannot logically support medical coverage for these other conditions but not for infertility.
As far as the “not fair to the fertile” argument… First, adding fertility coverage to an insurance plan would cost less than $2.50 per member per year. Second, by virtue of fewer childbirth procedures and fewer pregnancies, the average infertile couple and their progeny cost the health care system less than the average fertile couple, even if the infertile couple partakes in an IVF procedure or two. The medical costs associated with the typical pregnancy and birth make the cost of an IVF cycle look like chump change. So perhaps the question should really be, is it fair for infertile patients to subsidize fertile patients' medical expenses?
Furthermore, why is it fair for the young to subsidize nursing care for the elderly? Or for nonsmokers to subsidize the emphysema treatment of smokers? Or for women to subsidize the prostate cancer treatment of men?
Why is it fair? Because it’s INSURANCE, which by definition spreads the risk of one among many, THAT'S WHY.
4) Not providing infertility insurance coverage is penny-wise, pound-foolish
Above arguments not withstanding, lack of insurance coverage for infertility treatment results in sub-optimal outcomes and higher costs to the overall system. Insurance coverage for infertility makes macroeconomic sense.
First, IVF is not actually that costly (to the whole system, not to the patient) when compared to treatment for other common medical conditions. Although people claim that IVF is extremely expensive (in fact, "costly fertility treatments" is practically a cliche), this is true only from the uninsured patients' point of view because they must pay the full, retail price of $10K-$15K per cycle (those are the prices in the ultra-expensive SF Bay Area). But bring the bargaining power of an insurance company to the table, and the total payment (insurance payment + patient copay) is a much more reasonable $2-$3K, less than minor outpatient surgery.
Second, from a view of total-system costs, IVF is far less costly and more successful than patients' attempts to correct their reproductive abnormalities via surgery. It is also far less risky because IVF is not a true surgical procedure. However, because IVF is not typically covered by insurance, patients are left optimizing THEIR side of the cost equation. This frequently leads them to opt for insurance-covered surgical procedures, such as a laparoscopy to remove endometriosis or unblock fallopian tubes.
Third, saving a few pennies on IVF coverage ends up costing the health system many times that with the increase in twin and triplet pregnancies. 95% of patients are uninsured for IVF. The $10K+ retail price for an IVF cycle mean most couples are severely financially pressured to have their IVF cycles result in pregnancy. Also, like most would-be parents, infertile couples want to ultimately raise more than one child. So, couples undergoing IVF often hope for twins, to get “two for the price of one.” End result? Pressure to transfer at least two embryos, if not three.
This leads to dramatically more twin and triplet pregnancies, each of which are several times more expensive and risky in terms of prematurity and complications than normal singleton pregnancies. In fact, French researchers quantified the difference: twin pregnancies cost 3x singleton pregnancies, and triplet pregnancies are 8x. It would therefore make financial sense for insurance companies to cover 2 or 3 lifetime IVF cycles per patient, which would give couples the financial ability to opt for single-embryo transfers. As an example, I am personally fortunate enough to have coverage for 3 lifetime IVF attempts . I therefore opted for a single-embryo transfer at age 34, and I did get pregnant with a singleton as a result (although I later lost the pregnancy).
So, in closing, let me summarize by refering you to the "Abstract" at the beginning of this post.
And that's all I have to say about that. For now at least.
I will go take my chill pill now.
 See the U.S. Supreme Court case Bragdon v. Abbot, 1998.
 If you want to read the gory details of my history and struggle with infertility, you're in the right place. Check out posts in the "Complete Infertility Saga" category.
 I am fortunate enough to have insurance coverage for IVF, and can tell that my insurance company pays only $2500 for each IVF cycle, due to the discounts they have negotiated with providers.
 It makes sense that IVF cycles cost the system a lot less than most any outpatient surgical procedure (save wart removal?) because the procedures are comparatively non-invasive. IVF cycles include the following procedures over the course of a month:
- 3 or 4 transvaginal ultrasounds.
- An “egg retrieval” procedure, where eggs are gathered from the ovaries via a long needle. It takes 3o minutes to an hour, is performed in the doctor's office, and does not require incisions or general anesthesia.
- An “embryo transfer” procedure that is similar to a pap smear
- Preparation of the sperm (basically, spinning it in a centrifuge for 30 minutes)
- Embryologist time
- Fertility drugs
- A pregnancy test
All told, this is a lot less than a typical surgical procedure, which requires tons of drugs, OR time, and staffing by multiple physicians and nurses.