A Long Rant on Why Infertility Treatment Should Be Covered by Insurance

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  If you commented on the original post, I may have temporarily unpublished it to streamline a new conversation.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.

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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.

The Rationale

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[1] 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]

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
• appropriate

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:

1. 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.
2. 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[3], less than minor outpatient surgery.[4]

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[2]).

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.

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[1] See the U.S. Supreme Court case Bragdon v. Abbot, 1998.

[2] 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.

[3] 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. 

[4] 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. 

Comments

[sophie]

Susan - I read your post to the writer of that blog - you are 100% right in all you are saying. I read that article too (at my RE's office believe it or not). On another note, I wish you the best. I am starting IVF this cycle and at the same time, I have started the adoption process (even though they frown on it). Both are hard. I just want a family. Good Luck in making your decision.

[DD]

AD HOMINEMS: appealing to people's emotions and prejudices instead of their ability to think.

That must have been the phrase of the day in the Health Business Blog, even if it wasn't true as you presented the side that the majority of people fortunately never experience in factual and a succinct manner. Bravo (aka poop-in-a-group).

Thanks for so eloquently standing up for the cause. And by the way, the comparison comment on the implants was my grin for the day.

[David E. Williams of the Health business blog]

Susan,

Thanks for your comments on the Health business blog post. I hope it was clear that I'm not attacking IVF, bur rather advocating insurance coverage for fertility treatment and trying to make the broader point that the availability of more information and consumer choice in health care --what the consumer directed health care movement is all about-- is not a panacea for cost or quality.

The comments about adoption, breast enhancement and so forth are not mine.

I wish you the best.

David Williams

[B. Mare]

I don't think you were incomprehensible at all. In particular I thought your knee injury analogy was good.

It chaps my ass too when people try to argue on the basis of "medical necessity". As if that can be so closely circumscribed in every case, and as if insurance should only cover life-threatening illnesses- because really, unless it's going to kill you, is anything a "medical necessity"? That's such a black and white way to look at life, and in my view, not a very realistic one.

[B]

I didn't go to the linked sites (where the debate is taking place), but I think you have done a tremendous job here in this post. I was wondering if I could have your permission to reproduce some of this work you have done to send to my Representatives? I've been fighting this battle (with Congress) for nearly 2 years now.

[Jenn]

Great position paper.

[Wavery]

Susan,

You sold me and I'd only like to add to the 'vanity issues' section of the argument.
In cases of endometriosis, pregnancy is looked at as the best chance for a cure and in my case (not unique) IVF is likely the only way to obtain that cure. Without a pregnancy, my endo will continue to grow unchecked by the normol hormonal cycle of a pregnancy leading to ongoing debilitating pain, more complex laproscopic procedures performed by only a handful of surgeons in the U.S., billed at even higher amounts than the $18,500 for the first one. I could develop incontinance, up my way through more and more potent narcotics and potentially face the loss of not only my tubes, ovaries and uterus but a kidney or two. Vanity. Just a folly of mine.

[elle]

Rock fucking on, Susan!!!!!!!!!!!

[Lut C.]

This one is going into my 'Keep' folder.

[heleen]

Maybe another issue... but what puzzles me is the enourmous difference in costs for IVF between different western countries. In New Zealand state of the art IVF costs a little less than US$5000, drugs included. My insurance does not cover it, but I can have two government funded cycles next year. Also in South Africa and Australia you can get state of the art IVF for a good price in private clinics. So until the insurance companies have changed their policies based on your great article, come over to this side of the planet, have a great holiday included and you still save money...

[T]

Excellent. Imagine telling an absurdly fat american who doesn't exercise that insurance won't cover their knee surgery? They'd go ballistic. Yet a lot of infertiles are paying every dime for their own treatment - ridiculous,despicable. Fyi - MA clinics charge insurance co's between $5,000 and $7,500 per cycle.

[labia lady]

I second Heleen's comment about coming down under....... I honestly do not know what we would have done if it wasn't covered by government subsidy & insurance company.

[Jenny]

You are so clever. Marry me? No, wait, adopt me?

[akeeyu]

In one year, my insurance company spent about $25,000 on surgery, drugs, doctors fees and tests to diagnose and treat my Endometriosis. If they have to, they'll jolly well do that every year until I hit menopause, making the bill for my treatment a cool half a million dollars.

They won't, however, spend $11,000 on IVF which (unlike trying 'naturally') has a good chance of slowing the progress of the Endometriosis, therefore actually SAVING my insurance company money in the long run.

Let's see. $500,000. $11,000. Tough choice.

[Doctor Disgruntled]

Susan,

I am more sympathetic than you might guess but still disagree with some of the assumptions that characterize your post. For example, Medicare's definition of "medically necessary" is not a universal one, from either a legal or ethical standpoint (meaning other third-party-payors like ins. cos. can set their own standards for 'necessity' and also meaning that reasonable people can disagree intellectually about how to define medical necessity).

Then, you are arguing about what insurance companies "should" pay for based on comparing infertility to other covered services - and by that standard, you aptly show there are many viable comparisons between covered treatments and not-covered fertility. The problem here is that companies "should" cover (1) what they promise to cover and (2) what they choose to cover, which we assume is based on their financial best interests - remember, they're trying to make a profit on your payment$ - and possibly on their social/ethical interests - probably they want to appear sympathetic and generous, so as to attract more clients.

You take the view that providing IVF is a money-saver for the companies, but I'm skeptical. Sadly, it's probably cheaper for them to let women with infertility just hang, and pay for their own treatments, especially because as you point out, women trying to conceive are highly motivated, often emotionally desperate, and many will make enormous sacrifices even for the chance of having a child. Thus, the company can sit on its cash and let you do all of the work. I'm not convinced that except in extraordinary cases (possibly as in endometriosis, but even this seems unlikely to me) that effectively purchasing a pregancy helps an ins. co. save money in the long run.

Finally, dictating what MUST be covered by an insurance company tends to raise the costs of insurance - laws that mandate psychiatric coverage or birth control pills, both of which have been the subject of popular legislation, with politicians happy to crusade against rich companies "discriminating" against women or the mentally ill, force people who don't want or need those services to subsidize the care of those people who do. That may be ok with you (and reasonable people may disagree about this philosopical issue), but an alternative would be to free the industry of restrictions, and allow smaller players to explore niches like, say, FERTILITY insurance.

This is currently impossible under laws mandating what "Should" be offered, and prevents a solution that really would help lots of women like you - selling fertility insurance to women in their 20s that would cover IVF and whatever else they might need in later life.

Just some thoughts. My best wishes for you in your quest, truly.

Doctor Disgruntled

[kate #2]

You are my hero. I love the passion with which you approach this debate. Just last weekend, I mailed off yet another round of letters to my Sentators demanding insurance coverage. My DH say it and said, "Oh No! What are we going to get arrested for now?" lol

[Joie]

Well said! It is incredibly painful for my husband and I to accept that the only reason we don't have a child right now may be that we don't live in a state that requires insurance to cover infertility treatments. We are hoping to find a way to raise the $12,000 to fund an IVF on two teachers' salaries. It is SO not fair!

[Rich]

What about the higher rate of birth defects associated with birth defects? I'm not arguing on the basis of economics for the insurance companies. I'm arguing that it's not fair to the child that is potentially conceived, to bring him into the world with the significantly higher likelihood that they are going to have birth defects.

There was an article at Popular Science called "Sally has 2 Mommies and 1 Daddy", that might be interesting reading.
http://www.popsci.com/popsci/medicine/17e2c4522fa84010vgnvcm1000004eecbccdrcrd.html

[Lisa]

Great argument. Let me know if there's any way I can help you fight for coverage.

[Cyndi]

I just wanted to say thanks and respond to the comment that an infertility mandate would "force people who don't want or need those services to subsidize the care of those people who do". Isn't that what all infertility patients are doing? We subsidize the care of pregnant women, because insurance is mandated to cover prenatal care. This is a service we will never use.
That is all insurance companies and subscribers do, subsidize the care of others. We pay for triple heart bypass for people that ate fattening foods for decades and refused to exercise. We pay for surgery to correct shattered limbs following a bungee jumping incident. We pay for chemotherapy, surgery, and radiation therapy to treat lung cancer, caused by nearly 30 years
of smoking. We pay for prescriptions for Viagra so a man can engage in sexual activity.
Insurance and we as a society are symbiotic, yet somehow the infertile got the short end of the stick.

[Doctor Disgruntled]

Cyndi,
Yes, that's exactly my point - you and I are forced to subsidize the care of other people precisely because of mandates that force companies to offer specific types of coverage. If we weren't, the companies would be free to offer insurance products that would be much cheaper for most people, freeing up lots of $$ for you to buy what care you choose, and also allowing for the existence of a "fertility insurance" product I described above. You're saying the solution is "force coverage for more stuff" (which would raise the cost of medical insurance for everyone). I'm saying is "force coverage for nothing," and let the free market work. Then you would be much more likely to afford coverage of the type you want.

Again, best of luck. This argument pales in comparison to the stress and difficulty you're experiencing. My best wishes.

Doc Disgruntled

[Blue Cross of California]

Treatment shall be covered by health insurance as health coverage should be covering all health related events.

[Erin]

I agree with what you are saying. However, I'd like to point out that a vast majority of the insurance plans out there do NOT cover hearing aids...I should know, in the past few years I have shelled out $3K for mine.

[Infertile Canadian]

Here is a silly one for you... here in Canada, we have socialised medicine, which covers most medical procedures, but obviously not cosmetic ones.

My partner is sperm challenged, as as a result we require IVF/ICSI to get pregnant. However, as the insurance see it here *I* am not infertile, and therefore do not qualify for this now "elective" procedure.

Ahhh...Sexual discrimination in the insurance biz...

[Fendra]

I love the fact that I found this web site!!

I live in Massachussetts, where it is supposedly mandated that the insurance policies covers infertility. Well I have been trying for years. I am 32 years old and was diagnosed with PCOS. I have seen doctors after doctors and all say to me that I need to see a reproductive endrocronlogist to treat my PCOS which is the cause of my infertility, BUT they say (the doctors)that my insurance will not cover. I have Medicare for insurance, which I did research and found that they do cover infertility under the policy manual, also the rep I spoke to said that "as long as it is medically necessary, I can be treated". Well, I do believe PCOS would be medically necessary. What should I do. Medicare states that they didn't put a hold in the system to prevent me from further treatment and the doctors office says otherwise. Now the RE told me that Mediace does cover the infertility treatment, but not the IVF. Hello that sounds like shit!! I am seeking treatment for my infertility, but I still have to sign a self pay waiver and pay $450.00 out of my pocket for the consult. A consult that Medicare pays. Can anyone help? Suggestions? This is so upsetting!!!