Mandating Coverage for Infertility Treatment – What Does the Future Hold for Providers in Washington?

Author: Michaela Jester

January 7, 2019 9:00am

Lifting the Veil on Infertility

As American public figures have begun to advocate for infertility treatment by sharing their personal struggles and successes, realizing dreams of parenthood with the help of In Vitro Fertilization (“IVF”) and other assisted reproductive technology (“ART”) has begun to shed its cultural label as a “taboo” topic of conversation. Perhaps refreshing the conversation by bringing it to center stage, former First Lady Michelle Obama spoke candidly in a November 2018 interview about the couple’s heartbreaking miscarriage and the crucial role of IVF in the conception of their two daughters. In addition to Mrs. Obama, similar revelations by Jimmy Fallon, Mark Zuckerberg, and Celine Dion, brings hope by strengthening relatability between the many people challenged by infertility. As a result of this public discourse, more people are understanding how common infertility is and the solidarity behind seeking treatment for the condition. With the advancement of medical technology, the obstacle is not necessarily the existence of effective treatment, but rather the hindered accessibility of treatment due to the lack of coverage for such procedures.

Prevalence and Causation

Infertility is not an affliction reserved for celebrities. In general, the condition is prevalent across the country with an estimated 10% of American women of childbearing age (approximately 6.1 million) suffering from infertility according to the Center for Disease Control (“CDC”). These figures correlate to approximately 150,000 women in Washington. However, because infertility also affects men, it is estimated that 12%-15% of American couples are unable to conceive after one year of having unprotected sex. Further, after two years of trying to conceive, nearly 10% of couples are still unable to become pregnant.

Although the primary underlying cause of infertility’s pervasiveness is uncertain, the combination of medical knowledge and recent studies suggest at least a partial explanation. Physiological causes, known as “structural infertility,” are the more understood contributing factors. For instance, women of any age may experience problems with ovulation whereby eggs are not available for fertilization. Also, sperm may be prevented from having access to eggs as a result of blockages in the fallopian tubes. Further, low sperm counts or issues with sperm motility may result in infertility.

In addition to the physiological factors, researchers believe modern societal changes may also be major contributors. In 2017, the United States’ birthrate hit a thirty-year low for every age group of women of childbearing age except for women in their 40s. The data may be reflective of a trend in millennial women delaying motherhood past prime childbearing years longer than the preceding generation. The reason? Since the window of peak fertility in women occurs simultaneously with the window of time most critical for career advancement and pursuing higher education, women must weigh the risks and benefits associated with their choices in timing and many are choosing to make their careers a priority by waiting until later to start families. Many of these women also face generation financial insecurity. Living with multiple roommates (if not with parents, again), paying down student loan debt, and tying to accumulate even meager savings are new norms for the millennial generation, realities which do not provide the most healthy and supportive environments for raising children.

Treatment

Procedures for treating infertility vary and are circumstantially dependent. For instance, the most common method of fertilizing eggs with sperm outside the womb, and then planting embryos inside the uterus, is known as IVF. Alternatively, during a procedure known as intrauterine insemination (“IUI”), a woman often receives ovulation-stimulating hormones before being inseminated with specially prepared sperm. Other infertility treatments include egg-freezing, hormone therapy, and surrogacy.

The Scarcity of Coverage

Infertility’s designation as a disease and whether treatment of the condition through IVF or other ART methods should qualify for coverage by insurance providers is hotly debated. While experts at the World Health Organization (“WHO”), the American Society for Reproductive Medicine (“ASRM”) and the American Medical Association (“AMA”) have designated infertility as a disease, many insurance providers do not provide coverage for treatment because these procedures are considered experimental even though the success rate of IVF and ART hovers around 40%. In an effort to expand access to treatment, sixteen states have mandated most health-care plans to cover IVF or offer some coverage for infertility diagnosis and treatment. Those with comprehensive IVF coverage are witnessing results (4.5% of the births in Massachusetts are conceived through IVF). In states where coverage mandates are limited or nonexistent, such as New Mexico, only 0.5% of births are conceived through IVF.

While Washington does not currently place any fertility treatment coverage requirements on providers, the potential of such a mandate being on the state’s horizon merits discussion. Already, Washington-based employers are offering coverage to attract and keep talent. Starbucks, for example, offers a lifetime benefit of $20,000 for IVF and other ART procedures to its employees. As out-of-pocket costs for treatment may place parenthood out of reach for many, the incentive is enticing. The price tag for a single cycle of IVF can run up to $14,500 in bigger cities such as Seattle, and after medical and genetic expenses are factored in, the price can soar to over $20,000 without a guarantee of conception.

Since adoption can set a couple back $40,000 and three years of waiting, and since surrogacy costs upwards of $100,000, many couples are seeking IVF as the first line of defense in combating infertility. To reduce costs, some couples in Washington are opting for clinics associated with non-profit organizations and healthcare lending providers. Nonetheless, a majority of those who suffer from infertility still have limited economically-reasonable treatment options. Many have no choice but to pay out-of-pocket for these otherwise elective procedures. Some couples even go to the extremes of taking out second mortgages and dipping into IRAs in hopes of making their dreams of parenthood a reality.

Takeaway

Despite high out-of-pocket costs and lack of insurance coverage, the high demand for infertility treatment in the United States is reflective of Americans’ general regard of parenthood as a priceless life experience. In fact, analysts expect the infertility market to reach $5.87 billion (with IVF contributing $4.1 billion) in 2018 and $7.93 billion through 2023 even though many of these procedures will be considered elective and uncovered by providers. While the country’s birthrate is on the decline, many people who desire parenthood might not be able to become parents not because of the effectiveness of treatment, but because of the financial hardship attached to uncovered procedures. With the ever-growing demand for fertility treatment, it would be proactive for providers doing business in states such as Washington to anticipate discussion regarding mandated coverage of IVF and other ART procedures in the treatment of infertility.

Copyright © 2019 Tyson & Mendes LLP. All Rights Reserved. Website by Big Behavior.