Medical insurance should cover infertility treatment because:
- For most, infertility is a treatable medical condition
- Treatment meets the criteria for "medically necessity"
- 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 and 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 ones 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.
2) Infertility treatment is medically necessary," and therefore should be covered
What is medically necessary?
Medicare defines medically necessary treatment as:
- safe and effective
- not experimental
- appropriate
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, recurrent miscarriages, or sperm quality issues.
There are 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 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:
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, lets 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 would say ABSOLUTELY that health insurance should cover the surgery:
- even though you wont 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
Because, I'll tell you what, most all infertiles would take a permanent limp over never ever having children any day of the week. And besides that, your knee surgery is likely more expensive to the the health care system than any 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, 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 its 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 its 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. 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.
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