Outlook: Jon and Kate Plus Health Care

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Liza Mundy
Washington Post Staff Writer
Monday, June 29, 2009; 11:00 AM

Washington Post staff writer Liza Mundy, was online Monday, June 29, at 11 a.m. ET to discuss her Outlook article titled 'Would better insurance have saved this marriage?' about health-care reform and IVF (in vitro fertilization) insurance coverage.

Mundy is the author of "Everything Conceivable: How Assisted Reproduction is Changing Men, Women and the World."

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Liza Mundy: Hello to everyone who has written in. The list of questions sent in before the chat is certainly lively. In my experience the topic of infertility and infertility treatment tends to be extremely controversial, and the questions here certainly bear out that experience. I'll get to work answering them. Best, Liza

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washingtonpost.com: Jon and Kate Plus Health Care (Post, June 26)

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Rockville, Md.: Hello,

Your opinion piece was very interesting. I just assumed that all couples received practically the same IVF treatment.

Where I disagree with you is to have insurance companies pay for infertility treatments. It's a choice, not a right, to seek these treatments. I'd really like my insurance company to pay for a Botox treatment because I'm older and getting wrinkles. It's cosmetic, not life threatening.

To many women, like me, who do not want children, it almost seems like a vanity project that is fed by emotion, the fertility industry and now TV. What also makes it worse is when many couples say their multiples are a gift from God. No, it's a gift from science and money.

What happened to Darwinism and survival of the fittest? If having a baby doesn't work, isn't adoption a good option?

Thank you.

Liza Mundy: Thanks for your comments. There are lots of interesting points in your questions. To respond to the first one--in fact, there are many levels of fertility treatment, beginning, probably, with a low-level drug to induce ovulation, and moving through the IUI procedure described in the article, and culminating in IVF and a host of related high-tech procedures. Some insurance plans do cover the lower-level treatment. Some cover diagnosis of infertility but no treatment. Some do cover IVF. There is a wide variation.

I am intrigued by your view that infertility treatment is a vanity procedure. It's interesting to me that people do often have this view of the quest to have children through medical treatment. The fact is, though, that many causes of infertility are medical problems. I tend to view childbearing as a fundamental human activity, but obviously many others differ.

Oh, I do agree with you that it's off-putting when people who have availed themselves of medical and scientific treatment then attribute the outcome to the will of God. I mean, you could certainly argue that God gave us the brains and medical knowhow to come up with these treatments, but to repeatedly bring up God's will and deny one's own agency in seeking treatments seems short-sighted to put it mildly. And there is a lot of that in the book.

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Silver Spring, Md.: I blame their choices, not their health care, on their failed marriage. They made it a choice to have more children after the first two and they made a choice to use that method of conception. When they were pregnant with sextuplets, they made a choice to keep all the embryos. They made a choice to raise their children and live their lives in the public spotlight. Whether their choices were right or wrong is far from me to decide, but it is far easier to blame something else than take responsibility for our own choices.

Liza Mundy: I agree with you that the Gosselins made a whole series of choices; in fact, one of the things that struck me when I was writing my book is how very many incessant choices there are for people undergoing fertility treatment.

The fundamental premise of my piece is this: Given that many people ARE going to make the choice to seek treatment, shouldn't we be encouraging them to seek the treatment that is LEAST likely to saddle them, and the health care system, with high-order multiples? These are incredibly costly births and so many children suffer from lifelong health issues and disabilities as the result of being born prematurely. Simply paying neonatal care for a premature infant born before 28 weeks is almost $70,000. Even if you are turned off by the Gosselins, doesn't it seem cost-effective to make it easier for people who DO choose treatment to choose the treatment that is more likely to result in healthy children?

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Woodbridge, Va.: I read this story the other day and just haven't been able to get it out of my mind because it is what may turn me into a Republican. Enough already! Your fellow citizens do not owe you any and everything that you want that you can't pay for yourself! These people had two children already and the notion that my money should subsidize their (or anyone's) quest for more-more-more is insane. Here's a novel idea -- sometimes you can't have EVERYTHING you want in life and you should count your blessings. I've got no problem with my tax dollars being used for basic health care coverage, but this is nuts!

Liza Mundy: Your points are well-taken, but again, I would ask you to consider that making it more feasible for people to seek out the form of treatment that is least likely to result in high-order multiples is humane and cost-effective in the long run.

There is a good piece in Slate making the same argument, which ran a while back, written by Darshak Sanghavi, who is the chief of pediatric cardiology at University of Massachusetts and all too familiar with the sufferings of premature infants and their families. The link ishttp://www.slate.com/id/2211151/. He makes many of the same points: many lower-level fertility treatments are more likely to result in higher-order multiples, premature births and high health care costs associated with delivery. Moreover, when people pay out of pocket for IVF, they are more likely to want more embryos transferred (so as to raise the chances of success and avoid having to go through, and pay for, another cycle) so again, more likely to wind up with multiples.

So even if you object to enabling people to exercise their quest for biological children, there may be a bottom-line argument for doing so.

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Providence, R.I.: In my experience with infertility treatments, a physician wouldn't go right to IVF, whether or not it was covered by insurance. I'm lucky enough to live in a state where coverage for infertility treatments is mandatory, but my doctor had women go through at least three stimulated cycles before resorting to IVF.

Liza Mundy: Yes, this is often true, but I think the medical establishment is increasingly thinking that it can make sense to bypass IUI and go straight to IVF, and insurers may begin to follow suit. In a recent study comparing IUI- with-gonadotropins versus IVF, the success rate of IUI was just below ten percent, while the success rate of IVF was 30 percent for a single cycle. The fact is, over the past decade or so, IVF has gotten much more successful. It's still painful and difficult and agonizing, but it is more likely to work than it was ten or fifteen years ago.

According to Elizabeth Ginsburg, president of SART and a physician at Brigham and Women's Hospital in Massachusetts, a major insurer there has just waived the requirement to try IUI before moving to IVF. So this may signal the way things are going.

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Washington, D.C.: Your piece did an excellent job of taking a current popular events topic (the Jon and Kate situation) to a relevant policy issue. Bravo!

Liza Mundy: Thanks.

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Knoxville, Tenn.: Really? Really... That is one of the most absurd implications I have heard about health insurance, and I have heard them all. To suggest, yea flat out say, that their marriage could have been saved if insurance mandates were available to cover IVF is beyond asinine. People who have natural twins, triplets, quadruples, etc make their marriage last every day. This piece is poor journalism that is sensationalism at its worst. Then again, big media is journalism at its worst, so why should I be surprised. Dear Post, please replace columnist. Signed, a reader that can reason.

Liza Mundy: Yes, people do make those marriages last, but I can assure you that the strains and stress of high-order multiples are enormous. So are the health costs. I would argue that most media coverage of high-order multiple births, which the public somehow loves to gaze at, really minimizes the extensive health issues involved with quads, quints, even triplets and twins. And doctors who work with patients trying to figure out what to do about a high-order pregnancy are very familiar with the stresses of these decisions and discussions. Let's also not discount the strains on the mother giving birth, who is more vulnerable to serious problems like pre-eclampsia.

Most of the parents of high-order multiples whom I interviewed for my book were working hard at their marriage and working incredibly hard to take care of their kids, but they were doing so under enormously difficult circumstances. One young couple who were incredibly likeable and couldn't afford IVF did IUI and ended up with quadruplets suffering a host of health issues, who were unable to leave their house for a full year. They were among the most likable and committed parents I've ever met. Another problem with much coverage of the extreme parenting situations, like Nadya Suleman and the Gosselins, is that it introduces you to the less likable characters, and ignored the regular people who are struggling with these situations.

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New York: I think your argument that better IVF methods would actually save money over the long run could be applied to numerous medical treatments.

Liza Mundy: Doubtless it could.

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D.C.: Is it specifically childbearing (the act of giving birth to a genetically-related child) that believe is a fundamental right, or is it forming a family that you believe is a fundamental right? If you believe it's childbearing, isn't that sort of discriminatory against people who adopt due to infertility? Then it's no longer a fundamental right, but a right of only those whose bodies won't cooperate.

Personally, I don't think that childbearing or having kids is a right. We experienced infertility, and did not choose to seek further treatments. In my mind, our infertility was our bodies' way of telling us bio kids weren't meant to be.

Liza Mundy: I think adoption is a great option. It's also expensive, often, like IVF, and isn't there an adoption tax credit? This seems like a good thing to me. I don't see why insurance coverage for IVF would discriminate against people who choose to adopt instead.

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Reston Va.: The Supreme Court gives every citizen the fundamental right to procreate. Those with the DISEASE of INFERTILITY should have access to quality and affordable health care to treat this disease.

Adoption is not for everyone and is not a cure of the disease of the reproduction system.

The US Supreme Court Right to life Right to freedom of movement Right to own property Right to marry the person of one's choosing Right to procreate Right to freedom of association Right to freedom of speech Right to equal treatment or equal protection before the law (fair legal procedures) Right to freedom of thought Right to vote Right to freedom of contract

Liza Mundy: The old adoption-versus-infertility treatment option also ignores the fact that many people dealing with infertility pursue both options with the hope that at least one will turn out.

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Montpelier, Vt.: Hi, Liza. Huuuge fan here -- thanks for all your thoughtful coverage of ART.

You seem to be in favor of single-embryo transfer, but in many cases (repeated failed cycles, for example, or poor embryo quality) it wouldn't be the most appropriate treatment. Infertile people are scared that the government will want a say in their treatment decisions, possibly requiring SET if insurance coverage is mandated even when it's not the patient's best chance. Can you comment?

Liza Mundy: I think Connecticut's law shows that it's possible to devise a plan with some reasonable limits. Remember, there are a number of states that do mandate coverage and the inhabitants of those states do not seem to have been impoverished by it. Here is a link to state-by-state breakdown: http://www.asrm.org/Patients/insur.html#CT

Anyway, Connecticut says not more than two embryos, and only for women under 40. I know that there maybe people who disagree with both of these limitations but I think they are pretty reasonable, since the IVF success rates, alas, do decline precipitously when the woman is in her early 40s.

I do think that if an insurance plan were willing to pay for more cycles than CT does (CT will only cover two IVF cycles; three seems fairer to me) then maybe it would be possible to steer doctors toward single-embryo transfer.

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New York: Requiring funding for IVF? In a nation where tens of millions of people have no coverage at all? It seems to me that as from a public health perspective, the money could be much better spent.

Liza Mundy: Clearly, many people agree with you. I would argue that if you examine closely the extraordinarily high delivery and care costs of multiple births, you might be convinced that coverage that would reduce the number of high-order multiple births may well be cost-effective.

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Washington, D.C.: I didn't really think the article was about the Gosselins and their marriage. Rather, I understood it to be about the efficacy of IUI vs. IVF. The Gosselins were mentioned only as a hook and lead in. IUI/clomid is probably a bad idea and the medical establishment, public health, and public economics might be benefited by skipping IUI/clomid and moving straight to IVF. Did people not read the whole article??

Liza Mundy: You are right in your interpretation and thanks for making that point.

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Muncie, Ind.: As a liberal in the Texas of the Midwest, I predict the IVF debate will implode when it comes to requiring insurance and possible federal programs to pay for "reduction," a.k.a. baby-killing in some circles, and would restart the debate on what to do with unused embryos. Will insurance companies be required to keep unused embryos in refrigerators in perpetuity? (or until some inevitable power failure commits mass "infanticide?")

Liza Mundy: Oh, I think the debate on what do with unused embryos is still very much a live one. I have written about that, and about how hard it is for couples to know what to do with unused embryos at the end of treatment. There are currently about a half-million in storage around the country. It will be interesting to see whether the Obama administration addresses this problem as it tries to devise a policy on embryonic stem-cell research.

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Silver Spring, Md.:Thank you so much for this article! I hope it helps to educate people about the myths and misconceptions of infertility. You were so right that this society doesn't accept infertility as a legitimate disease. It makes experiencing the journey all the more difficult.

Liza Mundy: Thanks.

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Alexandria, Va.: I think the main problem with your assertion that health care should be required to cover IVF is that it is an elective procedure. Heath care generally does not cover elective procedures. This is akin to saying that health care plans should cover plastic surgery. Having your own biological children is not a right and I really wish more people would choose adoption or even becoming foster parents. It may be a more difficult route but it's also one that is very rewarding in the end.

Having less children grow up in a shoddy foster care system with bad foster parents and overcrowded group homes is better for society as a whole.

Liza Mundy: I know that there are people who think that having children is a sort of vanity project, and that there is something selfish about seeking treatment for infertility. This is a strong thread of many reactions and I just don't agree with that view.

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Herndon, Va.: Where would you draw the line with this? Suppose the problem had been that Kate could not carry a child -- do you think health insurance should pay a surrogate to carry a child for a couple? What if neither partner is fertile -- should health insurance purchase an egg and sperm for them?

Liza Mundy: I think it's quite feasible to draw reasonable lines. I wouldn't have insurance pay for a surrogate and I wouldn't have insurance pay for egg or sperm donation, sorry. Others are welcome to make that argument if they'd like to write in.

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Pay for it yourself: Hello! I spent 10 years in the underwriting dept of an IPA-model HMO, and no, fertility treatment was not covered. It is not medically necessary for someone to be pregnant, much less to conceive a litter of children.

If someone has tried for one whole year to get pregnant, that's not significant. The human body doesn't always work exactly on schedule, and rushing off to spend tens of thousands of dollars on specialists and invasive procedures because one doesn't get pregnant the instant one wishes to, is ludicrous.

And having a health-care plan pay for it is pure bad judgment. The costs are astronomical, and the point of health coverage is to cover NECESSARY medical care. Again, it is not medically necessary for someone to become pregnant. "Because I WANT it" is not always a good reason to do something.

Unsympathetic? Sure. Realistic? Yes.

Liza Mundy: Obviously, I disagree with some of what you say, because your point about the "astronomical" costs of IVF (which actually can be lowered significantly by insurance company pressure) ignores the "astronomical" costs of multiple births, which I can assure you, we are ALL already paying for, and will continue to do so, in some cases, for all of these children's' lives.

But I do agree that it's possible to be too hasty to dive into treatment--some patients are too hasty to seek a medical treatment--and that younger couples in their 20s and maybe even early 30s may in some cases be better off waiting a while to see what happens. Reading the Gosselin's book, it did strike me that Kate was in a big hurry. Good counseling from an experienced physician is of course called for, and in many cases the best advise may well be to wait a bit and see what happens.

On the other hand, as a society we are beginning our families later in life, which is not a bad thing in many cases; as Sanghavi points out in his Slate piece, "higher maternal age is a powerful predictor of financial security and the child's future social and educational attainment." But it does mean that the window for just waiting to see what happens is a little narrower, often.

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Atlanta, Ga.: I find it very peculiar that you would endorse publicly-funded fertility treatments, which so many find as morally repugnant as abortion, when such treatments depress the demand for adoption. Wouldn't it be more socially sensible and economically beneficial to illegalize fertility treatments, which are simply an exercise in vanity, so that children who so desperately need good homes can find them?

Liza Mundy: It doesn't strike me that the demand for adoption is depressed at all. I have reported on this topic as well, and it strikes me that demand adoption is quite high.

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Re: Rockville: To follow up on my post about the vanity project and child birthing being a fundamental right. I don't disagree that women have the right to give birth but let's accept the fact that you can't have everything that you want.

There is also the issue of even being able to afford the IVF procedure. If you can barely afford that, how do you afford the kid or kids that come from the procedure. People just appear somewhat broken as humans and unwilling to accept that perhaps it's not for them to have bio kids. That's how it seems like vanity.

Liza Mundy: Wow, I don't agree that people who seek fertility treatment are broken as humans. There are plenty of middle-class working parents who would find it hard to come up with $12,000 for one round of IVF or $25,000 if they need a second. It doesn't mean they can't afford or don't deserve a family. That's just my view and I am well aware that many people disagree, as you can see from some of these comments.

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society doesn't accept infertility as a legitimate disease: That is because for most recipients, it isn't a disease -- they've just aged beyond the point were conception is supposed to occur.

Liza Mundy: This is simply not true. I spell out in my piece that there are lots and lots of causes of infertility besides age.

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Washington, D.C.: In your article, you make the claim "Possibly nothing could have saved this marriage, but one thing would have made it less fragile: a mandate for health insurance to cover in vitro fertilization." However, such mandates are one of the primary reasons why health insurance is as expensive as it is. There is already a mandate to cover pregnancy-related costs. Great, if you want to have children. If you're a single, 21-year-old male who is (presumably) years away from entering parenthood, that's an additional cost that has to be paid for a service that will never be rendered. On the other side, a mandate for prostate exams and the woman who will never use them but must pay for them.

Why not allow people to chose the coverage that they want, which will allow a more rational pricing of elective services, instead of forcing all people to subsidize the activities of a much smaller few?

Liza Mundy: Don't people already get to choose the coverage they want, up to a point? But isn't it unwise to allow people to delete too many items? What if you fall off a ladder but have failed to include "back surgery" as one of your elective procedures?

If I object to paying for the treatment of drunk drivers who injure themselves in auto accidents, should I be able to X that off as well?

I do pay health insurance premiums and I am happy to pay for mens' prostate exams, and would be quite willing to pay a couple of dollars a year so people could get IVF and so I could AVOID paying for so many infants to be incubated and monitored in neonatal care units and for women to spend months and months in the hospital on bed rest. These are costs we already bear and I was simply trying to suggest that perhaps this could be avoided.

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Reston, Va.: In response to the many writers who say health insurance only pays for necessary, life saving treatment. Please. Most health insurance companies pay for Viagra.

Liza Mundy: Yes, Viagra is always an excellent riposte in these sorts of discussions.

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Germany: No questions. Just wanted to congratulate you and thank you for a fair and well-written article on IVF and infertility. We needed 14 cycles to get pregnant (self-pay) and are due in 3 weeks.

All the best!

Liza Mundy: Thanks, Germany. And thanks so all who contributed to this lively discussion, pro and con. It seems a healthy discussion to have whatever your viewpoint. Thanks, Liza

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Archive: Transcripts of discussions with Outlook article authors

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