Michelle Obama’s revelation in her new memoir that she and Barack Obama conceived their daughters through in vitro fertilization has placed the increasingly common medical procedure into the national spotlight. Malia and Sasha, it turns out, are among the more than 1 million babies born in the United States through IVF. Yet a full 40 years after the first IVF baby was born, even as the procedure has become safe and remarkably effective, it remains financially out of reach for many U.S. couples struggling to become parents.
Health insurance regulation is largely up to the states, and policies vary widely. Some have expanded IVF access by mandating that most health-care plans cover the procedure — including Connecticut, Delaware, Maryland, Massachusetts, New Jersey, Rhode Island, and the Obamas’ home state of Illinois (which enacted its mandate seven years before Malia’s birth).
But other jurisdictions — including California, New York, Virginia and the District of Columbia — still do not require health insurers to cover IVF. With a single IVF cycle costing $12,000 or more, many low- and middle-income couples can’t consider that option. And the burden falls disproportionately on certain demographic groups: African Americans are much less likely than their white counterparts to have access to IVF, for instance, even though the infertility rate is higher among black couples.
The case for universal IVF coverage is straightforward. A just society should strive to provide all of its members access to the resources that they need to lead healthy and fulfilled lives — at least where available resources allow it. This includes interventions necessary to delay death, such as chemotherapy and kidney dialysis, as well as treatments needed to make life more bearable, such as psychotherapy for depression and analgesics for acute pain.
Most parents would say that being able to conceive and raise children brings them more meaning and joy than, say, being able to run or lift heavy objects. Yet health insurance plans routinely cover treatment of non-life-threatening orthopedic conditions while excluding coverage for IVF.
It’s not the case that adoption is a readily available lower-cost option, either. The average cost of adopting a newborn through a U.S. adoption agency exceeds $40,000, with wait times sometimes topping three years. Couples can offset some of the costs of adoption through a federal tax credit of up to $13,810 per child. The only remotely comparable provision for IVF is a medical expense deduction that very few low- and middle-income couples will be able to claim.
Some medical procedures are excluded from health insurance coverage because they are experimental or highly unlikely to succeed. But while IVF was once the stuff of science fiction, it is no longer. In more than 40 percent of cases — after the “in vitro” (literally, “in glass”) combination of egg and sperm — the embryo transfer results in a live birth delivery.
According to the Centers for Disease Control and Prevention, approximately 1.5 percent of infants born in the United States in 2015 were conceived through IVF. But the nationwide figure masks dramatic variation across states. In Massachusetts, for example, 4.5 percent of infants are conceived via IVF. The state has one of the most comprehensive IVF mandates, requiring insurers to cover the treatment for women who have tried unsuccessfully for more than one year to conceive through other means. In states where coverage for the procedure is limited or nonexistent, the rate of IVF births is unsurprisingly much lower — as low as 0.5 percent in New Mexico, for example.
IVF insurance mandates raise premiums, but only slightly. A state-commissioned study of the Massachusetts mandate estimated that the law adds as little as 0.12 percent — and no more than 0.96 percent — to health insurance premiums, or 54 cents to $4.44 per person per month. The Affordable Care Act requires states to reimburse plans offered through the ACA exchanges for expenses associated with new state-imposed coverage mandates, shielding low- and middle-income families from what would otherwise be small premium hikes.
Current state-level IVF mandates have loopholes. For one thing, the Supreme Court has ruled that states cannot regulate self-funded plans — that is, plans offered by large employers that bear coverage costs themselves. Nor do state mandates extend to Medicaid, federal employees or patients in the veterans health-care system. To plug some of these gaps and to expand access to IVF in states without mandates, Sen. Cory Booker (D-N.J.) and Rep. Rosa L. DeLauro (D-Conn.) introduced legislation in May that would have required all private-sector health plans, plus the federal employees plan and the veterans health-care system, to cover IVF. The legislation left out some state employees and Medicaid recipients, but it would have transformed IVF into a treatment that most American families could access.
Neither the House nor the Senate acted on — or even debated — the Booker-DeLauro bill. But, hopefully, the former first family’s example will motivate a new Congress to take up the issue. Helping constituents become parents should be one priority that lawmakers from both major parties share. After all, it’s the ultimate family value.