Involuntary childlessness due to infertility affects at least one in eight couples in the United States. It can have a profound negative effect on an individual’s medical, psychosocial, and economic wellbeing.
Individuals who have the means can address their infertility through adoption and assisted reproductive therapies. But many barriers stand in the way of accessing these services, including cost and qualification for coverage and treatment. Only 24% of people in need of infertility treatment get it.
Currently, assisted reproductive therapy is only covered through private health insurance. The federal government does not require states to cover fertility treatments under their Medicaid programs. The current definition of infertility used by private insurance companies and states limits individual’s access to assisted reproductive therapy.
Infertility is usually defined physiologically: the inability to conceive or carry a pregnancy after at least one year of unprotected sexual intercourse. This qualifies infertility as a medical diagnosis and legitimizes health insurance coverage. Most of the 15 states that mandate some insurance coverage of infertility diagnosis and/or treatment use this definition.
However, this definition carries an underlying cis-heteronormative bias that excludes individuals who experience social infertility — same-sex and transgender couples, single individuals, and others who are unable to reproduce due to sociological, environmental, or psychological factors.
In recent years, activists, health care professionals, and policymakers have recognized these shortcomings and taken steps to reduce the systematic barriers in accessing fertility services. These include determining ways to reduce the cost burden of treatments and make the definition of infertility more inclusive.
While adjusting the definition of infertility will not solve all the concerns associated with reproductive therapy coverage, it may lead to more equitable access to these reproductive health services for populations who have historically been excluded.
For one, Drs. Weei Lo and Lisa Campo-Engelstein suggest defining infertility as social or physiological: “a condition of an individual with the intent of parenthood [who is] unable to conceive due to social or physiological limitations within twelve months.” While not perfect, this expanded definition could encourage the medical community, policymakers, and insurance companies to recognize that queer and single individuals also need medical assistance — and insurance coverage — to conceive.
In January 2020, New York state became one of only three states to offer insurance coverage to socially infertile women. Senate Bill 719 went into effect at the start of 2020, requiring large insurance companies to cover reproductive therapy costs. The bill “prohibits discrimination based on marital status, age, sexual orientation, or gender identity.” It includes donor insemination in addition to unprotected sexual intercourse as a viable attempt at impregnation. Presently, the bill does not have any clauses on gestational surrogacy.
Other states are also beginning to recognize the importance of inclusive reproductive therapy coverage. In 2020, Colorado introduced an infertility coverage bill, the Colorado Building Families Act, that would mandate insurance coverage of infertility diagnosis and treatment. The proponents of the bill are adamant that it also include members of the LGBTQ community.
The biggest argument against expanding insurance coverage for assisted reproductive therapy is the anticipated increase in costs associated with increased utilization. However, states such as Massachusetts have shown that comprehensive and inclusive reproductive therapy coverage does not have to result in significant health expenditures. In a state analysis, researchers found that the introduction of comprehensive fertility coverage resulted in a less than 1% increase in premiums.
Similarly, an economic analysis of assisted reproductive therapy coverage in wealthy countries found that, even in countries with high use of fertility services, costs were below 0.25% of both public and private healthcare expenditures.
While adjusting the definition of infertility will not solve all the concerns associated with reproductive therapy coverage, it may lead to more equitable access to these reproductive health services for populations who have historically been excluded.
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