First comes love, then comes marriage, then comes baby in a baby carriage – or so the story goes.
However, for an increasing number of couples in the U.S., that baby carriage needs a little push from the miracles of modern medicine to make baby arrive in it. And to meet this growing demand, an increasing number of health insurance plans include some form of coverage for fertility treatments.
Rising Infertility and Causes
According to a 2020 report by UCLA Health, 15% of couples in the U.S. experience trouble conceiving. Data compiled by the Centers for Disease Control and Prevention (CDC) show that infertility affects 10% of women and 9% of men between the ages of 15 and 45. The National Institutes of Health estimates that one-third of infertility cases are caused by female reproductive issues, one-third caused by male reproductive issues, and one-third caused by both or unknown issues.
Medical causes of infertility in women include ovulation disorders, cervical abnormalities, fallopian tube damage, uterine fibroids, among others. In men, issues often are caused by health conditions like diabetes or genetic defects, or lifestyle issues like smoking or substance abuse. However, the most common cause of infertility in both men and women is age. Fertility in women starts to decline around age 30 and even more so after age 35. In men, fertility begins to decline at age 40.
From 1999 to 2019, fertility rates of women ages 20 to 24 declined by nearly 43% and fertility rates of women 35 to 39 increased more than 67%, according to data from the U.S. Census Bureau and the National Center for Health Statistics (NCHS).
The reasons for delaying starting a family vary, but data from multiple studies has shown a corollary between higher education and career goals of women and starting a family later in life. Recent data also points to economic conditions as a factor. According to NCHS, U.S. birth rates never rebounded after the Great Recession in 2008 and continued to inch downward to a record low in 2020.
Although research has shown that increasing numbers of women and couples are choosing to not have children, a recent study by Ohio State’s Institute for Population Research using data from the decades-long National Survey of Family Growth shows that women born in 1991 to 1995 wanted to have 2.1 children on average when they were 20 to 24 years old, which is nearly identical for women born in 1965-1968 – that number was 2.2 children wanted at the same age.
What the data suggests, when all put together, is that educated, working women are going to want children when they are older and more financially secure, but may need help with conceiving them – and help with affording it.
Fertility Treatment Coverage
There are many kinds of fertility treatments, ranging from hormone supplements to in vitro fertilization (IVF) and surrogacy. Costs also vary.
According to a 2011 American Society for Reproductive Medicine study, the average out-of-pocket cost for a successful outcome using fertility treatments ranges from nearly $6,000 for medications only to more than $61,000 for IVF treatments and over $72,000 for IVF with egg donation.
The high cost of fertility services puts them out of reach for most U.S. couples. Infertility treatment is largely not covered by Medicaid, Medicare and is not considered an essential benefit under the Affordable Care Act.
As of 2023, 19 states have passed laws requiring at least some coverage for infertility treatments on at least some state-regulated plans, including California, but the coverage is only required on group plans and not on individual policies.
Coverage for working women has been growing, however, through employer-based insurance plans. According to a report in Mercer Health News from March of this year by Mercer Senior Associates Brittany Bono and Corina Leu, “37% of employers with 500 or more employees provide at least one specialized benefit or resource to support reproductive health, which could include benefits to support high-risk pregnancies, lactation, pre-conception family planning, pregnancy loss, or menopause. That number rises to 48% among organizations with 5,000 or more employees.”
The Mercer Health News report posits that while benefits packages that include coverage for IVF or egg freezing used to be considered “luxury,” a tightening labor market has made them “table stakes” in certain industries, such as tech.
The Mercer report was based on a 2021 survey the company conducted that found coverage for IVF from companies with 500 or more employees rose from 23% to 28% from 2015 to 2020; and coverage for egg freezing rose from 5% to 11%. In companies with 20,000 or more employees, coverage for IVF grew 36% to 42%; and egg freezing grew 6% to 19%.
The Mercer survey also found that 97% of employers reported not experiencing a significant cost increase, including employers that cover IVF. In a 2006 survey, the percentage was 91%, “so negative cost consequences appear to be even less of an issue now than they were 15 years ago,” the report states.
The percentage of employers currently not offering infertility coverage but are considering it has also grown from 2006 to 2021. In 2006, only 2% of employers responded they were considering adding IVF to their benefits package. In 2021, that grew to 18% of respondents, according to the Mercer survey. There were similar gains in consideration for all other types of infertility treatments, such as covering fertility evaluations, drug therapy and in-vivo fertilization. The percentage of companies considering offering at least some type of coverage grew from 7% in 2006 to 21% in 2021.
Large employers in competitive labor markets are increasing access to infertility treatment coverage for more professional women, but broader coverage will likely involve more government mandates or new legislation. That effort has already started.
Last year, the White House Office of Personnel Management directed Federal Employee Health Benefits program providers to expand coverage for prenatal and postpartum care and emphasized treatments for infertility.
Beneficiaries now have four plan options that will provide assisted reproductive technology, including one new option that will provide a non-FEHB benefit for discounted medical procedures such as IVF and fertility medications.
At the state level, mandates for at least partial coverage for infertility treatments are under consideration in Oklahoma, Virginia, Missouri, Texas, New Jersey and Washington.
In California, a bill (AB 2029) would expand the state mandate and require commercial and CalPERS health plans and policies to provide coverage for the diagnosis and treatment of infertility and fertility services, including IVF. According to an analysis of the bill, the insurance premiums among state funded Department of Managed Health Care-regulated CalPERS HMOs would increase by $5.77. Premiums for enrollees in individual plans purchased through Covered California would increase by $2.72 to $7.13, depending on the plan.
In 2019, New York passed a similar bill requiring IVF and fertility preservation services for comprehensive private health insurance policies in the state. The New York State Department of Financial Services estimated that IVF coverage would increase premiums .5% to 1.1% and fertility preservation would increase premiums by .02%.
In a 2020 report, “Coverage and Use of Fertility Services in the U.S.,” authors from the Kaiser Family Foundation explained:
“While these costs could be modest in comparison to the costs of paying out-of-pocket for these services, there are other costs to coverage mandates. The ACA requires states to offset some of the costs for any state mandated benefits beyond essential health benefits (EHBs) in the individual and small group market. This requirement was estimated to cost NY $59 to $69 million per year if covering one cycle or $98 to $116 million per year if covering unlimited cycles of IVF.”
Infertility Coverage Concerns
According to the Mercer survey, 55% of employers who do not offer infertility treatment in their benefits packages cite the potential of increased costs as their top concern. Other concerns and reasons for not offering coverage include lack of demand from employees (35%); concern over high utilization (13%); belief that fertility is not the employer’s responsibility (13%); and a belief in only offering basic coverage (9%).
Cost concerns were higher among larger employers, with 60% of employers with 500 or more employees citing cost as a barrier, compared to just 47% of employers with 10-499 employees.
The survey also found that potential financial incentives for covering infertility could change employers’ minds. If costs for covering infertility treatment were offset by eliminating other medical plan costs, such as covering multiple births, 47% of employers reported they’d be more likely to offer infertility treatment.
The survey report adds: “Without insurance covering fertility treatments, employees paying out of pocket for these procedures typically try to maximize the chance of pregnancy by transferring multiple embryos, which can lead to multiple births and time spent in a neonatal intensive care unit – expenses that would be covered by the employer’s plan.”