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Author/s: Diane D. Aronson Issue: Feb 8, 1999
Yes: Infertility is a medical disability like any other and should be covered as a disability.
What is the most important concern in your life.? For many people, the answer would be family. If you are a couple with a vision of building a family, the condition of infertility can interrupt this basic human desire. Infertility is a life-changing crisis that affects more than 10 percent of the reproductive-age population in the United States. Having children and raising a family, which comes easily to many couples, can be a heartbreaking challenge for those afflicted with infertility.
Infertility is a disease of the reproductive system which affects both men and women; it is not elective or selective. It strikes people in all walks of life, and it crosses racial, ethnic, religious and socioeconomic boundaries. Couples who experience infertility most often have to pay out of pocket for their diagnoses and treatments. Health-insurance coverage usually either is nonexistent or minimal.
For many couples, only medical treatment can enable them to become pregnant and have children. While adoption is an option for many, the costs can reach $30,000, and there are not enough babies available in the United States to meet the need. Proven medical treatments are available, and insurance coverage should be provided as it is for other diseases. Insurance covers the maternal and neonatal costs for fertile couples who are able to have children. Individuals with infertility pay into the insurance plans that cover those costs, even though they often cannot access care to bear children. Couples who need medical assistance should not be denied the opportunity to become pregnant and have children.
In any given month, a normally fertile couple has a 22 percent chance of becoming pregnant. Nearly two-thirds of couples receiving infertility treatments have successful pregnancies. Most who successfully obtain medical assistance for infertility are able to do so through relatively low-cost ($500 to $2,000) and noninvasive treatments such as medication or intrauterine insemination.
Approximately 5 percent of couples who seek treatment undergo assisted reproductive technology, or ART, such as in vitro fertilization, which costs approximately $12,000 per attempt. When the woman has blocked fallopian tubes or the man has a low sperm count, ART treatment may be the only method by which a couple can become pregnant. Another treatment option is surgery, which usually costs more than ART but often is covered by insurance plans. Because of this coverage, couples may undergo multiple surgical procedures, even if ART would be the best and most cost-effective option. Such partial coverage encourages inefficiency and, at times, incorrect treatment choices. Insurance coverage of the range of treatments would allow for better management of care, as physicians and patients could then better determine the most effective treatment path.
Infertility insurance coverage also would help to manage the rate of multiple births that result from some treatments. The multiple-birth rate among those who obtain infertility treatments is higher than among the general population. The neonatal costs following multiple births are high, as are the health risks to the mother and the babies. (The neonatal costs of the Chukwu octuplet births in Houston on Dec. 20, 1998, are estimated to be more than $2 million.)
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When couples are straggling to have a child and do not have insurance coverage, they may be more willing to take risks in treatment that increase their chances of having a pregnancy but also could increase the chances of having a multiple birth. When paying out of pocket, knowing that they will not be able to afford more than a certain number of treatments affects their decisions and their willingness to take risks. Insurance coverage would remove that incentive. Further, insurance coverage would bring about additional oversight and management of care from the insurance company, which could in turn reduce the rate of multiple births. A 1998 study, led by physician David Frankfurter of Beth Israel Deaconess Medical Center in Boston, found that in states with mandated infertility-insurance coverage the average number of embryos transferred in an in vitro fertilization attempt was lower and the multiple-birth rate per attempt was lower than in states without mandates. The study's authors concluded that this lower rate of multiple births may be a result of less pressure from patients to maximize the chance of pregnancy and increased pressure from insurers to minimize the likelihood of multiple births.
Couples who experience infertility ride an emotional roller coaster -- from diagnosis through treatment -- a very difficult experience. The physical and emotional struggles are further exacerbated when couples face financial hurdles because of a lack of insurance coverage. Alice D. Domar of the Mind/Body Institute at Beth Israel Deaconess Medical Center led a study of women with chronic diseases which found that the psychological effect of experiencing infertility was similar to that of cancer and heart disease. Compounding the emotional distress is the stigma of infertility and the difficulty that many couples have in telling their family and friends.
What is fair when it comes to insurance coverage? The Supreme Court strengthened the arguments in favor of infertility-insurance coverage when it issued a ruling in June 1998 that demonstrated the importance of reproduction and the ability to have children. In Bragdon vs. Abbott the high court ruled that reproduction is a major life activity under the Americans with Disabilities Act, or ADA. According to the ADA, an individual is disabled if he or she has a mental or physical impairment that substantially limits one or more major life activities. Therefore, those who are impaired in their ability to reproduce may qualify for protection from discrimination based on that disability. This ruling allows those experiencing infertility to make claims of discrimination when employers specifically exclude infertility treatment from insurance plans. A number of lawsuits have arisen in the wake of that decision.
While Bragdon was not a case involving infertility (the plaintiff was an HIV-positive woman who was denied dental care), lower courts have ruled in cases specific to infertility that it qualifies as a disability under the ADA. In Bielicki vs. The City of Chicago, police officers Anita and Vince Bielicki sued the city of Chicago for excluding infertility treatment from their health plans. After the U.S. District Court for the Northern District of Illinois ruled that reproduction is a major life activity and that the Bielickis' lawsuit could go forward, the city decided to settle. Most infertility-treatment costs incurred by employees in the previous 10 years were reimbursed, and city health-insurance plans now include infertility coverage. The precedents set by this case and the Supreme Court ruling, and the prospect of further lawsuits, have brought infertility-insurance coverage to the attention of a growing number of employers and legislators.
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