Clinical vignettes and global health considerations of infertility care in under-resourced patients

The American Society of Reproductive Medicine (ASRM) estimates that the current average cost of an in-vitro fertilization (IVF) cycle in the United States is $12,400 [13]. Even with government subsidization, the cost of an IVF cycle is around 50 % of the annual disposable income in the United States [14]. This is a huge cost to pay for the hope of having a child, yet of the 50 United States, only fifteen states mandate infertility treatment coverage. The following eleven states have a mandate to cover infertility treatments: Arkansas, Connecticut, Hawaii, Illinois, Maryland, Massachusetts, Montana, New Jersey, Ohio, Rhode Island, and West Virginia [3]. California and Texas have a mandate to offer the option to buy a health plan that covers infertility treatments; however, California does not require offering IVF coverage [3]. Louisiana and New York require that insurance companies cover the treatment of any correctable medical conditions, which includes some infertility treatments, but not IVF [3].

Under the Massachusetts State Infertility Insurance Mandate, coverage for infertility treatment is required from general insurance policies, non-profit hospital service corporations, medical service organizations, and health maintenance organizations that provide fertility-related benefits [15]. Boston Medical Center is a safety net hospital that offers underserved populations healthcare coverage under the Boston Medical Center HealthNet Plan. Safety net hospitals or hospital systems offer care without question to low-income, uninsured, and vulnerable populations [16]. HealthNet covers about 220,000 members across MassHealth (Medicaid), ConnectorCare, and Qualified Health Plans [17]. However, under the HealthNet plan, only those customers who have a Massachusetts Health Connector qualified health plan, ConnectorCare, a commercial Commonwealth Choice plan, or health insurance provided by an employer are covered for infertility treatments [18]. MassHealth, the Medicaid plan, covers infertility diagnosis and not treatment [18]. The situation is further complicated by the implementation of the Affordable Care Act, which mandates that four different plan designs be offered by health insurance companies that would cover 90, 80, 70, and 60 % of actual medical expenses depending on the price of the plan purchased [19]. Therefore, those customers that choose to purchase a health plan must decide between balancing the costs of an insurance plan and the anticipated costs of infertility treatments.

Even if a woman of child-bearing age meets the guidelines for IVF treatment in a state with mandated coverage, she will still need to make hard decisions about her choice of healthcare insurance, especially since IVF often needs repeated cycles in order to be successful. A mandate to cover infertility treatments leads to increased safer use of IVF, decreased use of riskier treatments, and higher first birth rates for women over 35 years [11, 17, 20–22]. Despite the demonstrated benefits, many states have yet to provide their citizens with mandated coverage. As a result, there is an unmet demand for infertility treatments in the United States. In 2003, only 24 % of the estimated demand for ART was met in North America [14]. The reason for this massive unmet demand, the highest amongst developed nations [14], may be due to the many barriers that infertile couples face when considering ART. Studies have shown that IVF use is closely associated with higher socioeconomic status [2, 4, 5] since the economic cost of IVF plays a large role in a couple’s decision to pursue treatment or not [23].

For refugees, the options are even more limited. Refugees can apply initially for a short-term eight month maximum health insurance called Refugee Medical Assistance, which does not cover the cost of any infertility treatments [24]. They can also apply for Medicaid or a safety net program, such as the Health Safety Net in Massachusetts [24]. However, these safety net programs only cover the cost of diagnosing infertility. If they are deemed ineligible for these programs, they will have to apply for refugee assistance from other sources or buy insurance independently through the Marketplace [24]. For this population, access to infertility care is a reach, and access to fertility preservation is an impossibility.