Fertility treatment costs: Should insurers pay for them?

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Update: Assembly Bill 2029 died in the Assembly Appropriations Committee on May 19, 2022.

Californians looking to start a family using in vitro fertilization are often on the hook for the full cost of treatment, in the tens of thousands of dollars. The cost can keep some people from having children, and it can leave others in excessive debt.

While 17 states have laws requiring health insurers to cover fertility treatments, most of which include in vitro fertilization, California does not.

The debate over whether health insurance plans should offer fertility coverage isn’t new to Sacramento, but even in a state where Democrats like to brag about their fight to promote reproductive health, these efforts haven’t gotten very far. The main holdout is money.

Assemblywoman Buffy Wicks, an Oakland Democrat, is trying again this year. Her Assembly Bill 2029 would require some health insurance plans to cover fertility treatments, including in vitro fertilization. The bill also broadens the definition of infertility so that more people would be eligible to be diagnosed and treated, including single people, same-sex couples and transgender people.

Wicks recently accepted amendments in an effort to reduce the cost of her bill, which as first drafted had a price tag of $715 million for employers and enrolled health plans. The coverage mandate in her revised bill would apply only to large group health insurance, which covers about 9 million Californians. Plans in the small group and individual markets will be released. Even as it was first written, the bill would not apply to Medi-Cal, the insurance program for low-income residents.

The bill would also now limit a person’s lifetime benefits to $75,000 and limit egg retrievals to three.

“This is my third time doing this,” Wicks said. “We’re trying to get it passed and that means making amendments to limit it.”

Wicks said the issue is personal to her — her second child is a product of in vitro fertilization. (In 2020, Wicks took her then-newborn to the Capitol to vote for a family leave bill.) The goal, she said, is to take a piecemeal approach and expand the benefit to more people over time.

California law currently requires insurance companies to offer fertility treatment except in vitro, but it is up to the employer or group to decide whether it is included as a covered benefit. This bill would make that coverage mandatory.

Annabel Adams, who recently testified in support of Wicks’ bill, paid nearly $50,000 for three rounds of in vitro fertilization. Born with a chromosomal inversion that makes it difficult for her to sustain a pregnancy, she suffered six losses.

Her doctors recommended in vitro fertilization, or IVF, a process in which eggs are removed from the ovaries and fertilized by sperm in a laboratory. The fertilized egg, or embryo, is then transferred to the uterus. For Adams, this process allows her doctors to test the embryos to ensure they are not affected by her genetic issue, increasing her chances of a viable pregnancy.

Her first round of treatment, including medication, cost her $25,600, she said. Her Kaiser insurance plan, as offered by her University of California employer, did not cover it. Her husband’s insurance helped cover some of the costs for the second and third rounds.

“Every pregnancy is filled with terror. These are wanted pregnancies; it’s children that we envision and plan a future around,” said Adams, a Long Beach resident and founder of California Fertility Advocates. “Finding out that IVF was essentially the cure for my illness and knowing that it wasn’t easily accessible to me felt like an extra layer of damage.”

The health insurance lobby and business groups oppose Wicks’ bill, citing the cost. They say that like other pieces of legislation that require new benefits to be covered, this bill will cause increases in health insurance premiums for employers and employees.

According to the California Association of Health Plans, it is the most expensive bill the organization opposes this year, and Wicks’ recent amendments do not change his position.

“As health plans, we have to be concerned about the cost to everyone,” said Mary Ellen Grant, a spokeswoman for the association. “We do not dispute the merits of this bill, but it increases health care costs for Californians. It’s just not something the health plans can figure out.”

Grant said lawmakers should consider the sum of all benefit mandates they choose to pass, not just a single bill. This year, the association opposes 14 bills that require new benefits to be covered — collectively, these bills could raise annual premiums by $1.5 billion, the association said.

The California Chamber of Commerce and several local chambers, which represent the interests of businesses, also expressed opposition to the bill because of the cost. The bill next heads to the Assembly Appropriations Committee, which weighs a bill’s fiscal impact.

In 2019, California introduced a law clarifying that insurers must cover the cost of preserving eggs, sperm or embryos for patients undergoing treatment for diseases that affect their ability to have children. Two previous bills introduced by Wicks in 2019 and 2020 that targeted fertility coverage more broadly did not advance.

While much of the conversation surrounding Wicks’ current bill has focused on in vitro fertilization, because it is the most expensive type of fertility treatment, the bill touches on the broader issue of fertility coverage in general, Dr. Marcelle Cedars, a reproductive endocrinologist at the University of California, San Francisco. Not everyone who is infertile needs in vitro fertilization.

“It’s really about recognizing infertility as a disease,” Cedars said. “As with any disease, all evidence-based, medically valid treatment options should be available to patients.”

Cedars said she has patients whose diagnosis is covered by their insurance, but not their treatment. “You would never say, ‘Oh, by the way, you have diabetes, but we’re not going to give you insulin to treat it.’ I mean, this is crazy, what other disease would you treat like that?”

Infertility is estimated to affect about one in eight couples, or about 15% of the population in the US. Dr. Cedars said that although infertility is recognized as a disease by the World Health Organization and the American Medical Association, socially and politically, it is more obscure. . Treatment is often considered elective.

“Reproductive health is difficult in this country, as we’ve seen this week,” Cedars said, referring to news of a leaked draft opinion that showed the U.S. Supreme Court is poised to strike down Roe v. Wade. “Reproductive health is really a spectrum, it’s not having children when you don’t want to and being able to have them when you do.”

In the abortion debate, California positions itself as a sanctuary state for people from out of state who want to terminate a pregnancy. Democratic lawmakers have drafted a package of bills moving through the Legislature to protect abortion access and affordability. Governor Gavin Newsom has already signed one of those bills, eliminating out-of-pocket costs for abortions.

Wicks and supporters of her bill said that ultimately this bill is also about choice — allowing people to start a family if and when they choose. “That’s why I’m working on bills for safe and legal abortion and ensuring that doulas are covered,” Wicks said. “All of these things are very connected to me.”

CalMatters COVID and health care coverage is supported by grants from the Blue Shield of California Foundation, the California Health Care Foundation and the California Wellness Foundation.