Illustration of fetus, DNA, lab supplies

Assisted Reproductive Technologies: A Bioethical Argument for Medicaid Coverage

By Sravya Chary

Assisted reproductive technologies (ARTs) such as artificial insemination, egg retrieval, and in-vitro fertilization (IVF) have revolutionized the landscape for people facing reproductive obstacles. Disappointingly, none of these technologies are covered under Medicaid — an insurance program for low-income adults and children, and people with qualifying disabilities.

Given the high prices of ARTs, those on Medicaid, which includes a disproportionate number of BIPOC individuals, are left behind in sharing the benefits of advancements in reproductive technologies. It is vital for ARTs to be covered under Medicaid to uphold reproductive justice and autonomy for this patient population.

Reproductive Justice and Autonomy

Reproductive justice, a framework developed in 1994, emphasizes “a woman’s right not to have a child, but also the right to have children and to raise them with dignity […]”

The right to have children, or reproductive rights, encompasses being able to “[…] freely and responsibly [decide] the number and spacing of [one’s] children and to have the information, education, and means to do so.”

Reproductive autonomy, according to the Bixby Center for Global Reproductive Health at UCSF, similarly involves “[…] control [of] whether and when to become pregnant […]”

According to these definitions, financial barriers to ARTs violate reproductive justice and autonomy.

High Costs of ARTs

Infertility treatments may require multiple rounds of artificial insemination, egg retrieval, and IVF. The out-of-pocket costs for these treatments are on average $300-$1,000, $10,000, and $12,000, respectively. In total, those paying out-of-pocket can expect an average cost of $23,474 for one IVF cycle. Further, it is important to note that most individuals must undergo multiple cycles of IVF for a successful live birth. The average patient spends roughly $50,000 per live birth.

Further costs associated with fertility treatments include IVF medications, which generally cost between $3,000-$5,000 and preimplantation genetic screening (PGS), which costs $3,500.

PGS, often foregone by low-income individuals, becomes increasingly pertinent for older mothers, due to the association between maternal age and chromosomal birth defects.

Medicaid Coverage and Demographics

The costs associated with ARTs are a significant barrier to access for Medicaid patients. According to the Kaiser Family Foundation (KFF), currently there are no state Medicaid programs that cover artificial insemination or in-vitro fertilization, and there is only one state program that covers any fertility treatment at all. Given the high list prices for these technologies, without coverage ARTs are unaffordable for Medicaid patients.

This is extremely troubling for the low-income individuals who are disproportionately BIPOC that rely on the Medicaid program for health services. In 2019, KFF reported that 58.9% of Medicaid patients were BIPOC individuals (83.7% of which identify as Black or Hispanic).

The lack of Medicaid coverage for ARTs therefore places a disproportionate burden on BIPOC individuals and violates reproductive justice and their reproductive autonomy.

A study conducted by Janitz et al. found that access to ARTs and infertility treatment education widely differed based on race and ethnicity. These services were underutilized by black women compared to white women and Hispanic women compared to non-Hispanic women. Overall, the study found that barriers (such as “[…] lower incomes on average among Black and Hispanic women […]”) to infertility treatments “may contribute to reproductive health disparities among underserved populations.”

These disparities are a barrier to realizing reproductive justice in the United States. The definition of reproductive rights highlights having the “means” to reproduce as a necessary condition of reproductive justice. With high out-of-pocket costs associated with ARTs, fulfilling this necessary condition will require financial assistance for Medicaid patients.

Potential Solution

To help mitigate the infringement on reproductive justice and autonomy faced by low-income, disproportionately BIPOC, individuals, these technologies must be covered under Medicaid.

As a potential solution, the state and federal governments should negotiate rates of ARTs with providers and cost share to fully cover at least one live birth (this can include multiple cycles of artificial insemination, egg retrieval, and IVF) with a cap placed on the number of overall IVF cycles to reduce harm to the mother. Embryo PGS and supplementary hormones/medications must be covered as well.

Upholding reproductive justice and autonomy for low-income and disproportionately BIPOC Medicaid patients requires these technologies to be covered. The federal and state governments should work together to make this a reality, allowing individuals — no matter their income status — to access assisted reproductive technologies.

 

The above opinions are wholly my own and in no way represent the opinions of my affiliated institutions.

Sravya Chary

Sravya Chary

Sravya Chary is a manager in the pharmaceutical industry, a Master of Bioethics (MBE) candidate at Harvard Medical School, and a Petrie-Flom student fellow for the 2020-2021 academic year.

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