The Brave New World of Reproductive Health

"The Brave New World of Reproductive Health"

At the 5^th National Health Policy Conference

Seattle, Washington-November 16, 2001

10:45 a.m. - 12:15 p.m.

Moderator:	Representative Tom Campbell, Washington
Speakers:	Delegate Adelaide "Addie" Eckardt, Maryland
	Mike Kreidler, Insurance Commissioner, Washington
	Michael R. Soules, M.D., President, American Society for Reproductive Medicine, University of Washington

The purpose of this session was to address some of the ethical and legal questions stemming from advances in reproductive health. Although many reproductive health issues were hot during the 2001 legislative sessions, insurance coverage for prescription contraceptives or infertility therapy were two of the most widely debated issues. This session was organized to provide an overview of legislative trends and policy issues as well as ethical and legal implications related to contraceptives and infertility therapy.

Dr. Michael Soules opened the session with a slide presentation on issues related to infertility. Dr. Soules clarified that infertility is a disease-not a lifestyle choice. Over the past 20 years, the number of infertility cases has increased. Infertility affects 10 to 12 million people, but only a minority seeks treatment for infertility. People often do not seek care due to the high price of treatment and lack of insurance coverage for treatment.

Dr. Soules discussed the difference between the two common approaches to passing state laws related to insurance coverage for infertility treatment-some states require insurance companies to cover infertility treatment, while others require insurance companies to offer coverage for infertility treatment. A mandate to cover requires that health insurance companies provide coverage of infertility treatment as a benefit included in every policy (the policy premium includes the cost of infertility treatment coverage). A mandate to offer coverage requires that health insurance companies make available for purchase a policy that covers infertility treatment (but this does not require employers to include the infertility treatment coverage in health plans they choose to offer employees).

Dr. Soules discussed unforeseen consequences that result when insurance plans do not cover infertility treatment, including excessive, prolonged use of tests, disproportionate numbers of assisted reproductive technology programs competing for the limited number of self-pay patients, and high rates of multiple pregnancies because people are more likely to want to implant more eggs or embryos to increase their changes of pregnancy when they pay for the expensive procedure themselves.

Illinois, Massachusetts and Maryland offer the most comprehensive coverage for infertility treatment. Dr. Soules explained that multiple birth rates are below average in the three states because physicians do not feel pressured to implant excessive numbers of eggs or embryos as a result of limited insurance coverage for the procedure. In other words, because the procedures are fully covered by insurance, the physicians tend to practice more conservatively-implanting only the recommended number of eggs or embryos. High rates of multiple births often result in increased numbers of low birthweight babies, higher costs for neonatal intensive care and higher rates of infant mortality.

Maryland Delegate Addie Eckardt provided a state perspective about insurance coverage for infertility therapy. She focused her presentation on Maryland House Bill 350 that passed in 2000. Although Maryland already required insurance coverage for infertility therapy through statute, the new bill puts limits oncoverage for in vitro fertilization. Delegate Eckardt explained that Maryland has the most mandates among the states-the first enacted mandate required insurance coverage for in vitro fertilization (IVF). The 2000 bill changed existing legislation, providing policyholders coverage for male factor infertility, reducing the waiting period for treatment to two years and limiting coverage for IVF to three cycles. The bill limiting insurance coverage for infertility therapy passed with little opposition. Delegate Eckardt explained that, in her experience, most insurance companies already cover infertility treatment, so she is not sure that a mandate to provide such coverage is necessary. In response to concern that limits on coverage may result in an increase in the number of premature or multiple births, Delegate Eckardt said that Maryland has not experienced this result.

Washington Commissioner Michael Kreidler focused his presentation on insurance coverage for contraceptives and the unique approach that he used to enact such a rule in the state. Commissioner Kreidler explained that seven out of 10 people support inclusion of contraceptive benefits in insurance policies. He has found that most opposition to mandates for insurance coverage for contraceptives usually comes from religious organizations and small businesses. Commissioner Kreidler felt legally responsible to enact the rule, and believes that not mandating insurance coverage for contraceptives contributes to discrimination against women. According to Commissioner Kreidler, Washington is the only state that has mandated contraceptive coverage through an administrative rule. Although the rule requires coverage for a variety of birth control pills and devices, it does not require coverage for sterilization or condoms. Commissioner Kreidler reviewed a few related statistics-one half of all pregnancies that occur are unplanned; women pay more for health care than men do; and contraceptives cost an average of $1.43 per month compared to the $8,000 cost of a delivery. Go to the Washington State Insurance Commissioner's website to read more about the rule.

Legislators and legislative staff who attended the session asked questions related to mandates for insurance coverage for contraceptives that include religious exemption clauses, negotiating rates with health maintenance organizations, and treating pregnancy like a disease.

Delegate Eckardt responded to a question about limiting the number of embryos that can be used in certain procedures. She believes that the Maryland law allowing up to three in vitro fertilization procedures allows physicians and patients enough treatment attempts, and eliminates the risk of a physician feeling compelled to implant "too many eggs." Dr. Soules emphasized that legislative action is "the worst way to approach an embryo issue." He recommended instead that policymakers use the American Society for Reproductive Medicine/Society for Assisted Reproductive Technology (ASRM/SART) guidelines. Representative Campbell cautioned against "putting limits on science," and explained that mistakes made in legislation often create loopholes.

Representative Graziano from Rhode Island said that, at first, she objected to coverage for contraceptives until insurance companies began providing coverage for Viagra. She said that the biggest controversy in Rhode Island relates to single women who choose to become pregnant through assisted reproductive technologies.

Representative Campbell asked for response from the audience regarding whether they would be interested in convening a roundtable on various issues related to assisted reproductive technologies, including access, costs and mandates.

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