“Who Pays? Mandated Insurance Coverage for Assisted Reproductive Technology,1” published by the American Medical Association Journal of Ethics, examines the arguments for mandating insurance coverage for assisted reproductive technology (ART) which includes in vitro fertilization (IVF). Overall, the researchers concluded, with almost palpable condescension, that while infertility is a hardship, it should not be mandated because the option of adoption is a good alternative.
Fertility Within Reach has written a five page response to this article. We are going to share our reaction over multiple blog posts throughout the week.
Retort #1: Infertility and Adoption was posted Monday, January 13, 2014. Here we utilize research to point out how Dr. Rosoff and Katie Falloon’s own research has minimized the adoption process, in terms of cost, time, and legal issues.
Retort #2: Equal Access was posted on Tuesday, January 14, 2014. FWR shares research to support the idea, as long as there are exceptions to providing infertility health benefits, there will be a lack of equal access to infertility health care. A lack of care denies infertility patients the opportunity to overcome their disability.
Retort #3: Medical Care vs. Alternative Treatments
I do not agree with the authors’ comparison of adoption with ART. Both are options of family building, not a treatment of a physical, medical condition. The authors’ state, “Moreover, if we choose to consider which option is better for society as a whole (rather than for a given infertile couple) we could reasonably argue that adoption is the better choice.” The question should never have been whether ART is preferable to adoption. The ethical question pertaining to state mandated insurance coverage should be, “Do infertility patients have a fundamental right to access treatment for their medical condition?” Here are two scenarios to consider. First is a female patient with Polycystic Ovary Syndrome (PCOS) (“PCOS is a term used to describe a common hormonal disorder that causes the ovaries to produce excessive amounts of androgens”6). Another couple experiences male factor infertility (“Infertility caused by a problem in the male, for example, inability of ejaculate or insufficient number of sperm.“)7, which can be caused by more than a dozen factors, including trauma.8 The only option for these patients to overcome the failure within their reproductive system, to overcome their disability, is through ART. Don’t these patients, ethically, have a right to access this level of care?
I challenge Dr. Rosoff and Katie Falloon’s concluding statement, “In our view, a reasonably just state should offer coverage for medical treatments for which alternatives do not exist, and ART does not meet the criterion—adoption remains an extremely good alternative.” To be clear, they believe if a nonmedical/alternative means is available, then the state should not offer coverage for medical treatment. Let’s consider other medical conditions and see if Dr. Rosoff and Katie Falloon’s conclusions apply to other kinds of medical conditions.
- Type II Diabetes. A patient develops Type II Diabetes, the body is not producing insulin correctly and the patient requires medical treatment to help the endocrine system function as it medically should. As an alternative to medical treatment, the patient could watch their nutritional intake, exercise regularly, take herbs, and undergo acupuncture. An article published in the American Journal of Preventative Medicine in 2013 concludes,“The age-gender weighted average of the lifetime medical costs was $85,200”9 to treat Type II Diabetes. Following Dr. Rosoff and Katie Falloon’s logic, a condition such as Type II Diabetes, where there are significant alternative options for treatment, should not receive government-mandated coverage.
- High Blood Pressure, High Cholesterol. According to the CDC, within their press release, “Most Americans with High Blood Pressure and High Cholesterol at Unnecessary Risk for Heart Attack and Stroke: 80 percent of adults with uncontrolled blood pressure or high cholesterol have insurance and availability to low cost effective treatment”, they state, “Cardiovascular disease costs the nation an estimated $300 billion each year in direct medical costs and those costs are increasing rapidly. Treatment for this disease accounts for $1 in every $6 US health dollars spent.”10 As an alternative to medical treatment, most of the population could reduce their high blood pressure and cholesterol with proper diet habits and exercise. Surely to be consistent, Dr. Rosoff and Falloon would argue that there is no need for government mandated coverage for conditions resulting from high blood pressure and high cholesterol, since there are alternatives to medical treatment.
- Cancer. As a pediatric oncologist, it is unlikely Dr. Rosoff would say cancer treatment should not be covered by insurance and yet, if he followed his own logic, there would be no coverage since there are alternative and complimentary therapies to treat this condition. We know the U.S. Department of Health & Human Services, National Institutes of Health have developed a National Center for Complementary and Alternative Medicine. They fund research with findings such as “Laboratory Study Suggests Potential Anti-Cancer Benefit of White Tea Extract”.11 In addition, the National Cancer Institute has developed the Office of Cancer Complementary and Alternative Medicine. Their research is vast and includes research such as “Phytonutrients Shown to Inhibit Cancer Stem Cells from Regrowing Tumors. “ 12 I would assume that since these alternatives to medical treatment exist, cancer is another disease for which mandated coverage is not necessary.
My argument with Dr. Rosoff and Katie Falloon’s conclusion is they are lumping patients into what they believe is the single superior option for family building for infertile individuals rather than treating patients with a medical condition, on an individual basis. I ask them, “Why have 20 different antibiotics available to patients. Why not just have one everybody should take?” The answer applies to the treatment of infertility as well.
Retort #4: The Impact of Infertility
Retort #5: The Cost of Infertility Health Benefits
About the authors:
Davina Fankhauser, MA is the co-founder and President of Fertility Within Reach, a national non-profit organization which helps patients gain access to infertility health benefits to treat their medical condition in a timely and appropriate manner. She works collaboratively with medical professionals and organizations to bring accurate information to patients, employers, insurers and legislators. Davina lobbied at the Massachusetts State House and saw the successful passage of an update to the medical definition of infertility within the state. She also testified before the Massachusetts Division of Insurance to request Oocyte Cryopreservation be a required benefit of infertility. Working with medical directors, she presented recommended Oocyte Cryopreservation guidelines to insurers. These companies are now offering Oocyte Cryopreservation to infertility patients as well as patients facing medical treatments which will render them infertile.
Katie Falloon is a second-year medical student at Duke University School of Medicine in Durham, North Carolina. She graduated magna cum laude from Yale University with a degree in English.
Philip M. Rosoff, MD, MA, is a professor of pediatrics (oncology) and medicine at the Duke University School of Medicine and Duke University Medical Center in Durham, North Carolina. He is also chair of the center’s ethics committee and a member of the Trent Center for Bioethics, Humanities and History of Medicine. His research interests and scholarly work are in the area of medical resource allocation, especially rationing. His book Rationing Is Not a Four-Letter Word: Setting Limits on Healthcare will be published in spring 2014 by MIT Press.
- Virtual Mentor. January 2014, Volume 16, Number 1: 63-69.
- American Society for Reproductive Medicine, Hirsutism and Polycystic Ovary Syndrome (PCOS) (2012). Retrieved from https://www.asrm.org/awards/detail.aspx?id=12227
- American Society for Reproductive Medicine, Male Infertility (n.d.). Retrieved from (https://www.asrm.org/topics/detail.aspx?id=1331
- Mayo Clinic Staff, Diseases and Conditions: Male Infertility. (n.d.) Retrieved from http://www.mayoclinic.org/diseases-conditions/male-infertility/basics/definition/con-20033113
- Xiaohui Z, Zhang P, Hoerger T. Lifetime Direct Medical Costs of Treating Type 2 Diabetes and Diabetic Complications. American Journal of Preventative Medicine, 2013; Volume 45, Issue 16, 253-261.
- Center for Disease Control and Prevention. (2011). “Most Americans with High Blood Pressure and High Cholesterol at Unnecessary Risk for Heart Attack and Stroke: 80 percent of adults with uncontrolled blood pressure or high cholesterol have insurance and availability to low cost effective treatment” Press Release February 1, 2011. Retrieved from http://www.cdc.gov/media/releases/2011/p0201_vitalsigns.html,
- National Center for Complementary and Alternative Medicine. “Laboratory Study Suggests Potential Anti-Cancer Benefit of White Tea Extract”, September 1, 2010 Retrieved from http://nccam.nih.gov/research/results/spotlight/092110.htm
- Farrar, William. (2008). “Phytonutrients Shown to Inhibit Cancer Stem Cells from Regrowing Tumors”. NCI CAM News. Volume 3, Issue 1. Retrieved from http://cam.cancer.gov/newsletter/2008-spring/6.html#phyto
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