Coverage Is the Exception

ABOUT 6 MILLION AMERICAN COUPLES grapple with infertility, some 10 percent of the reproductive-age population, according to the American Society for Reproductive Medicine. Only about 15 percent see a doctor about it, and fewer still opt for any kind of treatment. There are no reliable figures on exactly how many infertile couples pay for their own treatment out-of-pocket, but one study shows that fewer than a quarter of all employer health plans, at companies with at least 10 employees, include infertility as a covered condition. Most simply exclude infertility altogether.

The plans that do pay often limit coverage to diagnosis and basic treatments - artificial insemination, for example - while excluding costly advanced reproductive technologies such as IVF or intracytoplasmic sperm injection (ICSI), a laboratory procedure where just one sperm cell from a man with a low sperm count can be injected into the woman's egg to create an embryo.

Some infertile couples only discover the holes in their insurance umbrella when they try to open it for the first time. Pharmacist Bruce Glickman, owner of a small drug store in suburban Dobbs Ferry, N.Y., recalls several awkward occasions where clients handed over a prescription for expensive infertility drugs along with their insurance card, only to have the computer system reject them.

"Normally you'll go to your pharmacy for a cold or a backache and have your prescriptions filled for a $5 co-pay," Glickman says, standing behind the druggist's counter in his white coat. "Here you walk into the pharmacy and the drugs are not covered and suddenly it costs $2,000. It can be a stunning revelation."

Health insurance and employer groups say covering infertility in basic medical plans would benefit a tiny minority while boosting the cost for everyone else. But this is true for other conditions, infertility activists point out, including AIDS or rare forms of cancer.

A 1997 study by William M. Mercer, a human resources consulting firm, found that covering infertility treatments, including advanced procedures such as IVF, would add about $3 a year to each member's health insurance premium. The study noted that many insurance plans now cover surgery to repair an infertile woman's blocked or damaged fallopian tubes, when IVF might actually be a less expensive and more successful procedure.

Some infertile people have used the courts to get their medical bills paid. This year the city of Chicago agreed to cover infertility treatments for its employees and pay 10 years' and $ 1.5 million worth of previously denied claims after a female police officer sued the city for violating the Americans with Disabilities Act. The officer said her infertility was a disability because it impaired a "major life activity." The U.S. Supreme Court decided a case in summer, 1998 that may bolster others who want to make such claims under the disabilities act. In a ruling on an HIV discrimination case, the court found that infertility is, indeed, a "major life activity" under the terms of the disabilities act .

While advocates for insurance coverage argue the infertile are discriminated against, health policy expert George Annas, chair of the Health Law department at the Boston University's School of Public Health, says it's more complicated than that. Infertility is not a life-threatening condition, Annas points out, and health care is a finite resource. "People want their suffering addressed and I would, too," Annas says. "But we're past the point where we can cover everything."

Annas favors a national health insurance system under which all Americans are guaranteed basic health care. Infertility treatments could be part of that, he says, but would likely limit the number of high-cost procedures. "The real social justice question is how do we cover the 40 - 50 million completely uninsured people in the United States and the 50 million others who are underinsured. It's a much higher priority ethical and social justice issue than how do we increase the private coverage people have to include infertility."