By Mickey S. Coffler, M.D., FACOG, HRC Fertility
Lack of insurance coverage and high IVF costs may limit access to assisted reproductive technologies among minorities in the US.
There is some controversy in the literature as to whether there is a significant ethnic disparity in infertility prevalence in the US. While most studies reveal higher infertility rates among black and Latino women compared to white women of similar age (18% vs. 8%, respectively), other studies reveal a uniform prevalence of about 15% among all major ethnic groups. When access to care is assessed, however, many researchers agree that non-Hispanic, white women are more likely to receive treatment.
Infertility treatments, particularly IVF, remain mostly a fee-for-service type of provision, and mandated insurance coverage is available only in five states as of this writing. According to Fujimoto et al., national IVF data analysis reveals a nearly three-fold higher use of IVF services in states with comprehensive insurance coverage compared to states without mandated coverage. The usage rates are also higher in countries that subsidize IVF expenses. These findings suggest that a large number of women who might need treatment do not use IVF services, probably owing to financial constraints. Considering the above, it is interesting to notice that ethnic disparities are not totally eliminated by the health insurance mandates. For example, Feinberg et al. notes that in a lower cost, equal-access-to-care setting, Hispanic use of assisted reproductive technology is less than half of what would have been expected based on patient demographics. In her article “Beyond (financial) accessibility: inequalities within the medicalization of infertility,” Ann Bell argues that inequalities persist beyond financial accessibility issues because “medicine serves as a gatekeeper determining who should and should not mother according to hegemonic norms of motherhood.” In their book “Marginalized Reproduction: Ethnicity, Infertility, and Reproductive Technologies,” Culley et al. discuss access to IVF among economic disadvantaged minorities in the UK. Although infertility investigation and some “low-tech” infertility treatments are available via their National Health System, IVF treatment is costly and mainly paid for by patients. Culley et al. also notes that the extent of ethnic disparities in access to IVF treatment in the UK is not entirely well defined, as there are not enough studies documenting the ethnic background of infertility patients within the National Health System.
Overall it is agreed that additional research is needed in order to better understand the effect of economic and other factors limiting IVF access among minorities. Along those lines, one of the goals of the National Institutes of Health conference on Reproductive Problems in Women of Color from July 25, 2009 was to initiate a research network of investigators interested in studying these problems through the development of a new interest group within the American Society of Reproductive Medicine.