Generosity of insurance Coverage of Assisted Reproductive Technology and Incidence of Multiple Births in the US

More than 15% of women of childbearing age in the US reported struggle with fertility. At the same time, technological advances have provided a class of procedures known as Assisted Reproductive Technology (ART) which includes all fertility treatments in which both ova and sperm are manipulated in a laboratory. In-Vitro Fertilization (IVF) comprises 99% of the ART procedures. Infertility treatments are extremely expensive and  result in barriers to access. The average cost of one IVF cycle is $12,400, and it can often take multiple cycles to achieve a pregnancy. Since 1985, legislation has been passed in several states that mandates insurance coverage of infertility treatments in private insurance plans. Today, more than 25% of health insurance plans in the US cover infertility treatments. Mandated insurance coverage of ART treatments has made it available to many women who struggle with fertility and has helped them to conceive and deliver their own biological children. However, there are other unintended consequences associated with increased use of IVF treatments, whereby it has contributed to an increase in multiple births. Some women prefer implanting three to five embryos to maximize the chance of success in pregnancy. As a result, worldwide, 45% of IVF babies are high-order pregnancies. Multiple pregnancies carry with them associated risks including a higher incidence of mortality, birth defects, premature delivery and low birth weight.

In this paper, we empirically investigate whether more generous insurance coverage of infertility treatments increased the incidence of multiple births. The main issue here is that the women who use IVF treatments are a highly selective group among those who have fertility problems. To overcome this endogeneity issue, we use the differences in insurance coverage of IVF treatment in mandated states in the US as an exogenous source of variation. There are states which explicitly exclude coverage of IVF, while others cover only one cycle of IVF treatments and some others cover three or more cycles. We use this variation in generosity of IVF coverage to estimate the causal effect on incidence of multiple birth from mandated insurance coverage of IVF treatment in a difference-in-differences framework.  

 We use data from National Center for Health Statistics Natality Detail Files from 1985 to 2004. The results indicate a 1.4% increase in incidence of multiple births in states with more generous coverage than those with less generous ones. The estimated effect is robust after controlling for the state and time fixed effects along with mother’s characteristics including age, marital status, race and education level. The findings of this paper suggests that more generous coverage of IVF treatment leads to a more intense utilization which results in higher incidence of multiple births.  From a public policy point of view, covering IVF treatment as part of a public health program without imposing regulations on the number of implanted embryos, might imply a burden on the public health system both in terms of the costs associated with the utilization and costs associated with induced multiple births.