1. Health Insurance Coverage and Access to Technologies: The Case of Insurance Mandates for the Treatment of Infertility Melinda Henne Laurence Baker M. Kate Bundorf Supported by funding from the Agency for Healthcare Research and Quality and the Iris M. Litt Fund

2. Increasing utilization of ART in the U.S.

3. Trends in rates of multiple births

4. 15 States have insurance mandates 1980 200219851987198919912001 Maryland Arkansas Hawaii Massachusetts Montana Texas California Connecticut Rhode Island Illinois Ohio New Jersey Louisiana West Virginia New York

5. Effect of insurance coverage on treatment patterns Jain et al, 2002Comprehensive insurance coverage increases utilization, decreases number of embryos transferred, births, percent multiple births Jain et al, 2002Comprehensive insurance coverage increases utilization, decreases number of embryos transferred, births, percent multiple births Reynolds et al, 2003Comprehensive insurance coverage reduces number of embryos transferred in women <35, maybe reduce multiple birth rates (significant only in MA) Reynolds et al, 2003Comprehensive insurance coverage reduces number of embryos transferred in women <35, maybe reduce multiple birth rates (significant only in MA) –Both studies evaluated one year only (1998) –Jain et al did not address differences in demographic characteristics across states –Reynolds et al matched mandate states to geographically close states with similar size population

6. Research question How does comprehensive insurance for infertility affect birth outcomes at the population level?

7. Data Sources – Birth Certificates National Vital Statistics System from the NCHS 1980-1997 National Vital Statistics System from the NCHS 1980-1997 –Information abstracted from birth certificates –100% of births for most states for most years –Total number of births, multiple births (twins or higher order), triplets+ (triplets or higher order –Transform births to deliveries for calculation of multiples

8. Data Sources – Insurance Mandates RESOLVE and state legislation RESOLVE and state legislation Categorized based on likely effectiveness in changing treatment patterns: Categorized based on likely effectiveness in changing treatment patterns: –Comprehensive (3 states)– requirement that insurance companies (including HMOs) provide coverage for the cost of diagnosis and treatment of infertility, including ART of at least 4 oocyte retrievals. –Soft (5 states) – limited coverage –Offer only (3 states) – mandates insurance companies to offer coverage, but no mandate to purchase coverage –No Mandate

9. Data Sources - Other U.S. Census Bureau U.S. Census Bureau Bureau of Economic Analysis Bureau of Economic Analysis Bureau of Labor Statistics Bureau of Labor Statistics Current Population Survey Current Population Survey

10. Data Analysis – Birth Data where i indexes states and t indexes years y is a birth outcome including deliveries, multiple deliveries, and triplet+ deliveries per 1,000 women, multiples and triplets+ per 1,000 deliveries C, S, and O are time-varying indicators of mandates Y is a year fixed effect G is a state fixed effect

11. Effect on Deliveries per Capita

12. Effect on Multiple Deliveries per Capita

13. Effect on Multiples per 1000 Deliveries

14. Effect on Triplet+ Deliveries per Capita

15. Effect on Triplets+ per 1000 Deliveries

16. Summary of Results In states with comprehensive insurance mandates… In states with comprehensive insurance mandates… –At the population level, delivery rates are higher, although the effect is concentrated among 30-34 year olds. –At the population level, the proportion of multiple deliveries, particularly triplets or higher order, is higher for women 20-29, 30-34, 35-39. Effects are restricted to mandates providing comprehensive coverage. Effects are restricted to mandates providing comprehensive coverage.

17. Conclusions Generous insurance coverage of ART induces those for whom the expected benefits of therapy are lower to pursue treatment. Generous insurance coverage of ART induces those for whom the expected benefits of therapy are lower to pursue treatment. The result is that many women undergoing ART when insurance coverage is generous are those for whom the therapy did not increase the probability of a baby but did increase the probability of multiples. The result is that many women undergoing ART when insurance coverage is generous are those for whom the therapy did not increase the probability of a baby but did increase the probability of multiples.

18. Implications Broad insurance coverage for the treatment of infertility should have mechanisms to distinguish between those for whom the benefits of treatment are high and those for whom the benefits are lower.

19. Questions?