As fertility rates drop and more women postpone childbirth into their 30s and 40s, more states are considering mandating that private insurers cover fertility treatments to help people start a family without the crushing out-of-pocket expenses.

Such laws would help people such as Miraya and Andy Gran of Bloomington, Minnesota, who ended up spending $102,000 to have their now 2-year-old daughter, Isla, through in vitro fertilization after trying other expensive options. Miraya Gran has since become an advocate for state laws requiring insurance coverage for fertility treatments.

“I had a lot of resentment and a lot of anger on top of the financial sacrifice. I just thought it was wrong. I don’t want other parents to go through this,” Gran said.

Twenty-one states require such coverage, but a proposed mandate failed to pass the Minnesota legislature this year. With the exception of New York, Medicaid programs do not cover fertility treatments.

Minnesota was one of at least 16 states, including Missouri, where legislators introduced bills this year to create or expand fertility insurance mandates. The District of Columbia recently approved legislation and California, New Jersey and Pennsylvania are still considering bills. Last year, Illinois enacted a new law that requires insurers to cover the treatments and mandates that employers offer paid leave for people recovering from unsuccessful procedures.

Some states are expanding mandates to cover more residents, including single people or same-sex couples. They’re also expanding mandates to include coverage of fertility preservation procedures for cancer patients or others who would like to preserve sperm or eggs before undergoing treatments that could make them infertile.

Mayor Muriel Bowser, a Democrat, signed the District of Columbia insurance coverage mandate in July, but Congress still must approve it, said the bill’s sponsor, Councilmember Christina Henderson.

Henderson has said she heard from people who took on extra part-time jobs just because those employers’ health insurance covered fertility treatments. The bill would take effect in 2025.

Decades of history

Fertility coverage mandates have a long history, beginning with the first one passed in West Virginia in 1977 that required HMOs to cover unspecified “infertility services.”

Maryland’s mandate in 1985 was the first to specifically cover in vitro fertilization, widely considered the most effective fertility treatment. It has a roughly 50% success rate in producing babies in women under 35 years of age. But the cost of in vitro fertilization, in which fertilized eggs are transplanted to the womb, can be prohibitive without insurance.

“The cost of IVF remains the greatest barrier to infertility care in the US,” concluded a Duke University study published last year in the journal Reproductive Biology and Endocrinology, which notes that the cost for each successful birth can be $60,000. “State infertility insurance mandates are a crucial mechanism for expanding access to fertility care in the US in the absence of federal legislation.”

West Virginia’s mandate came before the first IVF birth, and recent bills to add the procedure to the state mandate — including proposed legislation this year — have failed to pass. Fourteen states include IVF in their mandates, according to RESOLVE: The National Infertility Association, which tracks state and federal legislation.

Limited mandates like those in Texas and California only require insurers to offer fertility coverage when employers request it. A California bill that would expand the mandate to require that all large insurance plans provide coverage passed the state Senate and has progressed in the state Assembly.

The proposed expansion of the California mandate would cover unlimited embryo transfers, though other states have set limits. Maryland limits its coverage requirement to three IVF attempts per live birth and sets a $100,000 lifetime cap. Connecticut has a lifetime limit of four embryo implantations.

Religious objections

Jessica Tincopa of Orange, California, and her husband, Rob Tran, have endured six miscarriages since 2015. They had saved $20,000 for an IVF procedure before the pandemic hit, but were forced to spend their savings to stay afloat when their wedding photography business dried up. They’ve tried to find jobs with IVF insurance but have not succeeded.

“Our insurance company was billed $100,000 for the miscarriages — they would have been better off covering one trial round of IVF for us at $30,000,” Tincopa said.

Last year, 61% of large employers had health plans that covered fertility treatment, and 47% covered IVF, according to an annual survey by Mercer, a consulting firm.

Even California’s new law wouldn’t cover the small group policy Tincopa has now, since it only applies to large group policies, but at least it would create more opportunities to find a job with insurance she can use, she said.

But in California and other states, insurers have raised objections to basic or expanded fertility insurance mandates.

One insurer in Oregon, for example, objected to a fertility insurance mandate bill that would cover IVF, saying that the procedure runs afoul of a Catholic doctrine that declares the method immoral.

The insurer, Providence Health Plan, asked in written testimony to the legislature for an exemption from covering IVF. Oregon’s bill did not pass, though there was an amendment stripping the IVF requirement.

An insurer in North Dakota said the procedure could create legal issues and uncertainty when people stop paying for embryo storage because of job changes or other reasons.

The Sanford Health Plan, which provides coverage throughout the upper Midwest, also argued there would be higher costs, citing a state study that showed a plan with a $50,000 maximum benefit could increase premiums by anywhere from $1.98 to $24.85 monthly for each person insured. By a quirk of North Dakota law, the mandate must apply first to retiree insurance before the legislature can pass a general fertility insurance mandate.

The bills in Oregon and North Dakota failed to pass this year, as did others in Connecticut, Illinois, New Hampshire, New York, Vermont, Virginia, Washington, West Virginia and Wisconsin.

In North Dakota, Republican state Rep. Mike Brandenburg said it was his third attempt to get the bill through the legislature.

“I’ll keep trying,” Brandenburg said. “We’re making headway. I can see more younger people coming in (to the legislature), and it’s gaining votes all the time. If we can assist people who want to have families, why not?”

Like the Grans in Minnesota, parents in North Dakota testified about the financial burden and emotional stress of fertility treatments.

Elizabeth Carter of West Fargo, in a January letter to the legislature, said she and her husband both have advanced degrees and full-time jobs but have started moonlighting to try to pay for treatments.

“I wish I had greater access to affordable medical care for infertility through my insurance benefits so that my husband and I could also have the chance to have even a single child, who could be born into a stable household to two parents who fought and worked very hard to bring them into the world,” Carter wrote.

In Wisconsin, Democratic Gov. Tony Evers added a fertility coverage mandate to the state budget this year, but the provision didn’t make it through the Republican-dominated legislature. Democratic state Sen. Kelda Roys told Stateline she plans a stand-alone bill later this year.

“Infertility is a common disease and should be covered by insurance like any other health need,” Roys said.

A New Hampshire bill to study the cost of extending a fertility insurance requirement to single people and same-sex couples stalled in committee, but state Sen. Rebecca Perkins Kwoka said she’s still hoping to convince the state Department of Insurance may do the study without legislation.

Postponing childbirth

Some bill sponsors have pointed out that residents may postpone childbirth because of the high cost of housing and child care, as well as the reality of younger women increasingly working to establish careers before parenthood. But it’s unlikely such laws will have an effect on fertility rates that have been below the replacement rate of two children per woman since 2010.

One study from the University of California, Irvine found a connection between low fertility and states’ willingness to pass mandates, though author Katherine Bogaard said in a video presentation last year that “states are following each other’s leads” as the issue gains more attention. Bogaard told Stateline she’s preparing to publish a more detailed study.

Alison Gemmill, a demographer and fertility expert at Johns Hopkins University, said lower fertility rates are linked to postponed childbirth. That’s likely what’s driving new state legislation, along with increased concerns with equality for groups like single parents and same-sex couples, she said.

“It’s about states being receptive to messaging and advocacy from infertility treatment advocates, including many from the LBGTQ+ community,” Gemmill said. Even with more insurance, however, birth rates overall are likely to keep falling, she said.

“The increasing use of fertility treatment won’t have a large impact on U.S. birth rates just yet,” she said. “Births involving assisted reproductive technologies make up a small share, 2% of all births. It would take quite an uptick to move the needle on overall births.”

Stateline is part of States Newsroom, a nonprofit news network supported by grants and a coalition of donors as a 501c(3) public charity. Stateline maintains editorial independence. Contact Editor Scott S. Greenberger for questions: [email protected]. Follow Stateline on Facebook and Twitter.