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
Increasing utilization of ART in the U.S.
120000
100000
80000
60000
40000
20000
Cycles
Births
01
20
00
20
99
19
98
19
97
19
96
19
95
19
94
19
92
19
91
19
90
19
19
89
0
Trends in rates of multiple births
350
300
250
200
150
100
50
19
80
19
82
19
84
19
86
19
88
19
90
19
92
19
94
19
96
19
98
20
00
20
02
0
Twins/10,000 deliveries
HOM/100,000 deliveries
15 States have insurance mandates
Arkansas
Hawaii
Massachusetts California
Maryland
1980
New Jersey
Montana
Connecticut
Illinois
Louisiana
Texas
Rhode Island
Ohio
West Virginia
1985 1987
1989
1991
2001
New York
2002
Effect of insurance coverage on
treatment patterns
• Jain et al, 2002—Comprehensive insurance coverage
increases utilization, decreases number of embryos
transferred, births, percent multiple births
• Reynolds et al, 2003—Comprehensive 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
Research question
How does comprehensive insurance for
infertility affect birth outcomes at the
population level?
Data Sources – Birth Certificates
• 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
Data Sources – Insurance Mandates
• RESOLVE and state legislation
• 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
Data Sources - Other
• U.S. Census Bureau
• Bureau of Economic Analysis
• Bureau of Labor Statistics
• Current Population Survey
Data Analysis – Birth Data
yi ,t    1Ci ,t  2 Si ,t  3Oi ,t  Gi  Yt   i ,t
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
Effect on Deliveries per Capita
Deliveries per 1000 Women
Age
20-49
20-29
30-34
Offer Mandate
3.252
6.782+
2.139
[2.535]
[3.519]
[2.049]
Soft Mandate
-0.309
-0.183
-0.724
[1.482]
[1.609]
[1.613]
Comprehensive Mandate
2.657*
1.079
4.018*
[1.066]
[2.204]
[1.551]
Constant
57.868** 111.417** 45.098**
[0.989]
[1.099]
[1.092]
Observations
918
918
918
R-squared
0.86
0.92
0.94
Robust standard errors in brackets
+ significant at 10%; * significant at 5%; ** significant at 1%
35-39
2.218
[1.830]
-0.172
[1.353]
2.982
[1.783]
11.191**
[0.798]
918
0.94
40-44
1.055
[0.782]
-0.18
[0.446]
0.501
[0.541]
2.126**
[0.240]
918
0.91
45-49
0.065
[0.065]
-0.019
[0.021]
0.004
[0.037]
0.120**
[0.020]
918
0.77
Effect on Multiple Deliveries per Capita
Multiple Deliveries per 1000 Women
Age
20-49
20-29
30-34
Offer Mandate
0.017
0.003
-0.016
[0.042]
[0.041]
[0.051]
Soft Mandate
0
0.027
-0.019
[0.026]
[0.018]
[0.046]
Comprehensive Mandate
0.071*
-0.004
0.193**
[0.027]
[0.032]
[0.046]
Constant
0.613**
1.168**
0.558**
[0.014]
[0.013]
[0.023]
Observations
918
918
918
R-squared
0.74
0.81
0.86
Robust standard errors in brackets
+ significant at 10%; * significant at 5%; ** significant at 1%
35-39
0.024
[0.047]
-0.009
[0.043]
0.124+
[0.071]
0.112**
[0.021]
918
0.85
40-44
0.032
[0.019]
-0.001
[0.009]
0.032
[0.025]
0.023**
[0.006]
918
0.73
45-49
0.011
[0.007]
-0.002
[0.002]
0.002
[0.004]
-0.004**
[0.001]
918
0.59
Effect on Multiples per 1000 Deliveries
Multiples per Delivery
Age
20-49
20-29
30-34
Offer Mandate
-0.619*
-0.643**
-0.668*
[0.267]
[0.114]
[0.301]
Soft Mandate
0.17
0.279
0.061
[0.281]
[0.200]
[0.288]
Comprehensive Mandate
0.743+
-0.043
1.174**
[0.428]
[0.101]
[0.267]
Constant
10.760** 10.504** 13.080**
[0.116]
[0.089]
[0.178]
Observations
918
918
918
R-squared
0.86
0.77
0.75
Robust standard errors in brackets
+ significant at 10%; * significant at 5%; ** significant at 1%
35-39
-0.926*
[0.450]
0.112
[0.809]
1.19
[1.089]
12.951**
[0.347]
918
0.68
40-44
1.18
[1.142]
1.770*
[0.676]
3.6
[2.477]
13.074**
[0.888]
918
0.38
45-49
11.528
[8.104]
6.159+
[3.120]
7.248
[8.209]
-9.279**
[3.013]
918
0.48
Effect on Triplet+ Deliveries per Capita
Triplet Deliveries per 1000 Women
Age
20-49
20-29
30-34
Offer Mandate
-0.002
-0.005**
-0.010*
[0.002]
[0.002]
[0.005]
Soft Mandate
0.001
0.001
0.001
[0.002]
[0.001]
[0.006]
Comprehensive Mandate
0.009**
0.002
0.031**
[0.001]
[0.003]
[0.003]
Constant
0.006**
0.016**
0.002
[0.001]
[0.001]
[0.002]
Observations
918
918
918
R-squared
0.75
0.51
0.72
Robust standard errors in brackets
+ significant at 10%; * significant at 5%; ** significant at 1%
35-39
0.002
[0.003]
0.004
[0.003]
0.013**
[0.003]
-0.005**
[0.002]
918
0.65
40-44
0.001
[0.001]
-0.001
[0.001]
0.001
[0.002]
-0.001**
[0.000]
918
0.41
45-49
0.001*
[0.001]
0
[0.000]
0
[0.000]
0
[0.000]
918
0.31
Effect on Triplets+ per 1000 Deliveries
Triplets per Delivery
Age
20-49
20-29
30-34
Offer Mandate
-0.077*
-0.059**
-0.147*
[0.030]
[0.016]
[0.055]
Soft Mandate
0.025
0.008
0.022
[0.039]
[0.014]
[0.082]
Comprehensive Mandate
0.155**
0.028*
0.284**
[0.025]
[0.011]
[0.024]
Constant
0.114**
0.143**
0.169**
[0.010]
[0.007]
[0.022]
Observations
918
918
918
R-squared
0.78
0.53
0.68
Robust standard errors in brackets
+ significant at 10%; * significant at 5%; ** significant at 1%
35-39
-0.019
[0.071]
0.173
[0.104]
0.245**
[0.045]
0
[0.047]
918
0.53
40-44
-0.029
[0.051]
-0.05
[0.159]
0.07
[0.238]
0.01
[0.058]
918
0.28
45-49
1.238+
[0.647]
1.216
[1.566]
-0.571
[0.678]
2.502**
[0.350]
918
0.22
Summary of Results
• 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.
Conclusions
• 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.
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.
Questions?