Health Insurance Coverage and
Access to Technologies:
The Case of Insurance Mandates for
the Treatment of Infertility
Increasing utilization of ART in the U.S.
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100000
80000
60000
Melinda Henne
Laurence Baker
M. Kate Bundorf
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20000
Trends in rates of multiple births
Cycles
00
01
20
99
19
20
97
98
19
96
19
95
19
94
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19
91
92
19
90
19
Supported by funding from the Agency for Healthcare Research and Quality and the
Iris M. Litt Fund
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89
0
Births
15 States have insurance mandates
Arkansas
Hawaii
350
Massachusetts California
300
250
Maryland
200
New Jersey
Montana
Connecticut
Illinois
Louisiana
Texas
Rhode Island
Ohio
West Virginia
New York
150
100
50
1980
1985 1987
1989
1991
2001
2002
00
98
96
02
20
20
19
19
92
94
90
88
86
Twins/10,000 deliveries
19
19
19
19
82
84
19
19
19
19
80
0
HOM/100,000 deliveries
Effect of insurance coverage on
treatment patterns
Research question
• Jain et al, 2002—
2002—Comprehensive insurance coverage
increases utilization, decreases number of embryos
transferred, births, percent multiple births
• Reynolds et al, 2003—
2003—Comprehensive insurance
coverage reduces number of embryos transferred in
women <35, maybe reduce multiple birth rates
(significant only in MA)
How does comprehensive insurance for
infertility affect birth outcomes at the
population level?
– 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
1
Data Sources – Birth Certificates
Data Sources – Insurance Mandates
• National Vital Statistics System from the
• RESOLVE and state legislation
• Categorized based on likely effectiveness in
NCHS 19801980-1997
– 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
changing treatment patterns:
– Comprehensive (3 states)–
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
Data Analysis – Birth Data
yi ,t = α + λ1Ci ,t + λ2 S i ,t + λ3Oi ,t + Giγ + Yt δ + ε i ,t
• U.S. Census Bureau
• Bureau of Economic Analysis
• Bureau of Labor Statistics
• Current Population Survey
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
Effect on Multiple Deliveries per Capita
Multiple Deliveries per 1000 Women
Deliveries per 1000 Women
Age
20-49
20-29
30-34
35-39
3.252
6.782+
2.139
2.218
[2.535]
[3.519]
[2.049]
[1.830]
Soft Mandate
-0.309
-0.183
-0.724
-0.172
[1.482]
[1.609]
[1.613]
[1.353]
Comprehensive Mandate
2.657*
1.079
4.018*
2.982
[1.066]
[2.204]
[1.551]
[1.783]
Constant
57.868** 111.417** 45.098** 11.191**
[0.989]
[1.099]
[1.092]
[0.798]
Observations
918
918
918
918
R-squared
0.86
0.92
0.94
0.94
Robust standard errors in brackets
+ significant at 10%; * significant at 5%; ** significant at 1%
Offer Mandate
Age
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
20-49
20-29
30-34
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%
Offer Mandate
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
2
Effect on Multiples per 1000 Deliveries
Effect on Triplet+ Deliveries per Capita
Triplet Deliveries per 1000 Women
Multiples per Delivery
Age
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 Triplets+ per 1000 Deliveries
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
Summary of Results
• In states with comprehensive insurance
Triplets per Delivery
Age
20-49
20-29
30-34
-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%
Offer Mandate
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
Conclusions
• Generous insurance coverage of ART induces
•
20-49
20-29
30-34
-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%
Offer Mandate
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.
mandates…
– At the population level, delivery rates are higher,
although the effect is concentrated among 3030-34
year olds.
– At the population level, the proportion of multiple
deliveries, particularly triplets or higher order, is
higher for women 2020-29, 3030-34, 3535-39.
• Effects are restricted to mandates providing
comprehensive coverage.
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.
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Questions?
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