Coverage of infertility treatment and fertility outcomes

Introduction

The average age at first birth in the United States has been rising steadily over the past decades, from 21.49 in 1968 to 23.72 in 1985 and 25.26 in 2004. As shown in Fig. 1, this increase has been accompanied by remarkable changes in the age distribution of first-time mothers, which has become less skewed with a substantially higher density of first-time mothers older than 25 and an extension of first-time motherhood beyond the age of 40.

Women, however, face a biological time constraint on bearing children because fecundity decreases with age. The introduction of and the subsequent increase in the use of assisted reproductive therapies (ARTs) have helped women in extending their reproductive lives (CDC 2007). ARTs, particularly in-vitro fertilisation (IVF), are very expensive procedures. For example, in 1992, a birth from an IVF procedure cost between 44,000 and 211,942 USD (Neumann et al. 1994). Over time, however, ART patients have faced substantially lower costs due to increased competition (Hamilton and McManus 2012), a reduced number of cycles due to better technology,1   ,  2 and most importantly, the availability of insurance in both the United States and in Europe.3 In this paper, we analyse whether easier access to ARTs induces women to delay motherhood and whether, in the long term, it affects women’s completed fertility by the end of their reproductive lives.

The perception that ARTs increase fertility has led the European Parliament to call on member states to insure ‘the right to universal access to infertility treatment’ (Ziebe and Devroey 2008). This movement’s incarnation in the United States has sponsored several attempts at approving the ‘Family Building Act of 2009’, which would extend coverage for infertility treatments, and the enactment by several states of infertility insurance coverage laws, which are referred to as infertility treatment mandates.4 Considering the high cost of infertility treatments (Bitler and Schmidt 2012; Collins 2001), policy interventions that grant insurance coverage for infertility treatments may affect fertility trends and ultimately, population age structures. The mid- to long-term consequences of ARTs are central to the European debate on possible solutions to an ageing population—i.e., can ARTs be part of a package of policies intended to increase fertility rates in Europe? (Grant et al. 2006; Ziebe and Devroey 2008).5

The answer is complex because the short-term effect of an increase in coverage for infertility treatments may be very different from the long-term effect. In the short term, an increase in the aggregate fertility rate is expected due to an increase in fertility amongst the least fertile women (a compositional effect). Typically, these are relatively old women who delayed motherhood and would be unlikely to conceive otherwise (Buckles 2005; Schmidt 2005a, 2007). Moreover, increased access to ARTs increases the frequency of multiple births in the population (Bundorf et al. 2007). These two effects are short-term and non-strategic and may be referred to as ex-post moral hazard. In the long term, however, easier access to infertility treatments and the possibility of extending reproductive life may induce women to further delay motherhood, possibly because of overly optimistic perceptions about the effectiveness of infertility treatments (Lampi 2006; Benyamini 2003). This response by relatively young women, which may be referred to as ex-ante moral hazard, is strategic and would increase the average age at first birth for several years after the policy was implemented.6 Such a response would be consistent, for example, with the delay in marriage due to increased infertility coverage documented in Abramowitz (2014). Therefore, it is possible that an increase in insurance coverage for infertility treatment may have negative effects on total fertility in the mid- to long-term. This paper examines these issues in the United States, where, by 2001, more than 1 % of live births were due to IVF (CDC 2007).

Our objective in this paper is twofold. First, we analyse the impact of an increase in infertility insurance on the timing of first births. Although this question was first explored by Buckles (2005), we believe that our paper contributes in a substantial way to the few existing manuscripts that address this topic by using more adequate data and methodology. Moreover, we go a step further by looking into the long term effects of increasing infertility insurance. Second, we ask whether the increase in infertility insurance affects completed fertility, i.e., fertility by the end of a woman’s reproductive life. This study represents, to the best of our knowledge, the first to address this issue.7 Both objectives are analysed using data from the United States.

To assess whether infertility insurance induces a delay in motherhood, one needs to combine evidence about reduced fertility of young women with information on when women become mothers, i.e., when (if at all) they stop delaying motherhood. This precisely describes the approach we adopt in the first part of this paper; we not only offer similar evidence as Buckles (2005) on the reduced probability that relatively young women in mandated states have children, but we also demonstrate that the average age of first-time mothers continues to increase in the medium to long term after the enactments of infertility mandates.8 Our long-term estimate (10–16 years after the first and the last mandates were passed) ranges from 3 to 5 months. These effects are substantial insofar as they represent between 15.7 and 18.8 % of the total increase in the age of first-time mothers during the period considered for the group of six states that enacted infertility treatment mandates9 and between 24.8 and 34.3 % for the three states with the most generous coverage (Illinois, Massachusetts, and Rhode-Island).10

The ageing of first-time mothers may impact women’s completed fertility in the long term. Hence, our second goal is to determine whether infertility insurance indeed increases women’s completed fertility by the end of their reproductive lives, a question that has not been addressed in the existing literature. In principle, any potential negative effects on fertility induced by a delay of motherhood may eventually be offset by a higher prevalence of multiple births,11 so the impact of infertility insurance on completed fertility is ultimately an empirical question. Overall, our estimates, based on data on the number of biological children from the June CPS, show no statistically significant effect of either the strong or the comprehensive mandates on completed fertility.

In sum, our paper shows that, despite being associated with higher birth rates among relatively older women and with a higher prevalence of multiple births, infertility insurance does not have a statistically significant effect on women’s fertility at the end of their reproductive lives. The reason lies, as we further show, in the fact that infertility insurance mandates also appear to delay motherhood among relatively younger women and, hence, make conception more difficult because fecundity decreases with age.

The rest of the paper is structured as follows: Sect. 2 describes the characteristics of infertility treatment mandates including where and when they were enacted; Sect. 3 describes the data sources used in this paper; Sect. 4 presents our evidence on the delay of motherhood; Sect. 5 presents an analysis of the impact of the mandates on women’s completed fertility; Sect. 6 presents conclusions; Sect. 7 contains figures and tables; and Sect. 8 is the “Appendix”.

Source - https://link.springer.com/article/10.1007/s13209-015-0135-0

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