For nearly three agonizing years, Mariah Freschi and her husband have been trying to have a second baby. The California mother recently underwent surgery to remove her blocked fallopian tubes, leaving in vitro fertilization as her only option to get pregnant. But the cost quoted by her Sacramento-area clinic was $25,000 — out of reach for Freschi, a preschool teacher, and her husband, a warehouse worker.
“When we first found out IVF was our only option, it just felt so overwhelming,” said Freschi, who has insurance through the California marketplace. “No one sets aside 20, 30 grand to grow your family.”
The Freschis are far from alone in requiring medical assistance to have children: About 13% of women and 11% of men in the U.S. experience infertility, while others are in a same-sex relationship, single, or want to preserve their eggs or sperm before undergoing various medical treatments.
And, like the Freschis, many Americans do not have health insurance that pays for IVF.
During his campaign, President Donald Trump vowed that the government would cover IVF or require insurers to cover it. In February, he signed an executive order seeking policy recommendations on expanding IVF access, dubbing himself the “fertilization president” a few weeks later.
Whether the administration’s efforts will change policy remains unknown, but state-level attempts to mandate fertility coverage reveal the gauntlet of budgetary and political hurdles that such initiatives face — obstacles that have led to millions of people being left out.
“There are economic opponents, and there are ideological opponents,” said Sean Tipton, a lobbyist for the American Society for Reproductive Medicine. “It is a tough lineup of opponents. And that’s very consistent from state to state.”
Twenty-two states have passed legislation requiring insurers to cover at least some fertility care, and 15 of those require coverage for IVF. The laws vary widely, though, when it comes to who and what gets covered, largely because of debates over cost. Fertility services can range from diagnostic testing and ovulation-enhancing drugs to IVF, widely considered the most effective but also the most expensive treatment, during which one or more lab-fertilized eggs are transferred to a uterus.
It’s mostly those footing the bill amid rising health care costs and state deficits that have voiced opposition. State insurance mandates “factor in significantly” when it comes to whether employers continue to provide coverage at all because of financial concerns, according to Chris Bond, a spokesperson for AHIP, which represents health insurers, who also said employers “want to have flexibility with how these benefits are structured.”
States cite concerns about higher premiums and the budget impact of having to cover government workers. In the past few years, infertility coverage bills in Minnesota, North Dakota, and Louisiana, for example, failed largely over cost.
IVF advocates, however, cite data from a decade ago showing that fertility care in states with mandates has accounted for less than 1% of total premium costs, a figure similar to estimates for newer mandates. And advocates often argue that building a family is a human right, though fertility care is disproportionately used by wealthy, white women. Covering IVF for the Medicaid population, which includes more than 70 million Americans, rarely works its way into legislative proposals.
The California Example
California is a case study in how many of these conversations play out. Cost concerns sank IVF legislation in the state for several years before lawmakers approved a mandate last year. SB 729 goes into effect July 1 and requires large employers with state-regulated health insurance to cover infertility diagnosis and treatment, including IVF. State employees will get coverage in 2027.
California’s mandate is considered one of the most comprehensive and inclusive in the country, said Barbara Collura, president of Resolve: The National Infertility Association, making same-sex couples and single parents eligible for coverage. But it still leaves out most of the state’s insured population, including those covered by Medicaid, the Affordable Care Act marketplace, and self-insured companies, which account for the majority of workers and are federally regulated.
Mimi Demissew, executive director of Our Family Coalition, an LGBTQ+ rights nonprofit that co-sponsored SB 729, said her group envisioned the broadest possible mandate, which would have included people covered by small employers, the marketplace, and other privately purchased plans. “We dreamed big,” she said. “But the pushback and the whittling down was because of the budget.”
Gov. Gavin Newsom’s finance department opposed SB 729 over concerns about the state’s budget and higher premiums. And groups representing the state’s health plansand employers cited costs in their opposition, with the California Chamber of Commerce calling health care “one of the most formidable expenses a business experiences,” per a legislative analysis.
The law going into effect this year is estimated to cover around 9 million people, 5 million fewer than originally proposed. Annual premiums, whose cost is typically shared by employers and employees, are projected to increase for people with state-regulated health insurance by approximately $40 per person covered in the first year.
Mandates Vary Widely by State
More than 10 states — including California — have what fertility experts call “comprehensive” coverage, which requires some insurers to cover IVF with minimal restrictions. But even in those states, large swaths of the population miss out.
In Massachusetts, which has one of the country’s oldest, broadest mandates for infertility coverage, including IVF, only about 30% of women were eligible as of 2019.
Those covered by these mandates, however, are grateful. Luisa Lopez, a nonprofit executive, credited the three IVF cycles that New York’s mandate covered with allowing her and her husband to have a baby after 10 years of trying.
“I feel very lucky to live in a state that prioritized this,” Lopez said. Still, she said, she was on the hook for thousands of dollars in copays and other costs.
In states with narrow mandates, coverage is elusive. With limited exceptions, only state employees have qualified for IVF coverage through Utah’s mandate, for example. Joseph Letourneau, a University of Utah fertility specialist who successfully lobbied for fertility preservation coverage for Medicaid patients and state employees with cancer, said he couldn’t recall ideological opposition to fertility coverage but that some legislators were concerned about raising costs.
Oklahoma and Kentucky limit coverage requirements to patients who wish to preserve their fertility because of specific medical conditions.
Pushback Beyond Costs
Some opponents of IVF coverage say life begins at the moment of conception and have expressed concerns about the disposal of embryos during the IVF process.
Chieko Noguchi, a spokesperson for the U.S. Conference of Catholic Bishops, said the Catholic Church teaches that IVF is morally wrong because it “involves the death or freezing of embryonic children and treats human beings like products that can be bought and ordered.”
In Republican-controlled-Georgia, some advocates say the proposal of abortion restrictions has distracted from efforts to mandate fertility coverage. SisterSong, a reproductive justice nonprofit, supports two bills that would require private insurers and Medicaid to cover IVF in Georgia. But, the organization’s director of maternal health and birth equity initiatives, Leah Jones, acknowledged a steep uphill battle given the costs and anti-abortion legislation that some advocates fear could criminalize IVF. Having to fight just for the legality of IVF, she said, detracts from expanding access.
“We’re always on the defense,” Jones said.
Several states, including Georgia, are weighing or have passed bills that would protect access to IVF after Alabama’s state Supreme Court ruled that embryos created through IVF should be considered children, leading to temporary suspension of those services. Zemmie Fleck, executive director of Georgia Right to Life, said the Georgia anti-abortion bill would not make IVF illegal.
This fissure in Trump’s base over protecting versus restricting or even prohibiting IVF has raised questions about how his executive order will play out. Letourneau of Utah said some of his patients have asked if the order will cover their treatment costs.
The White House did not respond to requests for comment.
An Uncertain Road Ahead
While a growing number of companies provide IVF coverage as a health benefit, most patients are left to find ways to pay on their own. Some have turned to loans — IVF financing startups such as Gaia and Future Family have raised millions in venture funding.
The Freschis have applied for grants, are crowdfunding, and have put their upcoming cycle on a credit card.
“It’s so scary,” said Freschi, describing worries about potential unexpected IVF costs. “It just feels like you’re constantly walking around with a weight on you.”
This article was produced by KFF Health News, which publishes California Healthline, an editorially independent service of the California Health Care Foundation.
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