Update: Congress approved a D.C. bill requiring insurance companies, Medicaid, and the D.C. Healthcare Alliance to cover infertility diagnoses and treatment last week. The bill, co-sponsored by At-Large Councilmember Christina Henderson, is now law, but it won’t be in effect for private insurers until 2025. Those covered by Medicaid and the D.C. Healthcare Alliance will be eligible for diagnosis and three rounds of IVF treatments starting in 2024.

Original: The D.C. Council is expected to vote on a bill Tuesday that would require private insurers, Medicaid, and the D.C. Healthcare Alliance to cover infertility diagnosis and treatment for District residents. At-large member and Health Committee chair Christina Henderson introduced the legislation to make these often costly services more accessible to everyone city-wide.

The Expanding Access to Fertility Treatment Amendment Act of 2022 would also prohibit insurers from adding additional costs or limitations on coverage, or placing pre-existing condition exclusions or waiting periods on coverage. If passed, D.C. would join a dozen other states that mandate companies cover both in vitro fertilization (IVF) and fertility preservation. D.C. would become the second state in the country to require that Medicaid covers fertility medication.

“I wish we had done this sooner,” Henderson said in an interview on Monday. She first introduced the bill in February 2022, but it didn’t make it to a vote that Council session. She re-introduced it in January.  “I’ve heard from people who’ve either sent me DMs or messages on Twitter in terms of the challenges they had to face to conceive, or even folks who said … they took a second job at Amazon, or they took a second job at Starbucks in the area, because those companies offer health insurance benefits [that] do include IVF coverage.”

According to the National Institutes of Health, about 9% of men and 11% of women of reproductive age experience infertility, yet insurance providers are less likely to offer financial support for it in comparison to other conditions that are just as common. (For example, about 8% of adults in the U.S. have asthma, and a vast majority of insurers cover asthma treatment.) Without insurance, the cost of one single cycle of in vitro fertilization — a process in which an egg is fertilized outside of the body and transferred into the uterus — can range between $10,500 to $20,855. The average patient usually requires somewhere between two and three cycles, meaning many individuals cease treatment after unsuccessful attempts, fearing a mountain of debt. Other fertility treatments like intrauterine insemination (IUI) can also be costly, and usually have a lower success rate than IVF; the birth-rate for IUI is 15% to 20%, while the success rate after one IVF cycle is 30%.

Removing the cost-barrier to fertility treatment would particularly expand access for the city’s Black and brown residents, who are more likely to experience fertility issues than their white counterparts but less likely to receive care. With the median income for a Black household in D.C. at around $54,000, one cycle of IVF could cost more than 25% of a family’s income. By comparison, the median income for a white household is $161,000. In addition to cost barriers, Black patients also face medical racism when trying to access fertility treatment. Racist and sexist policies from the U.S.’s eugenics movement continue to perpetuate myths about Black women’s fertility.

“Many people when they hear IVF, they think of rich white women, frankly not realizing that Black women face similar if not higher rates and incidences of infertility, but are less likely to seek treatment,” Henderson said.

Maya Martin Cadogan, a D.C. resident who testified in support of the bill last fall, went through three rounds of IVF to conceive her first child. The treatment was so expensive that, according to her testimony, she and her husband were weighing whether to fund purchasing a home, or another IVF treatment. Ultimately, they were able to avoid that choice because her husband is employed by a New York-based organization, and in 2020 the state passed a comprehensive fertility coverage plan that covered three rounds of treatment. However, Cadogan added that she knew of people who have left their jobs in the city for jobs in Maryland — where residents can receive coverage for up to three IVF cycles. In fact, one D.C. resident, a special education teacher at Two Rivers Public Charter School, told councilmembers in written testimony that they were considering leaving their job for a role in Maryland to get treatment covered.

“While Black women are more than twice as likely to suffer from infertility as compared to white women, infertility treatment is cost prohibitive to most Black women and families given our communities historical and glaring wealth gap,” Cadogan said during her testimony.

If passed, the bill will require private insurers to cover up to three complete egg retrievals, with unlimited embryo transfers from those retrieval, and to cover fertility preservation services — like protecting or freezing eggs, sperm, or reproductive tissue.

The legislation also requires private insurers to cover the transfer of an embryo to a third-party surrogate — a provision Henderson says is a step towards LGBTQIA+ equity in fertility care. Surrogacy can be necessary for a variety of reasons (including pre-existing conditions that make pregnancy impossible or unsafe), but insurance companies often deny surrogacy coverage, especially for LGBTQIA+ couples. This, in addition to updated language that expands the definition of infertility to “anyone who is unable to establish a pregnancy for a variety of reasons,” is meant to make the legislation as inclusive as possible, according to Henderson.

“People would be surprised to know that insurance companies and organizations in general define infertility in heterosexual terminology,” she said, noting that one insurance company wanted the legislation to denote that the sperm needed to come from a “spouse.” “There’s a lot of old thinking about fertility … even [if] you’re a heterosexual woman who hasn’t met a partner but you want to start a family, you need options for that as well. This bill would cover the gamut.”

Still, some limitations exist. IVF and IUI treatment is not covered by Medicaid in any state in the U.S., and the city can’t afford to fund 100% of that treatment. Additionally, Henderson says there are zero IVF providers in the region that would accept Medicaid coverage, anyway. Henderson’s bill would not require full coverage. However, it does require Medicaid and Alliance to cover fertility-enhancing medication.  The requirements for private insurers won’t go into effect until January 1, 2025, while Medicaid and the D.C. Health Alliance will be expected to begin covering services on January, 2024.

This story has been updated to reflect the D.C. Council approved the bill. 

Aja Drain contributed reporting.