Racial disparities persist in fertility treatment success despite insurance mandates

Despite state insurance mandates, racial and ethnic disparities in the use of IVF and its clinical outcomes remain, researchers reported.

“A recent retrospective cohort study using 2018 national IVF data concluded that comprehensive state-mandated insurance coverage of IVF services was associated with higher live birth rates per cycle, albeit with a small effect size, among other positive clinical outcomes,” Katharine Correia, PhD, an assistant professor of statistics at Amherst College in Massachusetts, and colleagues wrote. “However, they did not have patient-level data and thus could not assess whether the association between comprehensive mandates and clinical outcomes were the same for all races and ethnicities.”

Correia and colleagues identified 1,096,539 autologous IVF cycles from 487,191 women recorded in the Society for Assisted Reproductive Technology (SART) Clinic Outcome Reporting System from 2014 to 2019. The researchers evaluated rates of IVF utilization — defined as the number of cycles per 10,000 women of reproductive age — by year, state and race and ethnicity. They also assessed the rates of live birth, clinical pregnancy, spontaneous abortion and cycle cancelation.

Because only eight states had insurance mandates for the entire study period and one state had mandates for 2019, most cycles (72.9%) occurred in states without insurance coverage mandates.

IVF utilization

States with insurance mandates had higher rates of IVF use across racial and ethnic groups compared with states that did not have mandates. However, the relative increase in utilization rate between states with and without mandates were significant only for non-Hispanic white and non-Hispanic Asian women. For example, non-Hispanic white women in states with mandates experienced their lowest increase in IVF use in 2018 (RR = 2.42; 95% CI, 1.65-3.55) and the highest increase in use in 2017 (RR = 2.53; 95% CI, 1.72-3.74).

Although there were no significant differences in relative IVF use increases between states with and without mandates for non-Hispanic Black and Hispanic women, there were larger absolute differences compared with non-Hispanic white women. For example, the rate of IVF use increased by 23.5 cycles per 10,000 women among non-Hispanic white women and by 56.2 cycles per 10,000 women among non-Hispanic Black women in 2019 in mandated states.

Clinical outcomes

Analyses revealed no significant associations between state insurance mandate status, race and ethnicity, and clinical outcomes.

“This lack of significance means that the associations between patient race and ethnicity and clinical outcomes were the same among states with and without an insurance mandate and, likewise, the associations between state insurance mandate and clinical outcomes did not differ across patient race and ethnicity groups,” Correia and colleagues wrote.

Adjusting for patient characteristics, non-Hispanic Black women had lower odds of live birth compared with non-Hispanic white women regardless of state mandate status (nonmandated adjusted OR = 0.84; 95% CI, 0.8-0.88; mandated aOR = 0.81; 95% CI, 0.77-0.84).

Similar odds were observed for non-Hispanic Asian (nonmandated aOR = 0.86; 95% CI, 0.8-0.88; mandated aOR = 0.86; 95% CI, 0.83-0.9) and Hispanic (nonmandated aOR = 0.93; 95% CI, 0.9-0.96; mandated aOR = 0.91; 95% CI, 0.89-0.94) women compared with non-Hispanic white women.

Compared with non-Hispanic white women, women of other races and ethnicities had greater odds of spontaneous abortion. Additionally, non-Hispanic Black women and non-Hispanic Asian women had lower odds of clinical pregnancy compared with non-Hispanic white women; Hispanic women had similar odds.

The researchers theorized that disparities persisted because state mandates applied to only certain types of insurance plans and excluded Medicaid coverage of fertility treatment.

“Future multidisciplinary research efforts will be necessary to develop a deeper understanding of the root causes of these disparities to inform policy and public health interventions,” Correia and colleagues wrote. “Ongoing research efforts in other obstetrics and gynecology subfields can serve as examples for the IVF field.”