By David Adamson, M.D.
This article highlights the challenges of accessing and affording reproductive care in the U.S., particularly for marginalized groups like Black, Hispanic, and LGBTQ+ communities. It emphasizes the critical role employers can play in addressing disparities by offering inclusive, evidence-based reproductive health benefits to enhance employee well-being, retention, and productivity. Additionally, it explores the economic and social impact of declining fertility rates and the need for comprehensive family-forming benefits in the workplace.
Recent reports have highlighted significant shortcomings in the reproductive care system in the United States. A 2024 State Scorecard by the Commonwealth Fund raised concerns about the accessibility and affordability of fertility treatments across the U.S., pointing to a growing gap in reproductive care services, particularly post-pandemic. [1] This report illustrates significant regional and socioeconomic disparities that disproportionately affect marginalized communities, including Black, Hispanic, and LGBTQ+ individuals.
Despite advances in medical technology, many individuals and couples face prohibitive costs when seeking assistance to start a family. This financial burden is compounded by the uneven availability of care across the country, with disparities in access particularly affecting marginalized communities. For instance, in the South, more than 20% of women report skipping needed medical care due to cost, compared to just 10% in the Northeast. [2]
According to data from the Centers for Disease Control and Prevention (CDC), the U.S. fertility rate has been declining for decades and now stands below the replacement level needed to sustain the population. The total fertility rate (TFR) in 2021 was 1.64, significantly lower than the 2.1 needed to replace the population. [3]
This trend, influenced by various social and economic factors, underscores the critical need for comprehensive reproductive care. The consequences of inadequate care are far-reaching, impacting not only individuals and families but also the broader economy.
HISTORICAL CONTEXT OF REPRODUCTIVE CARE IN THE U.S.
The history of reproductive care in the U.S. has seen notable advancements, particularly the birth of the first American in vitro fertilization (IVF) baby in 1978. Initially, IVF treatments were very expensive and available only to wealthier families, limiting access to a small demographic.
Over the years, IVF and other assisted reproductive technologies (ART) have improved dramatically. These include intracytoplasmic sperm injection (ICSI) for male fertility, egg freezing to preserve fertility before cancer treatments or for other reasons, and preimplantation genetic testing (PGT) of embryos to diagnose serious diseases and abnormal chromosome numbers. [4] These new technologies have expanded the options available to individuals seeking to build families and resulted in the birth of two million babies from ART treatments in the United States.
However, despite gradual expansion of fertility coverage, wide gaps remain, and access to care remains limited to only about one in four who need help to form their families. The passage of the Affordable Care Act (ACA) in 2010 represented a major milestone in expanding access to reproductive healthcare by mandating coverage for essential health benefits, including maternity and newborn care. However, fertility treatments like IVF are not mandated under the ACA, leaving many patients dependent on state regulations and employer-sponsored insurance to cover these treatments. [5] This often leaves these technologies as unaffordable and out of reach for many, particularly those from lower-income or minority communities.
CURRENT DISPARITIES IN ACCESS
Access to reproductive care varies widely across regions and demographic groups in the U.S. Urban areas typically have more fertility clinics and reproductive specialists, providing easier access to care for individuals living in those regions. In contrast, rural areas often face significant shortages in available reproductive healthcare facilities, forcing residents to travel long distances for fertility treatments. [6]
Socioeconomic disparities also play a significant role in access to care. Lower-income individuals and families, particularly those in minority communities, face higher barriers to receiving reproductive treatments due to the prohibitive costs of procedures like IVF, which can be $12,000 to $30,000 per cycle without insurance coverage. Even when employer-sponsored insurance is available, coverage for fertility treatments is not guaranteed and varies by state. [7]
Moreover, disparities exist for marginalized communities, particularly Black, Hispanic, and LGBTQ+ individuals, who often face additional legal, financial, and social barriers when seeking fertility care. A 2024 Commonwealth Fund report emphasized that nearly half of U.S. states either ban or significantly restrict access to reproductive care, compounding the challenges faced by these communities. [8]
ECONOMIC AND SOCIAL IMPLICATIONS
The economic implications of declining fertility rates and inadequate access to reproductive care are profound. As the U.S. population ages, concerns are growing about the ability of the workforce to sustain the needs of an aging population.
Countries like Japan, which faces a similar demographic crisis, provide a cautionary example of the challenges the U.S. might face in the future. [9]
Japan’s shrinking workforce and aging population have strained its economy, leading to reduced productivity and higher costs for elder care. In the U.S., the lack of affordable reproductive care exacerbates these demographic concerns. The lack of affordability of fertility treatments such as IVF often forces individuals and couples to delay or forgo family-building altogether. As birth rates continue to decline, the U.S. workforce will shrink significantly in the coming decades. A 2023 United Nations study projects that the U.S. labor force may contract by 10% over the next 30 years if fertility rates do not improve. [10]
These demographic shifts not only place a burden on the economy but also pose challenges to social safety nets such as Social Security and Medicare. With fewer young people entering the workforce to replace retirees, there will be increased pressure on the remaining workforce to support an aging population. This dynamic could lead to labor shortages in critical industries and slower overall economic growth. [11]
THE VALUE OF FAMILY-FORMING BENEFITS
Offering family-forming benefits is not just a moral imperative but also a sound business strategy. Studies consistently show that employees who feel supported in their personal lives tend to be more engaged, productive, and loyal to their employers.
Research from the International Foundation of Employee Benefit Plans (IFEBP) reveals that employees with access to family-forming benefits—including fertility treatments and adoption assistance—are more likely to stay with their employers, reducing turnover and boosting overall job satisfaction. [12]
Family-forming benefits also play a crucial role in helping companies attract top talent, especially in competitive industries. Employees today expect their employers to provide benefits that align with their personal values and goals. By offering comprehensive reproductive health benefits, including IVF, surrogacy support, and adoption assistance, companies can differentiate themselves in the job market and appeal to a diverse workforce. [13]
THE ROLE OF EMPLOYERS
Employers play a pivotal role in closing the gaps in access to reproductive care. Offering family-forming benefits, such as fertility treatments, surrogacy support, and adoption assistance, can significantly reduce the financial burden on employees and foster a culture of inclusivity and support.
These benefits not only address the needs of employees but also demonstrate a company’s commitment to their well-being, leading to higher retention rates and improved employee engagement.
Promoting Diversity and Inclusion
Offering family-forming benefits allows employers to demonstrate their commitment to diversity, equity, and inclusion (DEI). Supporting diverse paths to parenthood—whether through IVF, surrogacy, adoption, or fertility preservation—shows that a company values all employees, regardless of their background or family structure.
This is particularly important for LGBTQ+ employees and those from marginalized communities who may face additional barriers to accessing reproductive care. Creating a workplace that embraces different family-building options fosters an environment of inclusivity, making employees feel supported in both their personal and professional lives. [14]
POLICY CONSIDERATIONS AND EMPLOYER RESPONSIBILITY
State-Level Disparities in Coverage
Government policies play a critical role in determining access to reproductive care across the U.S. Currently, there is significant variation in fertility treatment coverage depending on state regulations. According to a 2024 report by the National Conference of State Legislatures (NCSL), fewer than 50% of U.S. states mandate that insurance plans cover fertility treatments and even among those that do, the coverage requirements differ widely. [15]
In states like Massachusetts and New Jersey, insurance providers are required to cover IVF and other fertility treatments, making these services more accessible to individuals and couples seeking to build families. In contrast, states such as Texas and Florida either lack mandates or impose strict limitations on what insurance plans must cover, leaving many without coverage for these treatments. [16]
This disparity in state-level regulations contributes to uneven access to reproductive care and places a heavy financial burden on those living in states without comprehensive fertility coverage.
Federal Efforts to Standardize Access
The ACA made strides in expanding access to reproductive healthcare by requiring insurance providers to cover maternity and newborn care, but it did not mandate coverage for fertility treatments. This has left the decision on coverage for these services up to individual states and employers, resulting in significant inconsistencies in access to reproductive care.
Federal legislation such as the proposed Access to Infertility Treatment and Care Act aims to address these gaps by mandating that all health insurance plans cover fertility treatments, regardless of state laws. If passed, this legislation would create a more standardized system of care, reducing financial barriers and ensuring that all individuals, regardless of location or socioeconomic status, have access to reproductive services. [17]
ADDRESSING THE NEEDS OF DIVERSE POPULATIONS
Challenges Faced by LGBTQ+ Employees
LGBTQ+ individuals face unique challenges when it comes to reproductive care. Many traditional fertility treatment policies are designed with heterosexual couples in mind, often excluding the specific needs of LGBTQ+ employees.
The Human Rights Campaign’s 2024 Healthcare Equality Index highlights how many fertility plans only cover procedures for heterosexual couples experiencing infertility, leaving out essential services such as surrogacy and sperm or egg donation, which are critical for LGBTQ+ individuals seeking to build families. [18]
Employers can address these disparities by offering inclusive benefits that provide comprehensive coverage for surrogacy, adoption assistance, and fertility preservation. By doing so, companies can demonstrate a commitment to fostering an inclusive work environment and ensuring that all employees, regardless of sexual orientation or gender identity, have access to the reproductive care they need.
Supporting Single Parents by Choice
Single parents by choice have become a more prominent demographic in reproductive care, with a notable rise in the number of individuals pursuing parenthood through ART. According to a retrospective study from 2008 to 2019, the proportion of single women undergoing IVF increased significantly. In the early years (2008–2011), only 0.8% of IVF cycles involved single women, but this grew to 2.5% by 2012–2015 and further to 4.6% by 2016–2019. This rise reflects the growing visibility and acceptance of single parents by choice seeking reproductive treatments. [19]
These individuals often face unique financial and logistical challenges when pursuing fertility treatments. Employers can support single parents by offering flexible work schedules, financial assistance for reproductive treatments, and access to fertility counseling services. Providing such benefits will ensure that single parents can navigate the complexities of family-building without sacrificing their professional responsibilities.
FUTURE DIRECTIONS FOR FAMILY-FORMING BENEFITS
Technological Innovations in Reproductive Care
The field of reproductive care is evolving rapidly, offering new possibilities for individuals and couples looking to build their families. Advances in genetic screening of people planning for pregnancy allow for early detection of genetic disorders and the potential use of IVF with PGT to select embryos that will be disease-free. This gives prospective parents the opportunity to make more informed decisions about their reproductive options. PGT can also be used in selected clinical situations to choose embryos that have a normal number of chromosomes (euploid embryos), which increases the likelihood of a successful pregnancy in those selected populations. [20]
Egg freezing technology has also seen a rise in both demand and success rates. Egg freezing allows women to preserve their fertility before cancer treatments that will damage the ovaries and also to delay childbearing until they are ready. Recent studies show that women under 35 who freeze their eggs may see their chances of achieving pregnancy later in life rise to 50% to 80%. [21]
This option is particularly valuable for women who wish to focus on their careers or education before starting a family. Employers offering fertility preservation benefits provide employees with the flexibility to balance personal and professional goals.
Evidence-Based Reproductive Care
Another key development in reproductive care is the increasing use of artificial intelligence (AI) and big data to personalize fertility treatments. AI-driven algorithms can help predict the optimal time for implantation, reducing the number of failed IVF cycles and improving the overall success rate of treatments. This innovation has the potential to reduce the emotional and financial burden of repeated IVF cycles, offering a more streamlined and successful path to parenthood. [22]
Surrogacy has also become more accessible through advances in IVF, particularly through the use of gestational surrogates, where the surrogate carries a child genetically unrelated to her. However, surrogacy laws vary widely across the U.S., and navigating the legal landscape can be challenging for individuals and couples. Employers who offer comprehensive surrogacy benefits and legal support can significantly ease this process for employees, ensuring that they have access to all necessary resources. [23]
As the reproductive care landscape continues to evolve, it is crucial for employers to partner with providers that focus on evidence-based care. By doing so, they can ensure that their employees receive treatments that are proven to be effective, reducing unnecessary costs associated with unproven or experimental procedures. This focus on evidence-based practices not only benefits employees by increasing the likelihood of successful treatments, but also helps employers control healthcare costs.
This article originally appeared in the Nov/Dec 2024 issue of Journal of Compensation and Benefits.
- Commonwealth Fund, 2024 State Scorecard on Women’s Health and Reproductive Care, July 2024, accessed September 3, 2024, https://www.commonwealthfund.org/ publications/ scorecard/2024 /jul/2024-state-scorecard-womens-health-and-reproductive-care.
- Centers for Disease Control and Prevention, Health Disparities in Rural and Urban Areas, accessed September 3, 2024, https://www.cdc.gov/mmwr/ volumes/66/ss/ss6623a1.htm.
- Centers for Disease Control and Prevention, Births: Final Data for 2021, accessed September 4, 2024, https://www.cdc.gov/nchs/data/ nvsr/nvsr70/nvsr70-17.pdf.
- American Society for Reproductive Medicine (ASRM), The Advancements of Genetic Testing and Egg Freezing in Fertility, accessed September 4, 2024, https://www.asrm.org/.
- Affordable Care Act (ACA), Essential Health Benefits and Contraception Coverage Mandates, U.S. Department of Health and Human Services, accessed September 3, 2024, https://www.hhs.gov/healthcare/about-the-aca/index.html.
- Commonwealth Fund, State Restrictions on Reproductive Health Access, 2024 Scorecard, accessed September 3, 2024, https://www.commonwealthfund.org/ publications/scorecard/2024 /jul/2024-state-scorecard-womens-health-and-reproductive-care.
- RESOLVE: The National Infertility Association, Insurance Coverage by State, accessed September 8, 2024, https://resolve.org/learn/financial-resources-for-family-building/insurance-coverage/insurance-coverage-by-state/.
- Commonwealth Fund, State Restrictions on Reproductive Health Access, 2024 Scorecard, accessed September 3, 2024, https://www.commonwealthfund.org/ publications/scorecard/2024 /jul/2024-state-scorecard-womens-health-and-reproductive-care.
- United Nations, World Population Prospects: Key Findings & Advance Tables, 2023, accessed September 4, 2024, https://population.un.org/wpp/ Publications/Files/ Key_Findings_WPP_2023.pdf.
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- Social Security Administration, The Financial Impact of Aging Populations, Social Security Bulletin, Vol. 66, No. 4, 2006, accessed September 8, 2024, https://www.ssa.gov/policy/docs/ ssb/v66n4/v66n4p37.html.
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- Mercer, 2023–2024 Inside Employees’ Minds Survey Report, accessed September 8, 2024, https://www.mercer.com/en-us/insights/talent-and-transformation/ attracting-and-retaining-talent/2023-2024-inside-employees-minds-survey-report/.
- Human Rights Campaign (HRC), 2024 Healthcare Equality Index Report, accessed September 3, 2024, https://www.hrc.org/resources/healthcare-equality-index.
- U.S. Congress, Senate Bill 2386, 118th Congress, 1st session, introduced July 19, 2023, https://www.congress.gov/bill/118th-congress/senate-bill/2386/text.
- RESOLVE: The National Infertility Association, Insurance Coverage by State, accessed September 8, 2024, https://resolve.org/learn/financial-resources-for-family-building/ insurance-coverage/insurance-coverage-by-state/.
- U.S. Congress, Senate Bill 2386, 118th Congress, 1st session, introduced July 19, 2023, https://www.congress.gov/bill/118th-congress/senate-bill/2386/text.
- Human Rights Campaign, Healthcare Equality Index 2024: Executive Summary, accessed September 8, 2024, https://hrc-prod-requests.s3-us-west-2.amazonaws.com/HEI-2024-Executive-Summary.pdf.
- Estevez, Abittan, and Rausch, Single Mothers by Choice: Defining and Understanding Single Women Undergoing In Vitro Fertilization, Fertility and Sterility, vol. 114, no. 3, 2020, accessed September 8, 2024, https://www.fertstert.org/article/S0015-0282(20)31432-1/fulltext.
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- Hanassab, Abbara, Yeung, et al, The prospect of artificial intelligence to personalize assisted reproductive technology, NPJ Digital Medicine, vol. 7, no. 55, 2024, https://doi.org/10.1038/s41746-024-01006-x.
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