How Obamacare Will Impact Reproductive Health

Paul R. Brezina; Anish A. Shah; Evan R. Myers; Andy Huang; Alan H. DeCherney

Disclosures

Semin Reprod Med. 2013;31(3):189-197. 

In This Article

Applications of New Legislation for Reproductive Health

The field of reproductive endocrinology and infertility (REI) is particularly complex in terms of payment structure. Unlike the vast majority of medical fields, REI has a complex mix of services, some of which are paid by the patient directly and others that are paid by third-party payers. For clarity, the field of REI is best considered in terms of noninfertility-based medical care and fertility-based medical care.

Noninfertility-based Medical Care

Much of the medical care provided by reproductive endocrinologists is not directly related to the treatment of infertility. Rather, many services address significant endocrinologic and anatomical disorders. Although many of these conditions may be intertwined with infertility, they are medical disorders that independently justify medical evaluation and treatment. For example, anatomical uterine abnormalities, such as polyps or fibroids, may result in symptoms that justify surgical interventions. The treatment of these conditions may improve fecundity, but if the primary purpose of performing the procedure was not for fertility per se, such medical conditions are generally covered by third-party insurers. Similarly, the diagnosis and treatment associated with a broad spectrum of endocrinologic abnormalities is also generally covered by third-party insurance.

For many women who would otherwise be without insurance, the PPACA will increase access to care. Indeed, some estimates place the number of women currently lacking consistent health care coverage at ~19 million.[37] Consequently, the volume of patients seeking evaluation and treatment of these traditionally reimbursed medical conditions is likely to increase. In response to the increased patient volume created by the PPACA, certain REI practices may begin to focus their resources toward treating these noninfertility-based disorders in response to increasing demand.

However, even prior to the PPACA, there was a trend among REI groups to focus fewer resources, for a variety of reasons mainly concerning declining reimbursements, on noninfertility-based medical disorders. Independent of the PPACA, if reimbursements for surgical care continue to decline, this trend may continue to progress and ultimately leave this area for gynecologists to address.

Infertility-based Treatments and Assisted Reproductive Technologies

Nationally, the PPACA as currently written is unlikely to have a dramatic impact on the delivery of care for infertility. Unlike many other aspects of medical care, the diagnosis and treatment of infertility is not necessarily reimbursed by insurance providers. In fact, only 15 states currently mandate that infertility treatment be covered by private insurers.[53]

The PPACA does not directly address infertility coverage. There is no language in the PPACA that explains how state-mandated infertility coverage will or will not be affected. Similar to the insurance paradigm prior to the legislation, insurance companies will not be required to cover infertility services at a federal level. Furthermore, there is no language in this or other recent legislation that will oblige public payers (Medicaid) to cover infertility.

On December 16, 2011, the DHHS issued a bulletin further outlining the medical services that would be provided under the PPACA.[45] In many ways, this document gave increased flexibility and freedom to the states in determining the scope of insurance coverage for a variety of medical conditions including the treatment of infertility. Therefore, the new legislation as it currently exists does little to standardize the state-mandated insurance policies dealing with the diagnosis and treatment of infertility.

States With Current Mandated Insurance Coverage for Infertility

As briefly discussed earlier, 15 states currently mandate that infertility treatment be covered by private insurers.[53] However, the scope of this coverage in mandated states is quite variable.[53] In most of the mandated states, many exemptions exist that limit the functional access to fertility treatment for individuals with health insurance.[53] In some of these states, for example, small companies or large employers that self-insure or pay claims directly are exempt from providing any coverage for infertility. Furthermore, when coverage is provided, there are often limits on the infertility services offered.[53] Some companies and health insurance providers voluntarily offer infertility coverage in nonmandated states.

The PPACA will facilitate access to fertility treatments in mandated states. First, the PPACA will make health insurance available to many individuals who would be otherwise uninsured. Second, under the PPACA, insurers will be unable to use preexisting conditions to determine coverage eligibility. This will significantly help individuals seeking insurance, particularly in mandated states, with a prior history of infertility.

Because the PPACA will increase the number of individuals with health insurance, there will likely be increased demand for infertility care in states with mandated infertility coverage. However, the scope of this increase is currently unclear given the variation in the level of mandated coverage. Furthermore, speculation in this regard is also difficult because states that currently mandate infertility coverage may modify their legislation on this issue in the future.

States Without Mandated Insurance Coverage for Infertility

No language in the PPACA mandates insurance coverage for infertility-related disorders. Furthermore, as mentioned previously, the DHHS is currently unlikely to include infertility coverage as an EHB. Therefore, in states without some form of mandated fertility coverage, the status quo is likely to continue.

Aspects of Infertility Care Covered Under Obstetrics

In all 50 states, certain aspects of infertility treatments are covered by insurance because of their association with obstetric care. The PPACA will essentially guarantee the availability of health care coverage to all Americans. Therefore, as the new legislation is interpreted by many experts today, the obstetric care of gestational carriers should be covered under insurance. In some circumstances, this may actually decrease the out-of-pocket expenses associated with the use of gestational carriers for infertile couples.

Possible Unintended Consequences of New Legislation

As with any paradigm shift in public policy, there exists the possibility that this new legislation may introduce various unintended negative consequences.[24] Some aspects of the law may actually lead to decreased infertility coverage. For example, the PPACA will stop private insurers from using "lifetime cap" policies on spending for individuals.[9] This could create a powerful incentive for private insurers to search for services that can be eliminated. Therefore, where permissible by state law, insurers currently offering infertility coverage benefits may cease this practice in the future. This may cause a decrease in the number of policies nationwide that include infertility coverage.

The new legislation also curbs many of the individual tax deductions allowed for medical care spending. This could effectively raise the cost of "out-of-pocket" individual payment for infertility treatment. Additionally, structural changes such as the introduction of the ACO, if ever adopted on a large scale, have the potential to fundamentally reshape the structure of medical care delivery. The effect of such changes on the accessibility or delivery of infertility care is unknown. Some experts maintain that ACOs may enhance the practice of medicine for physicians through a variety of improvements including better communication with other health care providers.[42] However, widespread adoption of ACOs could conceivably create an incentive for infertility physicians wishing to remain autonomous to simply focus more on services that do not require becoming part of an ACO system. Finally, an increased demand for fertility specialists in mandated states could theoretically create a mild physician-to-patient supply/demand mismatch nationally.

The broad increase in access to care by millions of currently uninsured individuals also has the potential to further strain an already fiscally stressed system, particularly within the programs of Medicare and Medicaid.[27] This added strain coupled with planned decreases in long-term funding for these programs could result in a variety of outcomes. Although it is possible that cost savings from the provisions created by the law may offset these issues, it is also possible that further modifications such as increased taxation, professional liability reform, or even rationing may ultimately be required.[27]

The Supreme Court and the PPACA

In late March 2012, the U.S. Supreme Court heard arguments that addressed if elements of the PPACA are unconstitutional.[4–6,54] In particular, the aspect of the legislation that created a mandate for individuals to purchase health insurance was discussed in detail.[4–6,54] In the summer of 2012, the Supreme Court upheld the PPACA in its entirety including the individual mandate with the exception of requiring all States to adopt the Medicare and Medicaid expansion. Regardless of this decision, however, the process of providing health care coverage in the United States is sure to be as it has always been: a constantly changing and evolving set of private and public policies that carry with them significant complexities and challenges. Health care providers must constantly strive to maximize access to and quality of medical care in whatever paradigm evolves in the future.

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