Health Insurance Coverage and Health Insurance Coverage and Access to Technologies: Access to Technologies: The Case of Insurance The Case of Insurance

Mandates for the Treatment of Mandates for the Treatment of

InfertilityInfertility

Melinda Henne Melinda Henne

Laurence BakerLaurence Baker

M. Kate BundorfM. Kate Bundorf

Supported by funding from the Agency for Healthcare Research and Quality and the Iris M. Litt Fund

Increasing utilization of ART in the Increasing utilization of ART in the U.S.U.S.

0

20000

40000

60000

80000

100000

120000

Cycles Births

Trends in rates of multiple Trends in rates of multiple birthsbirths

0

50

100

150

200

250

300

350

Twins/10,000 deliveries HOM/100,000 deliveries

15 States have insurance mandates15 States have insurance mandates

1980 20021985 1987 1989 1991 2001

Maryland

Arkansas

Hawaii

Massachusetts

Montana

Texas

California

Connecticut

Rhode Island

Illinois

Ohio

New Jersey

Louisiana

West Virginia New York

Effect of insurance coverage on Effect of insurance coverage on treatment patternstreatment patterns

• Jain et al, 2002—Comprehensive insurance Jain et al, 2002—Comprehensive insurance coverage increases utilization, decreases number of coverage increases utilization, decreases number of embryos transferred, births, percent multiple birthsembryos transferred, births, percent multiple births

• Reynolds et al, 2003—Comprehensive insurance Reynolds et al, 2003—Comprehensive insurance coverage reduces number of embryos transferred in coverage reduces number of embryos transferred in women <35, maybe reduce multiple birth rates women <35, maybe reduce multiple birth rates (significant only in MA)(significant only in MA)

– Both studies evaluated one year only (1998) Both studies evaluated one year only (1998) – Jain et al did not address differences in demographic Jain et al did not address differences in demographic

characteristics across statescharacteristics across states– Reynolds et al matched mandate states to geographically Reynolds et al matched mandate states to geographically

close states with similar size populationclose states with similar size population

Research questionResearch question

How does comprehensive How does comprehensive insurance forinsurance for

infertility affect birth outcomes at infertility affect birth outcomes at thethe

population level?population level?

Data Sources – Birth CertificatesData Sources – Birth Certificates

• National Vital Statistics System from the National Vital Statistics System from the NCHS 1980-1997NCHS 1980-1997– Information abstracted from birth certificatesInformation abstracted from birth certificates– 100% of births for most states for most years100% of births for most states for most years– Total number of births, multiple births (twins Total number of births, multiple births (twins

or higher order), triplets+ (triplets or higher or higher order), triplets+ (triplets or higher orderorder

– Transform births to deliveries for calculation Transform births to deliveries for calculation of multiplesof multiples

Data Sources – Insurance Data Sources – Insurance MandatesMandates

• RESOLVE and state legislationRESOLVE and state legislation• Categorized based on likely effectiveness in Categorized based on likely effectiveness in

changing treatment patterns:changing treatment patterns:– Comprehensive (3 states)– requirement that Comprehensive (3 states)– requirement that

insurance companies (including HMOs) provide insurance companies (including HMOs) provide coverage for the cost of diagnosis and treatment of coverage for the cost of diagnosis and treatment of infertility, including ART of at least 4 oocyte retrievals.infertility, including ART of at least 4 oocyte retrievals.

– ““Soft” (5 states) – limited coverageSoft” (5 states) – limited coverage– ““Offer only” (3 states) – mandates insurance Offer only” (3 states) – mandates insurance

companies to offer coverage, but no mandate to companies to offer coverage, but no mandate to purchase coveragepurchase coverage

– No Mandate No Mandate

Data Sources - OtherData Sources - Other

• U.S. Census BureauU.S. Census Bureau

• Bureau of Economic AnalysisBureau of Economic Analysis

• Bureau of Labor StatisticsBureau of Labor Statistics

• Current Population SurveyCurrent Population Survey

Data Analysis – Birth DataData Analysis – Birth Data

where i indexes states and t indexes years

y is a birth outcome including deliveries, multiple deliveries, and triplet+ deliveries per 1,000 women, multiples and triplets+ per 1,000 deliveries

C, S, and O are time-varying indicators of mandates

Y is a year fixed effect

G is a state fixed effect

titititititi YGOSCy ,,3,2,1,

Effect on Deliveries per CapitaEffect on Deliveries per Capita

Deliveries per 1000 Women

20-49 20-29 30-34 35-39 40-44 45-49Offer Mandate 3.252 6.782+ 2.139 2.218 1.055 0.065

[2.535] [3.519] [2.049] [1.830] [0.782] [0.065]Soft Mandate -0.309 -0.183 -0.724 -0.172 -0.18 -0.019

[1.482] [1.609] [1.613] [1.353] [0.446] [0.021]Comprehensive Mandate 2.657* 1.079 4.018* 2.982 0.501 0.004

[1.066] [2.204] [1.551] [1.783] [0.541] [0.037]Constant 57.868** 111.417** 45.098** 11.191** 2.126** 0.120**

[0.989] [1.099] [1.092] [0.798] [0.240] [0.020]Observations 918 918 918 918 918 918R-squared 0.86 0.92 0.94 0.94 0.91 0.77Robust standard errors in brackets+ significant at 10%; * significant at 5%; ** significant at 1%

Age

Effect on Multiple Deliveries per Effect on Multiple Deliveries per CapitaCapita

Multiple Deliveries per 1000 Women

20-49 20-29 30-34 35-39 40-44 45-49Offer Mandate 0.017 0.003 -0.016 0.024 0.032 0.011

[0.042] [0.041] [0.051] [0.047] [0.019] [0.007]Soft Mandate 0 0.027 -0.019 -0.009 -0.001 -0.002

[0.026] [0.018] [0.046] [0.043] [0.009] [0.002]Comprehensive Mandate 0.071* -0.004 0.193** 0.124+ 0.032 0.002

[0.027] [0.032] [0.046] [0.071] [0.025] [0.004]Constant 0.613** 1.168** 0.558** 0.112** 0.023** -0.004**

[0.014] [0.013] [0.023] [0.021] [0.006] [0.001]Observations 918 918 918 918 918 918R-squared 0.74 0.81 0.86 0.85 0.73 0.59Robust standard errors in brackets+ significant at 10%; * significant at 5%; ** significant at 1%

Age

Effect on Multiples per 1000 Effect on Multiples per 1000 DeliveriesDeliveries

Multiples per Delivery

20-49 20-29 30-34 35-39 40-44 45-49Offer Mandate -0.619* -0.643** -0.668* -0.926* 1.18 11.528

[0.267] [0.114] [0.301] [0.450] [1.142] [8.104]Soft Mandate 0.17 0.279 0.061 0.112 1.770* 6.159+

[0.281] [0.200] [0.288] [0.809] [0.676] [3.120]Comprehensive Mandate 0.743+ -0.043 1.174** 1.19 3.6 7.248

[0.428] [0.101] [0.267] [1.089] [2.477] [8.209]Constant 10.760** 10.504** 13.080** 12.951** 13.074** -9.279**

[0.116] [0.089] [0.178] [0.347] [0.888] [3.013]Observations 918 918 918 918 918 918R-squared 0.86 0.77 0.75 0.68 0.38 0.48Robust standard errors in brackets+ significant at 10%; * significant at 5%; ** significant at 1%

Age

Effect on Triplet+ Deliveries per Effect on Triplet+ Deliveries per CapitaCapita

Triplet Deliveries per 1000 Women

20-49 20-29 30-34 35-39 40-44 45-49Offer Mandate -0.002 -0.005** -0.010* 0.002 0.001 0.001*

[0.002] [0.002] [0.005] [0.003] [0.001] [0.001]Soft Mandate 0.001 0.001 0.001 0.004 -0.001 0

[0.002] [0.001] [0.006] [0.003] [0.001] [0.000]Comprehensive Mandate 0.009** 0.002 0.031** 0.013** 0.001 0

[0.001] [0.003] [0.003] [0.003] [0.002] [0.000]Constant 0.006** 0.016** 0.002 -0.005** -0.001** 0

[0.001] [0.001] [0.002] [0.002] [0.000] [0.000]Observations 918 918 918 918 918 918R-squared 0.75 0.51 0.72 0.65 0.41 0.31Robust standard errors in brackets+ significant at 10%; * significant at 5%; ** significant at 1%

Age

Effect on Triplets+ per 1000 Effect on Triplets+ per 1000 DeliveriesDeliveries

Triplets per Delivery

20-49 20-29 30-34 35-39 40-44 45-49Offer Mandate -0.077* -0.059** -0.147* -0.019 -0.029 1.238+

[0.030] [0.016] [0.055] [0.071] [0.051] [0.647]Soft Mandate 0.025 0.008 0.022 0.173 -0.05 1.216

[0.039] [0.014] [0.082] [0.104] [0.159] [1.566]Comprehensive Mandate 0.155** 0.028* 0.284** 0.245** 0.07 -0.571

[0.025] [0.011] [0.024] [0.045] [0.238] [0.678]Constant 0.114** 0.143** 0.169** 0 0.01 2.502**

[0.010] [0.007] [0.022] [0.047] [0.058] [0.350]Observations 918 918 918 918 918 918R-squared 0.78 0.53 0.68 0.53 0.28 0.22Robust standard errors in brackets+ significant at 10%; * significant at 5%; ** significant at 1%

Age

Summary of ResultsSummary of Results• In states with comprehensive insurance In states with comprehensive insurance

mandates…mandates…– At the population level, delivery rates are At the population level, delivery rates are

higher, although the effect is concentrated higher, although the effect is concentrated among 30-34 year olds.among 30-34 year olds.

– At the population level, the proportion of At the population level, the proportion of multiple deliveries, particularly triplets or multiple deliveries, particularly triplets or higher order, is higher for women 20-29, 30-higher order, is higher for women 20-29, 30-34, 35-39.34, 35-39.

• Effects are restricted to mandates Effects are restricted to mandates providing comprehensive coverage.providing comprehensive coverage.

ConclusionsConclusions

• Generous insurance coverage of ART Generous insurance coverage of ART induces those for whom the expected induces those for whom the expected benefits of therapy are lower to pursue benefits of therapy are lower to pursue treatment.treatment.

• The result is that many women undergoing The result is that many women undergoing ART when insurance coverage is generous ART when insurance coverage is generous are those for whom the therapy did not are those for whom the therapy did not increase the probability of a baby but did increase the probability of a baby but did increase the probability of multiples.increase the probability of multiples.

ImplicationsImplications

Broad insurance coverage for the Broad insurance coverage for the treatment of infertility should treatment of infertility should have mechanisms to distinguish have mechanisms to distinguish between those for whom the between those for whom the benefits of treatment are high benefits of treatment are high and those for whom the benefits and those for whom the benefits are lower.are lower.

Questions?Questions?