State insurance mandates do not improve racial disparities in live births on ART

ANAHEIM, Calif. — Insurance mandates for fertility treatment with donor eggs may improve overall live birth rates, but current policies are failing to reduce racial disparities in assisted human reproduction (ART) treatment ), according to a retrospective study.

Overall, state insurance requirements for donor oocyte coverage were associated with a 10% increased chance of live birth (RR 1.10, 95% CI 1.05-1, 16), reported Caiyun Liao, MD, MPH, researcher in reproductive endocrinology and infertility at Yale University in New Haven, Connecticut.

However, there were significant racial disparities in live birth rates in states that did not mandate cycle coverage with donor oocytes: in a multivariate regression analysis, groups less likely to achieve a live birth after ART were:

  • African Americans (RR 0.82, 95% CI 0.77-0.87)
  • Hispanics (RR 0.93, 95% CI 0.88-0.98)
  • Asians and other races (RR 0.96, 95% CI 0.93-0.99)

The presence of an insurance mandate has not mitigated racial disparities, Liao said in a presentation at the annual meeting of the American Society for Reproductive Medicine.

“Insurance mandates that actually reach those most in need are necessary, but insufficient for equitable access and outcomes,” Liao reported. “Disparities in ART are a phenomenon that arises from a complex web of biological, social, cultural and psychological factors that act synergistically and must be addressed using a multi-pronged approach.”

Mandatory insurance coverage for autologous ART may be associated with improved access and pregnancy outcomes, but the impact these policies might have on racial disparities in ART is unclear.

Previous studies have shown that African American women and those from lower socioeconomic backgrounds are more likely to be infertile, but are also less likely to access treatment, Liao said. Additionally, people of color generally had poorer pregnancy outcomes with ART.

In this study, Liao’s group used the SART CORS database to compare live birth rates in 2014-2016 by race and ethnicity in states that have mandated egg donor insurance coverage – namely the New Jersey and Massachusetts – to those who haven’t. The representation of each racial/ethnic group in the study was compared to US census data.

The analysis included 40,546 cycles of donor oocytes from over 27,000 recipients. Approximately 36% of cycles used fresh oocytes and 64% used frozen and thawed oocytes. Most patients included in the analysis were over 42 years old, but non-Hispanic white patients were younger than the overall population.

Decreased ovarian reserve was the most common cause of infertility among egg recipients included in the study. African American patients were more likely to have a higher BMI and experienced a higher rate of recurrent miscarriage than women of other races and ethnicities.

Beneficiaries who were African American or Asian were less likely to reside in states with mandatory coverage or receive treatment at clinics in mandated states than those from other racial/ethnic groups. Additionally, African American recipients were the least likely to achieve a clinical pregnancy or live birth, the researchers found.

Liao acknowledged that this study may be limited by indiscriminate misclassification of recipients from New Jersey or Massachusetts who may have crossed state lines for fertility treatment. She added that the SART CORS database did not include information on important social determinants of health, such as income or level of education.

  • Amanda D’Ambrosio is a reporter on the business and investigative team at MedPage Today. She covers obstetrics and gynecology and other clinical news, and writes about the US healthcare system. Follow


Liao disclosed no potential conflict of interest.

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