The Infertility Shift | Bill of Health
By Valarie K. Blake and Elizabeth Y. McCuskey
In vitro fertilization (IVF), like most medical care in the U.S., costs far more than most people can afford out-of-pocket: over $12,500 per cycle, with multiple cycles typically required. But, unlike most other expensive medical care, IVF rarely has insurance coverage to defray the cost.
In 2020, only 27% of employers with 500+ employees and 42% of employers with 20,000+ employees covered IVF in their employer plans. Companies like Starbucks and Amazon know this and use it to draw in employees at low (or essentially neutral) wages.
Recent reports reveal women working second shifts for these corporations solely to qualify for employer health benefits that cover infertility treatments. Starbucks, for example, covers IVF for employees who work 240 hours over three months, or roughly 20 hours per week. Frequently, in these low-wage positions, workers earn just enough to pay for their health insurance premiums and sometimes the associated cost-sharing requirements.
How did we get to a place where women must work an “infertility shift” beyond their full-time jobs to access medical care?
No federal law requires employer plans to cover infertility care, despite the Affordable Care Act’s mandates that insurers cover many other services. Fifteen states require insurers to cover some infertility care, though these mandates are riddled with holes: caps on total benefits, lack of express inclusion of IVF, marriage requirements, definitions of infertility that exclude same-sex couples, and other lurking exceptions. Public school teachers in Denver learned this the hard way when they were excluded from Colorado’s 2022 infertility coverage mandate because Denver Public Schools were subject to an opt-out mechanism. ERISA preemption also exempts private self-funded employer plans (which account for 61% of employer-sponsored coverage) from even these porous state benefits mandates.
Non-employer sources of insurance offer little or no alternative. Individual-market plans sold on the exchanges in those 15 states that have infertility benefit mandates will have some coverage; the rest may not. And if a person’s employer offers insurance benefits which exclude IVF, she does not qualify for premium subsidies on the exchanges. No state Medicaid program covers IVF.
While IVF financing exists for some who qualify, it comes with interest rates as high as 35.99% on loans of tens of thousands of dollars.
Working the infertility shift may reduce IVF’s financial risk but increases health risks. Women on the infertility shift may face 60-hour work weeks at a time when most clinicians recommend they rest and de-stress. Retail work scheduling is notoriously unpredictable, and linked to poor worker wellness. Women must navigate this challenge during an intense period of medical appointments and procedures. The average worker with multiple jobs faces heightened risk of work-related injuries, increased rates of depression and other mental health issues, and greater financial instability and family strife. Fertility treatment and the infertility shift only add to this stress.
The infertility shift further distorts the already fun-house mirror effects of employer-sponsored insurance on the labor economy. HIPAA and the ACA both responded to concerns about “job lock” – that employer-sponsored insurance restricted job mobility and entrepreneurship. Economists and policymakers worried that job lock causes economic and individual harms “because it keeps [the worker] from making their preferred labor mobility choice, such as to change jobs, start a business, reduce work hours, or exit the labor force to stay home with children or retire.” The infertility shift resurrects job-lock in reverse, driving people into a labor market solely to get particular insurance coverage, when they might otherwise elect different work suited to their skills and schedule or forego additional part-time work. It poses similar economic and individual harms by limiting workers’ ability to leave the market, reduce hours, or choose self-employment while they require fertility treatment. It locks people into particular employers and therefore can discourage those employers from meeting their employees’ labor needs beyond health benefits.
The plight of workers with infertility results from and contributes to reproductive exceptionalism, singling out reproductive services for different (usually worse) status under the law. The pervasive exclusions of infertility care from insurance coverage impose increased physical, financial, and mental burdens on women who require these services to reproduce. And it reflects a value judgment, for the kinds of care we accept or reject in the risk-sharing of health benefits says much about what and who we most value.
Proposed federal legislation to require IVF coverage in private insurance and public benefits could eliminate the infertility shift and begin to reduce the significant disparities in access to this care based on race and income. But it would still leave people picking up shift work to get insurance coverage for gender-affirming surgery or abortion care. So, enacting this kind of piecemeal patch for IVF coverage would not adequately address the forces of reproductive exceptionalism that necessitate it. The infertility shift thus should remind health reformers that they must work overtime to confront these forces in pursuit of universal coverage.
Valarie K. Blake is Associate Dean for Faculty Development and Research and a Professor of Law at West Virginia University College of Law.
Elizabeth Y. McCuskey is a Professor at Boston University’s School of Public Health and School of Law.
