Boston Globe | He ‘hasn’t thought about this at all’: Experts react to Donald Trump’s pledge to make IVF free for everyone

By Adam Piore and Izzy Bryars | Originally Published by the Boston Globe

A little more than a week after Democrats made access to fertility treatments a central issue at their party convention, former president Donald Trump responded with a vow of his own: If elected to a second term, he promised, he will make in vitro fertilization treatment free for women.

“I’m announcing today in a major statement that under the Trump administration, your government will pay for — or your insurance company will be mandated to pay for — all costs associated with IVF treatment,” he said at an event in Michigan on Thursday. “Because we want more babies, to put it nicely.”

Trump did not detail how he would fund his plan or precisely how it would work, omissions that drew immediate skepticism from some health care economists.

But it highlighted the prominence of the issue. Access to fertility treatments has emerged in recent weeks as a central issue in the presidential campaign, as Democrats have warned that access is under threat by the same forces on the political right that have restricted access to abortion. Speaking at the Democratic National Convention, Tim Walz, the vice presidential nominee, recounted his family’s fertility struggles during his acceptance speech. Michelle Obama mentioned she underwent IVF. And Boston Mayor Michelle Wu publicly discussed her own use of assisted reproductive technology, telling the Globe that she “felt lucky to live in Massachusetts.”

IVF treatments are notoriously expensive and can cost tens of thousands of dollars for a single round. Many women require multiple rounds, and there is no guarantee of success.

Here’s what you need to know.

How common is IVF?

Very. Around 2.5 percent of all infants in the United States were born using assisted reproductive technologies in 2022. In Massachusetts, which has the highest percentage of births involving fertility treatments of any state, that number was 7 percent. Success rates for the procedure are variable and start at 50.7 percent for women younger than 35 and dwindle to 7.9 percent per egg retrieval for women over 40, according to the Centers for Disease Control and Prevention.

How could a universal in vitro plan affect Massachusetts?

Massachusetts has had a mandate requiring insurers to cover all “non-experimental fertility procedures,” which includes in vitro fertilization, since the late 1980s, said Lora M. Pellegrini, president and CEO of the Massachusetts Association of Health Plans. Massachusetts has what many consider to be the most comprehensive mandate in the nation. It covers all the diagnostic tests and up to six cycles of IVF.

But there are loopholes that result in only about a third of people seeking IVF treatment in the state actually having coverage, said Dr. Michael M. Alper, an associate professor of obstetrics and gynecology at Harvard Medical School and medical director of Boston IVF, a fertility clinic with more than 20 locations in New England.

Many companies are not subject to the mandate because they fall under the “self-insure” exemptions, meaning they insure their own employees, thereby assuming the risk of high medical expenses themselves. Currently 60 percent of privately insured employees in Massachusetts are in self-insured plans, Pellegrini said. Companies that have their headquarters outside of Massachusetts are subject to the laws of their home states.

In practice, that means many would-be parents still pay out of pocket. Billed per cycle, IVF, which involves fertilizing eggs outside of the body in a lab and then transferring the fertilized eggs into the uterus, costs about $20,000. Intrauterine insemination, the fertility treatment used by the Walz family, involves placing sperm directly into the uterus to increase the chances of pregnancy. It costs about $1,500-$2,000, according to Dr. Pietro Bortoletto, director of reproductive surgery at Boston IVF.

Massachusetts is the “best-case example” but “still it does not fully cover everyone who may have a need for infertility services,” Bortoletto said.

Would a federal law close those loopholes?

It depends.

“Any mandates is better than no mandates,” Alper said. “But there would have to be provisions in the legislation that prevent a large percentage of the insurance companies from getting around them. That’s all in the details. There’s a lot of ways for insurance companies to not offer it. So there’s all kinds of details that are critical to see what percentage of the population is excluded and will really influence how many people are going to be able to take advantage of a law.”

Legislation, for instance, could offer IVF but not explicitly state it is a universal requirement, which would allow insurance companies to exclude large numbers of potential patients. Currently some insurance companies and some states offer IVF for women under the age of 40 but don’t cover it for those over the age of 40. Others limit the number of cycles to two, which often isn’t enough to produce a live birth, especially in older patients. Other exclusions use tests to predict the likelihood of success and can use scores that fall below a certain threshold to deny coverage.

How much would Trump’s plan cost?

David Cutler, a Harvard University economist who studies health care, said it’s impossible to know without more details.

“It depends. It’s like saying I want to cover everybody for dinner. Do you mean dinner at McDonald’s? Do you mean dinner at the fancy restaurant? The cost of those two things varies by a factor of bazillions.”

He highlighted a number of other questions that remained unanswered. For starters, he asked how the mandate would apply to people who are uninsured.

“Does it mean that you’re going to give people coverage for IVF but not for other services? Is this part of a plan to give everybody insurance coverage? Is it going to cover people who are not insured for other things? For IVF, what about the doctors’ visits that lead up to the IVF? What about the delivery?”

How have local experts responded to the proposal?

Some were unconvinced of Trump’s sincerity.

“Donald Trump is full of bologna,” said Rebecca Hart Holder, president of Reproductive Equity Now. “The only thing we should be trusting is Trump’s record of overturning Roe v. Wade, wanting to punish patients who seek abortion, and criminalizing doctors who offer life-saving and life-affirming care. Trump is running from his cruel anti-reproductive record because he knows that American voters will overwhelmingly demand the ability to decide if, when, and how to start or grow their families this Election Day.”

Other skeptics noted that Trump’s campaign website links to a platform that could effectively ban IVF by establishing so-called “fetal personhood.”

Cutler compared the announcement to declaring, “I want there to be world peace, and I want people to be happy,” without providing any details, and said the lack of details suggests Trump “hasn’t thought about this at all.”