On the Importance of Context: Examining the Applicability of Infertility Insurance Mandates in the United States Using a Mixed-Methods Study Design

Accessibility of infertility services is disproportionately experienced in the United States. Although there exist state-based health insurance mandates for infertility services, these mandates contain language that disqualify people from using them. In order to better understand why these mandates are not able to reduce the financial burden and bridge the income disparity for using infertility services, the purpose of this study is to add context to the applicability of these insurance mandates through qualitative and quantitative inquiry. Using the Glass and McAtee model of risk regulators as an operational paradigm, this research explores the role of environmental context, or “place”, as a risk regulator for accessing infertility services. The qualitative inquiry consists of informal interviews with people using those services and expert interviews with representatives from organizations providing types of financial assistance for infertility services. The quantitative inquiry consists of a survey instrument observing aspects of travel, health insurance, residence, health education, and self-efficacy in relation to seeking infertility services. The quantitative spatial analysis includes cluster analyses of CDC reporting fertility clinics in the United States, and spatial autocorrelation of census-tract level fertility estimates to give context to future spatial analyses of the use of infertility services. Based on the survey results (n=134), only 20.41% of people living in a mandated state reported having all infertility services covered by health insurance. The results from 66 informal interviews and eight expert interviews suggests that both place and policy (infertility insurance mandates) act as risk regulators that affect levels of insurance coverage for, and decisions regarding, infertility services. Having residence in a mandated state does not mean one will have access to their state’s mandated coverage, but residence of the individual and of their employer’s headquarters can regulate degrees of insurance coverage provided by a state’s infertility insurance mandate. Spatial distribution of “All women with births” suggests that human reproduction is a highly spatially autocorrelated phenomenon based on age, education, ethnicity, nativity, and poverty status (p \u3c 0.0001 for all variables), however the directional distributions show different directional patterns. Spatial distribution of fertility clinics shows significant spatial clustering of clinics in metropolitan areas, regardless of the presence of an infertility insurance mandate, and qualitative accounts of travel related to using infertility services suggests that placement of clinics near business centric areas is beneficial for patients. The existing infertility insurance mandates place the state directly in the way of reproductive autonomy. Greater attention should be paid to the role of employers in facilitating insurance benefits for infertility services, considering employers establish insurance policies for their employees and can therefore mitigate the degree of infertility insurance benefits available to them. Due to the nature of the state-based insurance mandates, both place and policy will continue to be intra-active risk regulators that mitigate the access of infertility services and will be differently experienced at the individual level