The Impact of Mandated Insurance Coverage on Early Care Discontinuation in Assisted Reproductive Technology

INTRODUCTION: Given the high cost of assisted reproductive technology (ART) in the United States, we assessed the association between state-mandated insurance coverage for fertility services with rates of care discontinuation after an initial ART cycle that did not result in a live birth. METHODS: This retrospective cohort study using data from the National ART Surveillance System included patients who began their first autologous ART cycle between 2016-2017 and did not have a live birth. Patients were divided into those that continued and discontinued ART care within 12 months. Multivariable analyses were conducted to evaluate factors associated with discontinuation, including categories of state-mandated insurance coverage. Institutional review board approval was obtained. RESULTS: Among 91,234 patients who underwent their first autologous ART cycle that did not result in live birth, 24,072 (26%) discontinued care. Compared to patients who lived in states with comprehensive mandated insurance coverage (≥3 ART cycles), states with mandated insurance coverage excluding ART, or states with no mandated insurance coverage, were 46% (adjusted relative risk [aRR] 1.46; 95% CI, 1.31–1.63) and 26% (aRR 1.26; 95% CI, 1.15–1.39) more likely to discontinue care, respectively, after controlling for patient and cycle characteristics. Increasing patient age, distance from clinic >50 miles, prior live birth, fewer oocytes retrieved, and not having embryos cryopreserved were also associated with higher rates of discontinuation. Non-Hispanic Black, non-Hispanic Asian, and Hispanic patients had higher rates of care discontinuation compared to non-Hispanic White patients for any insurance coverage level. CONCLUSION: Comprehensive mandated insurance coverage for ART is associated with lower rates of ART care discontinuation.