MASTROIANNI 3/8/2016 3:00 PM BRIDGING THE GAP BETWEEN THE “HAVE” AND THE “HAVE- NOTS”: THE ACA PROHIBITS INSURANCE COVERAGE DISCRIMINATION BASED UPON INFERTILITY STATUS Marissa A. Mastroianni* I. INTRODUCTION Due to the high costs of infertility treatment, many infertile Americans find themselves without the means to procreate.1 Compounding this issue, access to infertility treatment varies greatly from state-to-state largely due to the differences in state insurance coverage mandates.2 The access to infertility treatment, such as artificial reproductive technology (“ART”), often correlates to factors like household income, marital status, education level, race, ethnicity, and age.3 Therefore, a dichotomy exists between the “haves,” those with the financial means to undergo infertility treatment, and the “have-nots,” those who lack such means. In an effort to curb this preclusive effect, a total of fifteen states have passed legislation that requires insurers to provide coverage, or at least offer coverage, for infertility treatment.4 The infertile individuals living within the other thirty-five states and the District of Columbia, however, do not enjoy similar insurance coverage.5 * J.D., 2015, Seton Hall University School of Law; B.A., 2012, Lehigh University. I would like to thank Professor Gaia Bernstein and Professor John Jacobi for their invaluable feedback and support in writing this article. I would also like to thank Michael Spizzuco and the ALBANY LAW REVIEW staff for their editing assistance. The views expressed in this article are mine alone. 1 See ANJANI CHANDRA ET AL., U.S. DEP’T OF HEALTH AND HUMAN SERVS., INFERTILITY SERVICE USE IN THE UNITED STATES: DATA FROM THE NATIONAL SURVEY OF FAMILY GROWTH, 1982–2010 2 (2014); Debora Spar & Anna M. Harrington, Building a Better Baby Business, 10 MINN. J.L. SCI. & TECH. 41, 49, 50 (2009). 2 Spar & Harrington, supra note 1, at 51–53. 3 See CHANDRA ET AL., supra note 1, at 10. 4 State Laws Related to Insurance Coverage for Infertility Treatment, NAT’L CONFERENCE OF STATE LEGISLATURES, http://www.ncsl.org/research/health/insurance-coverage-for-infertility- laws.aspx (last updated June 2014) [hereinafter State Laws Related to Insurance Coverage]; Saswati Sunderam et al., Assisted Reproductive Technology Surveillance – United States, 2011, MORBIDITY AND MORTALITY WKLY. REP. (Nov. 21, 2014), at 9, http://www.cdc.gov/mmwr/pdf/ss/ss6310.pdf. 5 See State Laws Related to Insurance Coverage, supra note 4. 151 MASTROIANNI 3/8/2016 3:00 PM 152 Albany Law Review [Vol. 79.1 Even within the fifteen states that have passed infertility coverage mandates, the scope of the laws vary and may be significantly limited.6 Thus, individuals without the necessary financial means to pay out-of-pocket for infertility treatments are disadvantaged depending on the laws of the state in which they reside. Allowing the states to choose whether to provide infertility insurance coverage has proven to yield discriminatory effects upon infertile individuals. In fact, only about 25 percent of U.S. health insurance plans include infertility benefits.7 The lack of access to infertility treatment for the majority of Americans is not a new concern. For example, in 2001, a Michigan Federal District Court held that infertility is a disability under the Americans with Disabilities Act (“ADA”) and therefore, relevant federal protections apply to infertile individuals.8 Moreover, the National Women’s Law Center spearheaded a campaign called “Being a Woman Is Not a Preexisting Condition” that seeks to prevent insurers from raising insurance premiums based upon gender.9 Despite the court ruling and political efforts, there were no reforms made on the federal level to mandate health insurance coverage for infertility treatment.10 The advent of the Patient Protection and Affordable Care Act (“ACA”),11 however, changed the landscape for the health insurance market and provides a new lens in which to view this issue. The ACA instituted large-scale health insurance reform at the federal level in an effort to control the steadily increasing cost of health care in the United States.12 Specifically, health care spending in 2009 represented 17.6% of the United States’ GDP and was projected to increase to 19.8% of GDP by 2020.13 The most highly publicized provision of the ACA is the individual mandate requiring the vast majority of Americans to enroll in either private or public health 6 See id. 7 Kate Devine et al., The Affordable Care Act: Early Implications for Fertility Medicine, 101 FERTILITY & STERILITY 1224, 1224 (2014). 8 See LaPorta v. Wal-Mart Stores, Inc., 163 F. Supp. 2d 758, 763 (W.D. Mich. 2001). 9 Devine et al., supra note 7, at 1226. 10 Valarie Blake, It’s an ART not a Science: State-Mandated Insurance Coverage of Assisted Reproductive Technologies and Legal Implications for Gay and Unmarried Persons, 12 MINN. J.L. SCI. & TECH. 651, 661–62 (2011). 11 Patient Protection and Affordable Care Act, 42 U.S.C. §§ 18001–121 (2013) (effective Jan. 16, 2014). 12 See Trends in Health Care Cost Growth and the Role of the Affordable Care Act, EXEC. OFFICE OF THE PRESIDENT OF THE U.S., 1, 24 (Nov. 2013), https://www.whitehouse.gov/sites/ default/files/docs/healthcostreport_final_noembargo_v2.pdf. 13 Paul R. Brezina et al., How Obamacare Will Impact Reproductive Health, 31 SEMINARS REPROD. MED. 189, 191 (2013). MASTROIANNI 3/8/2016 3:00 PM 2015/2016] Infertility Status Discrimination 153 insurance plans.14 More pertinent to this article, the ACA greatly affected the private insurance market and public health plans.15 First, the ACA created a generalized list of categories for minimum “essential health benefits” that all qualified health plans must offer to its beneficiaries.16 Significantly, there are several statutory provisions within the ACA regarding nondiscrimination.17 The Department of Health and Human Services (“DHHS”), the authoritative decision- maker on implementing the ACA, issued several regulations regarding nondiscrimination in the health insurance market.18 In particular, qualified health plans may “[n]ot employ marketing practices or benefit designs that will have the effect of discouraging the enrollment of individuals with significant health needs.”19 Therefore, the ACA and subsequent regulations represent a new legal framework in which to view discrimination in the national health insurance market. The ACA’s statutory language is silent as to infertility treatment coverage, and its effect upon the fifteen states that have enacted state insurance mandates.20 Additionally, DHHS has not included infertility coverage as an essential health benefit in any subsequent regulation.21 This is partly due to the fact that DHHS provided states with the authority to create their own essential health benefit standards.22 Specifically, DHHS proposed a policy in December 2011 that provided states with “the flexibility to select . . . ‘benchmark 14 See 26 U.S.C. § 5000A(a) (2013); Brezina et al., supra note 13, at 191. 15 See infra Part IV.A. 16 42 U.S.C. § 18022(a)(1), (b)(1) (2013); see infra notes 160–67. This provision, however, does not affect “grandfathered” insurance plans that were in existence before the enactment of the ACA. See 42 U.S.C. § 18011 (2013). Moreover, the essential health benefit standard does not apply to self-insured groups and large group plans. See Kate Greenwood et al., Implementing the Essential Health Benefits Requirement in New Jersey: Decision Points and Policy Issues 1 (Seton Hall Univ. Sch. of Law, Ctr. for Health & Pharm. Law & Policy, Research Paper No. 08, 2012), http://papers.ssrn.com/sol3/papers.cfm?abstract_id=2146806. It is important to note that Congress gave the Department of Health and Human Services (“DHHS”) the power to formalize essential health benefits after receiving input from the Department of Labor, Institute of Medicine, Congressional members, private citizens, and physician groups. See 42 U.S.C. § 18022(a)(1); Brezina et al., supra note 13, at 193. 17 See, e.g., 42 U.S.C. §§ 300gg-3, -4, -5, -16, 18116 (2013). 18 In enacting the ACA, Congress authorized DHHS to “issue regulations setting standards for meeting the requirements” under Title 1 of the ACA, which includes the relevant ACA provisions for the purposes of this article. 42 U.S.C. § 18041(a)(1) (2013). 19 45 C.F.R. § 156.225(b) (2014). 20 Brezina et al., supra note 13, at 194, 195; see also Devine et al., supra note 7, at 1224 (noting that the long-term effects of the ACA with respect to infertility treatment is unknown). 21 See Brezina et al., supra note 13, at 194. 22 Devine et al., supra note 7, at 1225. MASTROIANNI 3/8/2016 3:00 PM 154 Albany Law Review [Vol. 79.1 plan[s]’” based upon typical insurance coverage plans within the state.23 On February 27, 2015, DHHS renewed this policy through 2017.24 In accordance with this policy, the states with insurance mandates regarding infertility treatments adopted essential benefit standards that incorporated such laws.25 Therefore, in this context, the status quo has been maintained, so far. In light of the changes created by the ACA, the question arises: Does the fact that some infertile individuals in the United States lack access to insurance coverage for infertility treatment violate the ACA’s anti-discrimination framework? This article answers in the positive. Although medical practitioners and scholars have already addressed the problem of unequal access to infertility treatment,26 this article will use the ACA as a new lens to view this inequality. Interestingly enough, congressional hearings regarding the passage of the ACA uncovered stories of women who were wholly “denied insurance coverage because their infertility [status] was treated as a preexisting condition.”27 Due to financial restrictions, often no hope exists for many infertile individuals who live in states without insurance mandates to obtain the means to procreate.28 This article will proceed as follows. Part II will discuss the various types of infertility treatment and the associated costs. This section will also discuss established demographic patterns in the type of 23 Id. 24 See CTR. FOR CONSUMER INFO. AND INS. OVERSIGHT, ESSENTIAL HEALTH BENEFITS: LIST OF THE LARGEST THREE SMALL GROUP PRODUCTS BY STATE 3 (2015), https://www.cms.gov/ CCIIO/Resources/Regulations-and-Guidance/Downloads/largest-smgroup-products-4-8-15- 508d-pdf-Adobe-Acrobat-Pro.pdf; see generally 45 C.F.R. § 156.100 (2015) (granting States the ability to select their own benchmark plan). 25 Devine et al., supra note 7, at 1225. 26 See, e.g., CHANDRA ET AL., supra note 1, at 1–2 (“[W]omen who use infertility services are significantly more likely to be married, non-Hispanic white, older, more highly educated, and more affluent than nonusers.”); Blake, supra note 10, at 660–61 (arguing that the necessity to pay out-of-pocket for fertility treatment is a deterrent for infertile women); Anne Fidler & Judith Bernstein, Infertility: From a Personal Public Health, 114 PUB. HEALTH REP. 494, 497 (1999) (discussing statistics which indicate that race and wealth are directly correlated to women’s use of fertility treatment); Marianne P. Bitler & Lucie Schmidt, Utilization of Infertility Treatments: The Effects of Insurance Mandates 12–13 (Nat’l Bureau of Econ. Research, Working Paper No. 17668, 2011), http://www.nber.org/papers/w17668.pdf (noting that statistics from the National Survey of Family Growth demonstrate that older and more educated women have greater access to infertility treatment as a result of State infertility insurance mandates allowed for by the ACA). 27 Devine et al., supra note 7, at 1226; see also RICHARD KIRSCH, FIGHTING FOR OUR HEALTH: THE EPIC BATTLE TO MAKE HEALTH CARE A RIGHT IN THE UNITED STATES 271 (2011) (describing a woman whose children were approved for coverage, but who was denied coverage because her infertility was considered to be a preexisting condition). 28 See Fidler & Bernstein, supra note 26, at 504 (arguing that insurance coverage is required to make infertility treatment widely available). MASTROIANNI 3/8/2016 3:00 PM 2015/2016] Infertility Status Discrimination 155 individuals who undergo such treatment. Part III will address the different insurance mandates in the fifteen states that have enacted legislation to provide coverage for infertility treatment. It will also argue that inherent inequalities arise from the fact that access to infertility treatment is, in part, based upon state residency. Part IV explains the relevant federal insurance law reforms instituted by the ACA and illustrates the ways in which the reform brought about more inclusive coverage standards. Finally, Part V argues why the inequality in access to infertility treatments amongst Americans violates the ACA’s anti-discrimination framework. II. INFERTILITY IN AMERICA AND THE ASSOCIATED HIGH COST FOR TREATMENT Similar to many health issues, no single universal definition for infertility exists. The most common definition of infertility is a “disease of the reproductive system”29 where an individual is unsuccessful in becoming pregnant after more than one year of unprotected sex.30 The definitional variations for infertility produce different statistical findings on the number of infertile individuals and how they are treated.31 Moreover, defining infertility as the inability to do something is problematic for statistical purposes.32 For example, a physician treats two women who both have blocked fallopian tubes, but only one woman is trying to get pregnant. Despite both women having blocked fallopian tubes, only one of them would be diagnosed as infertile.33 Therefore, the below statistics should be viewed in light of these difficulties in collecting adequate data. According to the Centers for Disease Control and Prevention (“CDC”), approximately 6.7 million women between the ages of 15– 44 suffer from an impaired ability to become pregnant.34 Therefore, almost eleven percent of women in the United States suffer from this 29 Infertility is a Global Public Health Issue, WORLD HEALTH ORG., http://www.who.int/ reproductivehealth/topics/infertility/perspective/en/ (last visited Nov. 15, 2014) (internal quotation marks omitted). 30 Fidler & Bernstein, supra note 26, at 497; State Laws Related to Insurance Coverage, supra note 4. 31 Fidler & Bernstein, supra note 26, at 497. 32 See id. 33 See id. 34 Infertility, CTRS. FOR DISEASE CONTROL & PREVENTION, http://www.cdc.gov/nchs/fastats /infertility.htm (last updated Feb. 6, 2015); Quick Facts About Infertility, AM. SOC’Y FOR REPROD. MED., http://www.asrm.org/detail.aspx?id=2322 (last visited Nov. 15, 2015). MASTROIANNI 3/8/2016 3:00 PM 156 Albany Law Review [Vol. 79.1 impaired ability.35 Additionally, infertility affects men and women equally. For example, the male partner is either the sole cause or a contributing cause for infertility in approximately 40 percent of infertile couples.36 In addition to the high financial costs associated with infertility treatment,37 a diagnosis of infertility is associated with a significant emotional toll. Evidence shows that the psychological effects sustained by infertile individuals are similar to the effects on heart disease and cancer patients.38 Further, an infertility diagnosis may contribute to a patient developing clinical depression, social isolation, and overall affect his or her quality of life.39 Indeed, infertility affects a “major life activity” as determined by the United States Supreme Court in Bragdon v. Abbott.40 These additional considerations, that are too personal to be monetarily valued, must not be overlooked. Part A of this section will briefly discuss the types of infertility treatment and the associated financial costs. The impact that information has on the United States population will be examined in Part B. A. Varying Types of Infertility Treatments and the Costs Associated with Such Treatment Infertile individuals have several options for medical procedures to increase their chances to conceive a child. Defining infertility treatment can be undertaken in a broad or narrow sense. For example, some physicians may believe providing general advice to increase a couple’s chances of becoming pregnant fits within the infertility treatment umbrella and therefore, reflects a broad meaning of infertility treatment.41 For the purposes of this article, however, a more narrow perspective on infertility treatment is adopted that includes only the three levels of treatment described below. As a preliminary matter, physicians will first run diagnostic exams of each partner’s reproductive organs if a couple is experiencing 35 Infertility, supra note 34; Quick Facts About Infertility, supra note 34. 36 Quick Facts About Infertility, supra note 34. 37 See infra Part II.B. 38 Fidler & Bernstein, supra note 26, at 497. 39 Id. 40 Bragdon v. Abbott, 524 U.S. 624, 639, 655 (1998) (holding that HIV infection is a disability under the Americans with Disabilities Act because it substantially limits a major life activity, reproduction). 41 See CHANDRA ET AL., supra note 1, at 2. MASTROIANNI 3/8/2016 3:00 PM 2015/2016] Infertility Status Discrimination 157 difficulty in getting pregnant.42 About fifty percent of patients who receive infertility evaluation decide to undergo some type of infertility treatment.43 Depending upon these results, there are generally three categories of infertility treatment: (1) Level I; (2) Level II; and (3) Level III.44 The treatment structure follows a pyramid-like scheme. Many infertile couples who choose to undergo Level III procedures have already unsuccessfully tried Level I and Level II.45 Level I infertility treatment involves ovarian stimulation with clomiphene citrate (a medication) for up to six ovulation cycles.46 Level II procedure involves another medication with exogenous gonadotrophins to stimulate ovulation with the option of using intrauterine insemination47 for up to six cycles.48 Finally, Level III infertility treatment encompasses the various ARTs for as many cycles the couple can pay for.49 There are various types of ART, which include: (1) in vitro fertilization50 (“IVF”); (2) zygote intrafallopian transfer51 (“ZIFT”); (3) gamete intrafallopian transfer52 (“GIFT”); and (4) intracytoplasmic sperm injection53 (“ICSI”).54 The infertility treatment variations discussed above inherently lead to varying levels of cost. For example, hormone therapy used in Level I and Level II can cost anywhere from $200 to $3,000 per 42 See Bitler & Schmidt, supra note 26, at 7. 43 Devine et al., supra note 7, at 1224. 44 See Bitler & Schmidt, supra note 26, at 7. 45 Id. at 7–8. 46 Id. at 7. 47 See CTRS. FOR DISEASE CONTROL & PREVENTION, 2011 ASSISTED REPRODUCTIVE TECHNOLOGY: FERTILITY CLINIC SUCCESS RATES REPORT 513 (2013), http://www.cdc.gov/art/ ART2011/PDFs/ART_2011_Clinic_Report-Full.pdf [hereinafter ASSISTED REPRODUCTIVE TECHNOLOGY] (providing a definition showing that this Level II procedure is generally not considered an artificial reproductive technology because the sperm is injected directly into a woman’s uterus to facilitate egg fertilization, and no manipulation of the egg itself is conducted); Bitler & Schmidt, supra note 26, at 7. 48 See Bitler & Schmidt, supra note 26, at 7. 49 See id. 50 Eggs are removed from a woman’s ovaries and are fertilized outside of her body. ASSISTED REPRODUCTIVE TECHNOLOGY, supra note 47, at 514. The fertilized egg (embryo) is then “transferred [back] into a woman’s uterus through [her] cervix.” Id. 51 Similar to the IVF procedure in that the eggs collected from a woman’s ovaries are fertilized outside of her body. Id. at 515. It differs from IVF because a laparoscope is used to place the zygote “into the woman’s fallopian tube through a small incision in her abdomen.” Id. 52 Eggs are removed “from the woman’s ovary, combining them with sperm, and using a laparoscope to place the unfertilized eggs and sperm into the woman’s fallopian tube through small incisions in her abdomen.” Id. at 514. 53 “A procedure in which a single sperm is injected directly into an egg; this procedure is commonly used to overcome male infertility problems.” Id. 54 Id. at 513. MASTROIANNI 3/8/2016 3:00 PM 158 Albany Law Review [Vol. 79.1 cycle.55 Once you move into ART procedures that require tubal surgery, then the price can range from $10,000 to $15,000 per cycle and hospitalization costs are added on top of the price tag.56 As with any type of surgery, there are associated complication risks that could lead to more financial cost. An average IVF cycle in the United States can cost between $10,000 and $15,000 with only a 25%–30% live birth success rate.57 Therefore, many couples will need to undergo several IVF cycles to achieve their desired outcome.58 The cost to conceive a child through IVF ranged from $44,000 to $211,940 in 1992 dollars.59 Comparative analysis with other countries helps put these numbers into perspective. The average cost for one IVF cycle is about $6,534 in the United Kingdom, $5,645 in Australia, and $3,956 in Japan.60 Additionally, “the gross cost of a single IVF cycle as a percentage of annual disposable income was highest in the United States, at 50%, compared with, for example, 12% in Japan.”61 Thus, ART costs in the United States are more expensive than in many similarly developed countries. There are other financial costs to ART procedures due to an increased risk of multiple-order births.62 Specifically, the high cost of ART and the relatively low success rates influence people to maximize their investment by implanting more than one egg into the woman’s ovaries in any given cycle.63 Infertile individuals choose to do this in an effort to save money on ART cycles. The logic being, pregnancy chances are increased because there is more than one egg 55 See Bitler & Schmidt, supra note 26, at 8. 56 See id. 57 Barton H. Hamilton & Brain McManus, The Effects of Insurance Mandates on Choices and Outcomes in Infertility Treatment Markets, 21 HEALTH ECON. 994, 994 (2012); Bitler & Schmidt, supra note 26, at 8 (discussing how the average cost for one IVF cycle in the United States is $12,400). 58 See Hamilton & McManus, supra note 57, at 944 (discussing how there is only a 25%–30% success rate for IVF, and as a result, those who choose to undergo such treatments oftentimes do so more than once). 59 Bitler & Schmidt, supra note 26, at 8. 60 See Georgina M. Chambers et al., The Economic Impact of Assisted Reproductive Technology: A Review of Selected Developed Countries, 91 FERTILITY & STERILITY 2281, 2288 (2009). 61 Bitler & Schmidt, supra note 26, at 15 n.12. 62 See CTRS. FOR DISEASE CONTROL & PREVENTION, NATIONAL PUBLIC HEALTH ACTION PLAN FOR THE DETECTION, PREVENTION, AND MANAGEMENT OF INFERTILITY 13 (2014) [hereinafter NATIONAL PUBLIC HEALTH ACTION PLAN], http://www.cdc.gov/reproductivehealth /Infertility/PDF/DRH_NAP_Final_508.pdf. 63 M. Kate Bundorf et al., Mandated Health Insurance Benefits and the Utilization and Outcomes of Infertility Treatments 3–4 (Nat’l Bureau of Econ. Research, Working Paper No. 12820, 2007), http://www.nber.org/papers/w17668.pdf. MASTROIANNI 3/8/2016 3:00 PM 2015/2016] Infertility Status Discrimination 159 implanted into the ovary, thereby improving the chance that only one ART cycle is needed.64 Implanting more than one egg, however, has its trade-offs. Since more than one fertilized egg is implanted into the woman’s ovaries, the risk of having multiple-order births as a result of ART is relatively high.65 About 30% of ART deliveries involve multiple births while only 3% of the general population experiences multiple birth deliveries.66 The multiple birth rates increased from 1.93% in 1980 to 3.3% in 2002.67 This increase represented 65% more twin deliveries and 397% more higher-order deliveries.68 In a study that compared ART usage data in the United States, Canada, United Kingdom, Scandinavia, Japan, and Australia, the United States had the highest multiple birth rates per ART cycle at 34.2%.69 The CDC estimated that 80% of the multiple birth rate increase could be ascribed to ART and ovulation stimulating drugs.70 Multiple births are associated with higher health risks for both the mother and children, which leads to more expensive health care.71 Generally speaking, multiple order infants have lower birth weight, which is positively correlated within infant mortality and serious health conditions.72 Indeed, perinatal costs of multiple births are more costly than ART procedures themselves.73 A study concluded in the early 1990s found the average cost for the delivery of one baby was $9,845 compared to $18,974 per baby for twin deliveries.74 Although insurers cover these costs after birth, it is important to discuss in the context of infertility treatment cost. In essence, if infertility treatment was not so expensive, there would be fewer multiple births overall because people would be less inclined to accept the aforementioned health risks in exchange for potentially saving money on ART cycles. 64 See Hamilton & McManus, supra note 57, at 995. 65 Bundorf et al., supra note 63, at 3. 66 Id. 67 Melinda B. Henne & M. Kate Bundorf, Insurance Mandates and Trends in Infertility Treatments, 89 FERTILITY & STERILITY 66, 66 (2008). 68 Id. 69 Chambers et al., supra note 60, at 2285. Compare this with Japan’s multiple birth rate of 17.1% per ART cycle. Id. 70 Henne & Bundorf, supra note 67, at 66. 71 NATIONAL PUBLIC HEALTH ACTION PLAN, supra note 62, at 13. 72 Laura A. Schieve et al., Low and Very Low Birth Weight in Infants Conceived with Use of Assisted Reproductive Technology, 346 NEW ENG. J. MED. 731, 731 (2002). 73 Chambers et al., supra note 60, at 2292. 74 Tamara L. Callahan et al., The Economic Impact of Multiple-Gestation Pregnancies and the Contribution of Assisted Reproduction Techniques to Their Incidence, 331 NEW ENG. J. MED. 244, 244 (1994). MASTROIANNI 3/8/2016 3:00 PM 160 Albany Law Review [Vol. 79.1 B. The National Impact of the High Cost for Infertility Treatment The cost for infertility treatment impacts how accessible the procedures are to the infertile population within the United States. Studies show that approximately 12% of childbearing-aged women in the United States received some sort of assistance for infertility.75 In 2008, more than 61,600 children were born in connection with ART.76 According to the CDC, ART accounts for approximately 1% of total births within the United States.77 Below the surface of these statistics, patterns emerge as to infertility treatment accessibility and the resulting inequality of individuals receiving treatment. In a 2014 report on infertility treatment usage within the United States, data was collected from women ranging from fifteen to forty- four years of age from a period between 1982 and 2010.78 This study is helpful in illuminating accessibility patterns to infertility treatment, but it must be introduced with one caveat—the study encompasses a broad definition of infertility treatment.79 Specifically, the study not only considers the three levels of infertility treatment described above, but also includes services like general advice, infertility testing, and medication to prevent miscarriage.80 Therefore, the statistics will reflect greater usage of infertility treatment because these additional services come at a significantly lower cost than the types of infertility treatment this article is based upon.81 The type of person who receives infertility treatment fits a general profile. An infertile woman that uses infertility treatment is “significantly more likely to be married, non-Hispanic white, older, more highly educated, and more affluent than nonusers.”82 In fact, 19% of women between twenty-five and forty-four who obtained a master’s degree or higher have received medical help in getting 75 State Laws Related to Insurance Coverage, supra note 4. 76 Id. 77 Id. 78 CHANDRA ET AL., supra note 1, at 1. 79 See id. at 1, 2–3. 80 Id. at 2–3; see also supra notes 46–54 and accompanying text (describing the three levels of infertility treatment). 81 See supra note 55 and accompanying text. 82 CHANDRA ET AL., supra note 1, at 2; Marilyn B. Hirsch & William D. Mosher, Characteristics of Infertile Women in the United States and Their Use of Infertility Services, 47 FERTILITY & STERILITY 618, 623–24 (1987). But see, Anjani Chandra & Elizabeth Hervey Stephen, Infertility Service Use Among U.S. Women: 1995 and 2002, 93 FERTILITY & STERILITY 725, 733 (2010) (finding that older age, formal marital status, and higher socioeconomic status are associated with the use of infertility services, but also asserting that race and Hispanic origin does not have any significant association).