While she and her husband were trying to conceive, Elizabeth Marshall had to spend about a week each month taking pregnancy tests, waiting and hoping.
Hoping the test would come back positive, because the Phoenix woman and her husband have wanted to start a family since they married in 2008.
Hoping it would come back negative, because she hadn’t had the medical treatment necessary to prevent another miscarriage.
“It was seven days of taking pregnancy tests every day, hoping I was pregnant and all the while hoping I wasn’t because we hadn’t had progesterone,” she said.
Marshall’s body doesn’t naturally create enough progesterone — a steroid hormone produced in the ovaries that prepares the uterus for pregnancy and nurtures the fetus during pregnancy. Without treatment, she has only a one-in-five chance of carrying a pregnancy to term.
Her insurance company will cover progesterone treatment after Marshall conceives, but she needs it several weeks before conception to increase the odds of a successful pregnancy.
Seventeen states now require insurance companies to cover infertility treatment. Arizona does not. Marshall is fighting to change that law and she’s likely to run into tough opposition at the Legislature.
It took a few years to realize that something was wrong.
After their wedding, Marshall and her husband weren’t actively trying to have children, but they also weren’t doing anything to avoid having a baby. Then, they started seeing birth announcements from couples they knew who had been together for less time than they had.
It finally happened for them in 2012, but Marshall miscarried on Christmas Day. Four more miscarriages — three from natural pregnancies, one from a cycle of in vitro fertilization they paid for with what was supposed to be a house down payment — followed.
Out of pocket, one cycle of IVF costs between $6,000 and $10,000, with medication and bloodwork adding an additional roughly $5,000 to $10,000. Just paying for progesterone treatment costs about $120 a month including bloodwork and medication, plus additional fees for doctor visits, Marshall said.
“It’s not like Vitamin D, right? It’s not like you can just go to the store and get it from the pharmacy,” she said.
About 137,000 Arizonans have issues with infertility, according to RESOLVE, a national infertility association that has worked with Marshall. And roughly one-quarter of those affected cannot afford treatment.
Even if they’re able to conceive, either naturally or through IVF, women affected by infertility issues are more likely to have high-risk pregnancies, miscarriages and higher medical costs.
Because of the cost of IVF, women may also choose to have multiple embryos implanted to increase their chances that one will succeed — leading, in some cases, to more expensive, higher-risk multiple pregnancies, or medical advice to abort one of the fetuses.
Adoption is an option for some people who hope to become parents, Marshall acknowledged, but it’s not for everyone. It doesn’t treat underlying medical issues.
And adopting means opening your home and life to scrutiny from strangers who will decide if you’re fit to be a parent — something Marshall described as being particularly difficult to take when infertility already feels like your own body is saying you don’t deserve to be a mother.
“If I adopted a child, I would still have infertility,” Marshall said. “It’s not like ‘Congratulations, you’re infertile, have a baby.”
Marshall and her boss first tried to add infertility coverage to their company insurance plan, but learned that insurance companies only allow larger businesses with 100 or more employees to elect for fertility coverage. Marshall, an accountant at a small firm in Mesa, and her husband, who works at a Gilbert auto manufacturing company, are among the 45.1% of Arizonans employed by small businesses.
“No one really likes a mandate, but this is the one disease that’s allowed to be discriminated against by insurance,” Marshall said.
Changing insurance mandates isn’t as simple as introducing and voting on a bill. State statute requires anyone advocating a legislative proposal that would affect coverage by insurance companies to submit a report detailing the social and financial effects of such a change to the Joint Legislative Audit Committee by September 1 of the year prior to the bill’s introduction.
The joint audit committee then sends the report to a standing legislative committee, which has to hold a hearing and send recommendations to the Senate president, House speaker, governor and Department of Insurance by December 1.
Earlier this month, the Audit Committee referred Marshall’s report to the Senate Finance and House Regulatory Affairs committees, which are expected to schedule hearings later this fall. Getting even to this preliminary step has taken three years of work.
The study required to change state law cost about $10,000, a sum RESOLVE was willing to pay if Marshall first found a lawmaker willing to introduce a bill. Sen. David Bradley, D-Tucson, introduced one in 2018 – his bill died without a hearing.
Miscommunication about the report due date meant it was too late to introduce a bill this year, making 2020 the earliest such a bill could be heard in the Legislature.
In the meantime, Marshall kept talking to lawmakers and seeking support from Republicans, who are critical to getting anything passed. Sen. Heather Carter, R-Cave Creek, and Rep. Regina Cobb, R-Kingman, have been receptive, she said.
Cobb is out of the country this month and wasn’t available for an interview. Carter said she has heard similar stories from constituents and wants to do something to help.
“This is an issue that many families are faced with, and I think we should at least have a conversation about it in the Legislature,” Carter said.
She said she hasn’t had enough conversations with colleagues about the issue recently to know whether the effort has a chance in the Legislature.
As proposed, the bill would require insurance companies to cover medically necessary tests and treatment for patients with an infertility diagnosis. Covered treatment would include hormone treatment, artificial insemination and up to three cycles in vitro fertilization.
The bill also would require coverage for fertility preservation for patients undergoing chemotherapy. Surrogacy and vasectomy reversals would not be covered.
Adding infertility to the list of covered conditions could increase premiums by about $1.37 per month, according to the report Marshall submitted.
A requirement that insurance companies cover IVF is a non-starter for some Christians, particularly Catholics. Church teaching allows infertility treatment through fertility drugs, but describes IVF and other forms of artificial insemination as immoral.
Earlier iterations of IVF resulted in unused embryos being thrown out. Technology has advanced to the point where they’re frozen rather than discarded, but Cathi Herrod, president of the Center for Arizona Policy, said that still isn’t acceptable.
“Creating embryos is creating a human life,” she said. “It’s a pro-life concern. We’re concerned about creating embryos that will basically be left in a frozen safe in a clinic forever.”
Herrod said she and the influential conservative advocacy group she leads will be waiting to see what the introduced bill looks like before deciding whether to weigh in on it.
“If the issue is as simple as an insurance company providing progesterone to help a woman maintain a pregnancy, that’s a different issue than mandating coverage for infertility treatment that produces multiple embryos of which some may be implanted and carried to birth and some may be left in a frozen state,” she said.
Sen. J.D. Mesnard, the Chandler Republican who leads the Senate Finance Committee, is skeptical of changes to mandated insurance coverage. He said he’s willing to hear Marshall out when his committee reviews her report, but the committee also has to look at tradeoffs of any expanded coverage.
“At some point, you transition away from what is a need versus. what is a want, even if it’s a strong want,” Mesnard said.