Close-up of the in vitro fertilization procedure, with needle injecting into egg under microscope.
During the most recent debate with Vice President Harris, former President Trump declared that he has “been a leader on IVF… everybody else knows it.” Trump, of course, was referring to his recent campaign promise that the government pay for or that insurance be mandated to pay for all IVF treatment costs.
Whether Trump’s proposal would make him a leader is a point of debate, given Democrats and introduced a bill mandating insurance coverage of IVF earlier this summer. But whatever the case, Trump’s IVF proposal would certainly lead in the wrong direction.
The proposal has many downsides. To begin with, government-funded IVF would be enormously costly. A back-of-the-envelope estimate indicates that government funding IVF would cost about $7 billion annually. This figure assumes that the average IVF cycle costs between $15,000 and $20,000, doctors perform about 413,776 assisted reproductive technology (ART) cycles annually, and IVF constitutes more than 99 percent of ART procedures/cycles.
This figure, however, assumes that the current number of ART cycles and average IVF cycle costs stay consistent, which is highly unlikely. Currently, most patients self-pay for IVF, which limits IVF use. Furthermore, a subsidized program creates new incentives for would-be parents to delay childbearing or engage in elective fertility preservation, leading to growing use of the program over time.
Israel provides a case in point: in Israel, IVF has been publicly funded since it was first introduced in 1981. Reliance on the technology has grown since then, when it was a nascent technology, and between 1990 and 2012, the number of IVF cycles increased eightfold.
Some of the increase in utilization is no doubt due to innovations that improve the procedure’s effectiveness. For instance, the development of intracytoplasmic sperm injection (ICSI) in the early 1990s meant that IVF became beneficial to a much larger portion of the population, as ICSI helped resolve many cases of male infertility. Even since major technological innovations like ICSI, IVF utilization in Israel has grown. The percentage of births attributable to IVF in Israel in 1995 was only 1.7 percent, but by 2018 that figure had nearly tripled.
In large part due to its generous policy, Israel also has by far the highest per capita IVF use of any country. Israel’s generous IVF program funds unlimited IVF until a woman has delivered two live children, and benefit eligibility continues up until 45 years of age. Israel also covers elective fertility preservation, and in line with Trump’s proposal, Israel’s policy covers “all treatment costs,” including medication, procedures, testing, and more advanced add-ons like preimplantation genetic testing (PGT).
If the US implemented a program that subsidized or mandated coverage for “all treatment costs,” substantial growth in IVF use would likely occur. Current IVF use in Israel is more than six times greater per capita than in the US. In countries like Denmark, which subsidize IVF generously but to a lesser extent than Israel, IVF use is still more than four times greater per capita than in the US.
If a US policy were so generous that it induced Israeli levels of IVF use, the program would cost around $43 billion annually, or about what the federal government spends annually on its major housing rental assistance programs (housing vouchers and project-based rental assistance). Even if the program were “only” generous enough to induce Denmark’s level of IVF use, it would cost $27 billion per year, or more than NASA’s annual budget.
Yet, unlike the federal government’s housing assistance programs, the benefits of an IVF subsidy would surely be regressive if fertility patterns hold. Under existing patterns, women with higher education or higher income are more likely to delay childbearing: according to CDC research 42.9 percent of women with a bachelor’s degree or greater delivered their first child at 30 or older. In comparison, just 3.3-10.5 percent of women with less than a bachelor’s degree delivered their first child at 30 or older. But older women are also more likely to run into fertility issues and subsequently utilize IVF.
Given the current national debt and deficit’s threat to our economic stability and the related need for fiscal restraint, creating a new, expensive entitlement program with benefits captured by highly educated and high-income beneficiaries is misguided.
Even setting aside such a program’s steep price tag and regressive profile, would the money be “worth it”? Trump’s stated motives for the program are pro-natal, yet it is not clear that a subsidized program would actually result in more births.
The new incentives created by such a program suggest that growing reliance on IVF alongside fewer births overall is possible or likely. This is partly because would-be beneficiaries may falsely believe that a subsidized or mandated policy allows them leeway to delay childbearing, only to find that childbearing is more difficult later in life, even with the assistance of reproductive technology.
Countries like Singapore, Japan, Australia, and Denmark have subsidized reproductive technology and still seen fertility decline in recent years. And in all countries that subsidize IVF besides Israel — a unique country not only because of its extremely generous subsidies but also its broader cultural commitment to natalism — the fertility rate is currently below replacement.
Beyond the program’s enormous cost and uncertain or negative influence on births, a subsidy or mandate would conflict with some taxpayers’ views on conception and reproduction. While most Americans disagree with more extreme views put forward by IVF critics, it is nonetheless reasonable that critical parties not be forced to subsidize activities that they find objectionable.
Although Trump’s plan is a disaster from the perspective of cost, incentives, and value neutrality, IVF is a true medical miracle for many couples with fertility challenges. Protecting IVF means protecting individuals’ freedom to avail themselves of the most successful procedure to treat a range of fertility issues and create human life, and doing so is critical.
But protecting IVF from efforts to limit its use and reduce its efficacy does not mean subsidizing or mandating coverage. Trump and future policymakers would do well to enthusiastically defend the procedure, but avoid the cost and pitfalls of a government-supported industry.
