State Insurance Mandates Don't Improve Racial Disparities in ART Live Births

ANAHEIM, Calif. -- Insurance mandates for fertility treatment with donor oocytes may improve overall live birth rates, but the current policies fail to reduce racial disparities in assisted reproductive treatment (ART), according to a retrospective study.

Overall, state insurance requirements for coverage of donor oocytes were linked to a 10% increase in the odds of live birth (RR 1.10, 95% CI 1.05-1.16), reported Caiyun Liao, MD, MPH, a reproductive endocrinology and infertility fellow at Yale University in New Haven, Connecticut.

However, there were significant racial disparities in live birth rates in states that did not mandate coverage of cycles with donor oocytes: On multivariable regression analysis, groups less likely to achieve live birth after ART were:

• African Americans (RR 0.82, 95% CI 0.77-0.87)
• Hispanics (RR 0.93, 95% CI 0.88-0.98)
• Asians and other races (RR 0.96, 95% CI 0.93-0.99)

Presence of an insurance mandate did not lessen racial disparities, Liao said in a presentation at the American Society for Reproductive Medicine annual meeting.

"Insurance mandates that actually reach those in greatest need are necessary, but insufficient for equitable access and outcomes," Liao reported. "Disparities in ART is a phenomenon that arises from a complex network of biological, social, cultural, and psychological factors that act synergistically, and should be addressed using a multi-pronged approach."

Mandated insurance coverage for autologous ART may be associated with improved access and pregnancy outcomes, but the impact these policies could have on racial disparities in ART are not clear.

Previous studies have shown that African-American women and those from lower socioeconomic backgrounds are more likely to have infertility, but are also less likely to access treatment, Liao said. Additionally, people of color have typically had worse pregnancy outcomes with ART.

In this study, Liao's group used the SART CORS database to compare live birth rates in 2014-2016 by race and ethnicity in states that mandated donor oocyte insurance coverage -- namely New Jersey and Massachusetts -- to those which did not. Representation of each racial/ethnic group in the study was compared with U.S. Census data.

The analysis included 40,546 donor oocyte cycles in more than 27,000 recipients. Approximately 36% of the cycles used fresh oocytes, and 64% used frozen and thawed oocytes. Most patients included in the analysis were over 42 years old, but non-Hispanic white patients were younger than the overall population.

Diminished ovarian reserve was the most common cause of infertility among egg recipients included in the study. African-American patients were more likely to have a higher BMI, and experienced a higher rate of recurrent pregnancy loss than women of other races and ethnicities.

Recipients who were African American or Asian were less likely to reside in states with mandated coverage, or undergo treatment in clinics in mandate states than those in other racial/ethnic groups. Additionally, African-American recipients were least likely to ever achieve a clinical pregnancy or live birth, the researchers found.

Liao acknowledged that this study may be limited by undifferentiated misclassification of recipients from New Jersey or Massachusetts who may have traveled across state lines for fertility treatment. She added that the SART CORS database did not include information on important social determinants of health, such as income or education level.

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