But all medical care for women is supposed to be free! That's obvious to every decent person, right?

"Every doctor and infertility consultant that I spoke to about this issue agrees -- the insurance system and the political system has to change. "

Yes, as someone who produces goods and/or services, I would love to have a government-guaranteed captive market for what I produce. Obviously it's a matter of vital national interest, besides being just plain fair.

While not exactly ugly, I'm not nearly as good-looking as, say, Benedict Cummerbund, or Bandersnatch, or whatever his name is. That's unfair, and the system for providing plastic surgery has to change.

Health insurance is pooled risk. Pooled risk is collectivism. Refuse collectivism and pay for your own damned healthcare.

"Health insurance is pooled risk. Pooled risk is collectivism. Refuse collectivism and pay for your own damned healthcare."

So is police protection. Refuse collectivist police protection. And then wait for us to come for you.

If you and your partner can get pregnant naturally you are a dead end as far as nature is concerned.

I dont think IVF should be available to anyone, aside from women who have suffered damage to their reproductive system due to outside agency, such as a physical assualt, but not poor diet or cancer

IVF should be covered by health insurance, if the insurance program you purchased includes it.

However, if you've on a taxpayer-paid program, the rest of us should not be on the hook for you to have children (and then be on the hook to pay for the children).

OK, this is a bit of a tangent, but. . .

Is it me, or is anyone ELSE getting a little tired of the equating of Health INSURANCE with Health CARE ????

Health Insurance was supposed to cover MAJOR, UNEXPECTED costs. . .not everyday visits to the Doctor, etc. . .

Is it me, or is anyone ELSE getting a little tired of the equating of Health INSURANCE with Health CARE ???? ~ Posted by: Keith Glass at December 31, 2013 10:31 AM

I've been decrying that all along.

As much as I'd like to blame Obamacare for that trend, it's not Obamacare's fault on that one. Checking into a hospital or seeing a doctor has long meant showing an insurance card. The HMOs only exacerbated that trend.

Even then, it was expected that there was some portion of medical bills that were not covered by insurance and would be covered by the patient - payment for services rendered.

Health insurance was like the fire department, an infrastructure we pay for and build beforehand so when the house on fire, we can put it out. We don't build hospitals and train doctors when we become sick. Paying for health insurance made sure those things were available for us when we become sick enough to use them.

Of late, we've come to expect that our $36,000 per year in premiums will cover $72,000 in medical expenses every year.

Now, Obamacare promises us that even if we pay nothing until the moment we're diagnosed, our medical bills will be covered by someone else.

"Is it me, or is anyone ELSE getting a little tired of the equating of Health INSURANCE with Health CARE ????"

Oh yeah. Lots of people need to look up the meaning of the word "insurance" in the dictionary. One of the many huge failings of our educational system is that most people are taught absolutely nothing about the nature of probability and risk. Add that to the post-modern obsession with total risk avoidance, and here we are. Insurance is supposed to pay for everything, damn it! From my cancer surgery to my car's oil changes. Where do I sign up for grocery insurance?

The caveat is that preventative health care saves everyone money in the long run. Better for the taxpayer/government/insurance provider to cover a $200 routine check up than a $200,000 emergency surgery. It doesn't make economic sense for a routine doctors visit to be prohibitively expensive while an emergency room visit becomes effectively free.

Not only that, we've had a good 40 years of media sob stories about how this or that condition should oughta be "covered" by those mean old insurance companies.

What they never said was they also wanted was SS disability expanded, Medicare/Medicaid benefits, welfare food stamps Section 8 extended to the sufferers. The expansion went on for decades under our noses.

"The caveat is that preventative health care saves everyone money in the long run."

That's more propaganda than actually true. Because it is not one $200 check up, but 1,000 healthy people getting checkups that they didn't before, vs one $200,000 surgery that could have been prevented with a check up.

Smart preventative care might, but that requires everyone using it to be smart. But we already have millions of people going to the Dr every year for antibiotics for colds.

The only problem with 'preventative health', besides meaning any number of things depending on who is footing the bill, is that statistically it does little to improve life or longevity (morbidity or morality in medical-speak), and economically many of the things it does end up costing much more money than if nothing was done. It started early last century when the bean counters found that people who go see the doctor for preventative care tended to live longer. Go figure: people with disposable income who are specifically interested in their health tend to live longer. But we seem to have a problem with correlation and causation.

Be advised: I am not talking about things that clearly have long lasting benefits for small costs (e.g. vaccinations, rational use of antibiotics, specific medications under special circumstances).

Most every cancer screening is not really effective since it is only good at catching slow-growing, benign growths or the occasional fast-growing malignant growth that is found incidentally. Overall, as a population, it does little to improve life or longevity. However, we love to talk about that rare malignant growth that gets found. The plural of anecdote is not data.

Many of the long-term medications (e.g. cholesterol, blood pressure meds in most situations) don’t really improve life or longevity in a population. While there are evidence-based, medically-indicated uses, for the most part they are aimed at ‘hitting the target’ number rather than improving outcomes. We love to treat the number and not the patient.

What about your yearly checkup? Again, a waste of money. Surprisingly, people are fairly familiar with their own body and can figure out when they are sick [/sarc]! When they come into the hospital saying they ‘feel off’ or have specific complaints, we can do symptom-specific investigation and usually come up with an answer. Unfortunately, this is like the cancer screening phenomenon: we find the occasional life-threatening disease that is in its asymptomatic/minimally symptomatic stage but this is the exception and not the rule. All the docs are giving each other high-fives over their diagnostic acumen since we especially realize how rare it is to find something like that. Again, the plural of anecdote is not data.

But we will go on breaking the bank because of anecdote.

The caveat is that preventative health care saves everyone money in the long run. ~ Posted by: Shannon at December 31, 2013 11:41 AM

That was the thinking behind the HMOs of the '80s.

As Joe J. points out, it didn't work because people started going to the doctor for minor ailments that they used to treat with over-the-counter remedies or simply power through. Those little visits added up and did little or nothing to defray the costs of the major medical treatments. So, instead of a cost saver, preventative care became an additional cost.

And now, preventative care is an expected benefit of any healthcare management program (what we today call health insurance).

Health insurance is pooled risk. ~ Posted by: Andre Friedmann at December 31, 2013 9:20 AM

Except with government-mandated health insurance requirements, it's no longer pooled risk, it's pooled cost - and reduced risk for the smokers, fatties, and couch potatoes because they won't be dropped or see their premiums rise because of their behavior.

Collectivist health insurance is a chicken pox party. Everyone gets to pay the price for one guy's illness.

I doubt that the demographics of IVF recipients would change dramatically even if it were fully covered. Despite what Tanya assumes, I think that most women are pretty well aware of the viable age range of their fertility. It seems to take a certain ideological disposition and a lot of formal education to become confused on that matter.

IMO it's unlikely that the 'economically segregated' women she's concerned about have the same preference, or resources, to have kids in middle age that women of her cohort do. So this policy would be a subsidy from poorer people to wealthier ones.

Sooooo…(warning, here comes TL;DR)

From a moral/ethical/fairness point of view, I agree that insurance companies should *not* be forced to cover IVF. In addition to the other good points Amy makes, the fact is that we live in a world of scarce resources, and conditions such as cancer, cystic fibrosis and heart disease should be prioritized over infertility (unless you're dealing with a condition that is also debilitating, such as endometriosis, that can be helped with surgery). I have argued this for quite a few years, and having to deal with infertility and pay for IVF out of pocket did not change my mind. I have always wanted kids. Being unable to have bio-kids would have been very tough…but it wouldn't have killed me or my husband. (Yeah, it's easy to say this now that I have a couple of toddlers wreaking havoc, but I felt this way before we knew anything would work.)

In addition, knowing that insurance wouldn't cover anything allowed us to be as aggressive about treatment as we wanted and doctors found reasonable. No, we didn't head to the clinic after a month of trying or anything, but, without going into too many details, we were at least able to conceive on our own. Had we not had treatments, it's more likely than not that we would have eventually had at least one baby. We followed the advice of medical professionals and that advice was based on test results…but fertility doctors are always going to err on the side of recommending treatments over not doing so. Bygones. (On the flip side, IVF allows every facet of the process to be controlled, hormonally and otherwise; I think that may have been the difference for us. Enough, before I get TMI.)

BUT.

IVF isn't cheap. To say the least. But know what's more expensive? MUCH more expensive? Extended NICU stays for high-order multiples. Much, MUCH more expensive. And NICU stays for babies who would die without the care are *always* covered by insurance when parents have it, and typically picked up by hospitals when parents don't. (And if you would like to propose a scheme in which babies resulting from fertility treatments aren't covered and are left to die at home, you go right ahead and try to convince insurance and hospital CEOs that being pilloried in every media outlet is a good idea. I'll stand over here, way out of the way.)

I bring this up because…there are two primary approaches to treating infertility in a high-tech way. Method #1 is IVF -- woman is treated with fertility drugs with goal of producing maximum number of eggs, sperm is extracted through natural or surgical means, sperm and egg are joined in petri dish, resulting embryos are either transferred into a uterus or frozen for later use. (Sometimes donor eggs are used; sometimes embryos are frozen and transferred later.) Method #2 is lower-tech, and involves treating a woman with lower doses of fertility drugs, with the goal of having her produce a few more eggs than usual, with fertilization then taking place inside her body, either through the old-fashioned method or artificial insemination. The hope is that one of those eggs is able to produce a healthy baby.

Method #2 is less expensive and less invasive than Method #1. If you have the option of either one, and insurance won't cover either, Method #2 is likely going to be your first choice. The problem with Method #2 is…there is a LOT less control than there is with IVF. There's no way to predict precisely in advance exactly how many eggs will be produced. Responsible doctors do frequent ultrasounds to get a good idea, and order things shut down if it looks as though 20 eggs are a-poppin', but you still have more of a risk of having, say, triplets than you do with an IVF cycle in which only 1 or 2 embryos are transferred. AND…people can and have gone ahead with cycles even after doctors cancel them. The drugs used in fertility treatments are ordered, kept and administered by the patients. If your doctor tells you to shut things down with Method #2, and you're willing to take the risk, you typically have a preliminary schedule to use as a reference, plus the drugs and syringes around to make things happen.

With the exception of the Octomom, all of the super-high-order multiples -- the babies born five, six, seven at a time -- from the last 15 years are from Method #2. No, doctors doing IVF are not saints…but they are assessed on, among other things, their rates of *live births*, and that data is publicly accessible. A woman who gets pregnant with 6 babies at a time is considerably less likely to have a 100% live birth rate (even after selective reduction) than one who gets pregnant with 1 or 2. In addition, genetic testing of embryos in IVF is becoming more widely used, and allows even more refinement. If you know the embryo you're dealing with has 46 chromosomes -- no more, no less -- AND if your clinic is using modern embryo freezing techniques, you're a lot more comfortable having just one transferred.

I bring this up because…there have been a couple of studies indicating that insurance coverage of IVF leads to significantly lower rates of multiple births, both by allowing some patients to choose IVF over Method #2, and by encouraging those who do choose IVF to transfer lower numbers of embryos. Patients who think they can only afford one round of IVF tend to under-emphasize the risk of transferring two embryos and ending up with twins; those who have insurance coverage for 2-3 rounds tend to think, "Gee, wouldn't one baby at a time be easier than two?" http://news.yale.edu/2011/04/05/fewer-multiple-births-states-insurance-coverage-infertility

I hear a lot about how European countries provide "free" IVF. (TANSTAAFL.) However, those countries typically have hard, government-set limits on how many embryos can be transferred at a time. Do I think those health-system regulators are more "compassionate" than U.S. insurance CEOs? Nope, I think they've looked at the numbers and decided that minimizing the number of babies in NICUs is the strategy most likely to save them money overall. (And it's worth noting that there are still private fertility clinics -- and people willing to pay out of pocket! -- in countries with "free" infertility treatments. You do get what you pay for.)

I have written this mini-novel to say…again, I agree with Amy's main point. However, I wouldn't be surprised to see insurance companies start offering more coverage for IVF in the next 10 years, even without government mandates -- with the caveat that single-embryo transfers are mandated. If this happens, it won't be because insurance companies get "progressive" or "enlightened" -- it will be because they ran the numbers and decided it would, in the end, save money. Think of it like fetal surgery -- some insurers now cover fetal surgery for spina bifida, because analysis indicated that that was cheaper than insuring severely disabled children. If you assume that most people won't abort fetuses with spina bifida, the numbers can make sense. If you assume that the majority of people experiencing infertility for whom assistance is recommended will try to avail themselves of that assistance, whether or not they have insurance, the same situation may be in play.

(cont.)

(broken up to avoid crashing Amy's server)

The best approach to fertility? Have your babies when you're young. If you've found your SO and you know you want kids, and you're not financially bereft and/or hitting each other with spoons in anger all of the time, get cracking. Advanced maternal age doesn't just affect egg quality -- it also makes all sorts of pregnancy complications more likely, from heart defects to placental issues to whatever. Do I think it's a bad idea for young women to freeze their eggs? No, but that doesn't mean you eliminate all risks of later childbearing -- especially not later childbearing of *first* babies. Insurance coverage for *egg freezing*? With the possible exception of cancer patients about to undergo radiation and chemo, NO NO NO NO NO.

Look, I know this is easier said than done -- I was on the cusp of advanced maternal age when I met my husband. But you know what? I was able to figure out on my own, with readily available information, that I couldn't postpone childbearing indefinitely and rely on IVF to swoop in and save me. So was my husband. Not sure why Tanya Selvaratnam wasn't. The fact that she appears to have avoided learning that until it was too late, and now wants the information forced down everyone's throat, makes me highly annoyed. (And of course the doctors and infertility consultants she spoke to think IVF should be covered! THEY WOULD BE RECEIVING THE DOLLARS.) And as for the "top-down, imposed attitude that having a child should be a pursuit of those who can afford to have a child"…yep! That is in fact my belief. (Also, that coverage of IVF in Israel that Tanya raves about comes in a social context in which having kids is overtly pushed by everyone in a way that I bet Tanya would never, ever tolerate on a daily basis, and especially would have hated back when she was closing her eyes to fertility realities back in her 30s.)

Sigh. I wish Bujold's uterine replicators or Weber's prolong process would get here already. In the meantime, I plan to continue to mention when relevant that hey! Those 49-year-old Hollywood stars having babies are using donor eggs. And hey! Those of us who wait longer to have babies are more likely to need help. And hey! I need to keep reading Amy and avoiding NY Mag.

(The really amusing thing about Tanya? She seems unaware of the fact that one of the things that poor women are, on average, much better about than smart women is having babies while they're young. Now, sometimes that is directly related to why they stay poor…but that's another issue…)

"Checking into a hospital or seeing a doctor has long meant showing an insurance card."

But the purpose of that card has been hidden.

It is to PAY DOCTORS, not the patient.

NOT. THE. PATIENT.

Andre Friedmann: "Health insurance is pooled risk. Pooled risk is collectivism. Refuse collectivism and pay for your own damned healthcare."

Collectivism isn't necessarily bad. It's the element of coercion that makes it bad. The only reason to get the government involved is for its ability to coerce (i.e. to mandate or prohibit)

I don't see anything wrong with free people voluntarily associating to form and participate in collectives, whether they be HMOs, food co-ops, home school groups, child care co-ops, insurance companies, home owners associations, credit unions, or whatever.

Marion- Great to hear from you. Great comment, insights.

What's meta is your enthusiasm. For those of us who don't feel compelled to pay for other people's fertility, having so much to say about how things work —and how things should work— seems indecent. And authoritarian. And coercive. And fascist, you freaking Commie....

I'll never concede that individual fertility is something deserving of our shared attention, and certainly not our shared support. We're never going to run out of people, and that's as much as government should worry about... Anything more is going to be oppression, or racism, or corruption.

Hang on! Since when is dermatology a luxury or elective? Oh, since people associate it now with botox.

For those who don't know, most of dermatology IS NOT elective stuff. There are various skin ailments that require treatment. Some you might have heard of, such as melanoma. As somebody who sees a dermatologist regularly - and not for wrinkles, acne, or the like - I find that to be a ridiculously uninformed statement... to the point of not considering the author to be at all believable.

A list of medical reasons for a dermatologist:
painful scars
eczema
psoriasis
various skin cancers (there are a few)
warts (in some places that are hard to treat with OTCs)
having moles checked
persistent dry/cracked/bleeding skin

That's what I can think of off the top of my head.

I'll get off my soap box now.

"Most every cancer screening is not really effective since it is only good at catching slow-growing, benign growths or the occasional fast-growing malignant growth that is found incidentally. "

Yeah, the problem is we really can't do it often enough affordably. In order to be effective, what would need to happen would be a whole-body MRI and lab workup on a biweekly or monthly basis, for everyone. The day will probably come when technological advances make this feasible, but we aren't there yet.