My wife and I have been dealing with some infertility issues. Simply put, we would like to have children–in the near future if possible–and it seems that this will require some extra medical attention. As I perused our insurance policy to find out what of this extra attention would be covered, I was disappointed to discover that infertility services and medications are not included in our plan; in fact, they are explicitly excluded. I know very little about the actuarial science involved in designing these policies, so I can only speculate about why this might be the case. Whatever the reason, it seems that we may have to pay out-of-pocket for any fertility treatment we seek with this insurance.
At about the same time that I discovered this, I received an email announcing that, as of the upcoming school year, my insurance policy will be covering “transgender services” (their term, and I do not know what all it entails).
Before I go on, let me be clear: I am not writing this post to take issue with transgenderism or with my insurance policy. But I am struck by how this coincidence captures something significant about current cultural dynamics. I do not suggest that my policy is universally representative; I’m sure there are some insurance policies that cover infertility services and do not cover transgender services. Some states even have an infertility coverage mandate. That said, I believe that this new policy is an illuminating artifact of our society, and although it is not entirely representative of insurance policies in general, it is not alone in its representation of ongoing shifts in our cultural values.
Simply put, my insurance policy seems to privilege medical treatment relating to an individual’s sexual/gendered identity over his or her procreative identity. Sexuality seems to be principally conceptualized as an individual expression/experience. What does this say about our society? If some future archaeologist were to discover this policy, what might she conclude about the culture that crafted it?
Let’s assume that the purpose of a student health plan is to allow those enrolled in it to get the medical care they need and deserve without prohibitive personal cost. The school which pays for the policy obviously does not want to pay for services that it is not obliged to provide. It wouldn’t want to, for example, cover the costs of plastic surgery for any students desiring a nicer-looking nose, just as it wouldn’t want to imply that people “deserve” to have weekly massage therapy. These are things we generally agree people do not necessarily need or deserve. So, somewhere along the line, there are value judgements made about what people are entitled to, and what institutions are obliged to provide their constituents.
If we take my insurance policy as the creation of those values, it would seem that our society values self-realization (specifically sexual self-determination and expression)–and this is explicitly distanced from the context of childbearing. We seem to think that people have a basic right to express themselves as individuals, but not necessarily as parents; they are entitled (and encouraged) to have sex, but not to have children. It would seem that we believe that someone with gender dysphoria has some fundamental right to receive medical treatment relative to that condition, while someone with PCOS is not entitled in the same fundamental way to analogous treatment.
I see in this an individualistic bias. Self-determination contrasts with social imposition as expression does with suppression. As we exalt the individual, we tend to abase the social. After all, it is against the social context (culture, tradition, roles, norms) that individuals assert themselves; that is the backdrop to all individual behavior. When we focus on the individual in the foreground, our view of the social background blurs. While this bidirectional movement and refocusing has undeniably benefited certain marginalized populations, it does so at a cost. We cannot sustain both our traditions and our revolutions, even though there is arguably good in both. Eventually, in the shuffle, something of value on one side or the other is lost.
I see my insurance policy as one example of this. And, assuming it is not unique, I think it should give us pause: In almost imperceptible ways, we seem to be subverting biological family–a basic social unit. While there is some value is transcending biology, I worry that a society that rejects it will be like a kite without a tether.
In our exaltation of the individual, we have decontextualized sex, destigmatized non-normative sexuality, and deinstitutionalized sexual relationships. Although, as I’ve said, some good has come of this, I am not sure whether the net result of this movement will be more constructive or destructive to society. As we try to tear down the relics of past ages, what do we build in their stead? We may be moving forward, but we seem to do so in increasingly individualistic ways. And what comes of this great oxymoron–the individualistic society? We are convinced that we are destined for Utopia, and that the path before us is clear. But as I look back, I worry that somewhere along the way, we may have misread the signs. I fear we are driving towards Myopia.
The Brothers Sabey 
Very well articulated, David. You expressed something I’ve been feeling for a while now. “We cannot sustain both our traditions and our revolutions, even though there is arguably good in both. Eventually, in the shuffle, something of value on one side or the other is lost.” That was my favorite line…or is it the wordplay at on Utopia at the end?
Thanks, Matt. Good to hear from you!
Just a nitpick as an actuary – “I know very little about the actuarial science involved in designing these policies” – actuaries typically aren’t the decision makers in what is covered and what is not. They will price the cost of these items and that will be used to inform the final decision.
Very interesting. If I’m understanding correctly, that seems to suggest an even more prominent role for cultural values in the decision. I’d be very interested to learn more about how those decisions are made. For example, I can imagine a scenario in which they decide to cover something, despite low profitability, because it’s “the right thing to do.” But how do they decide what is right?
Each company is different, but here is what I have typically seen – The company will start out by covering the minimum state-mandated benefits. Then they will add coverage for things that the leadership deems “the right thing to do”, keeping well in mind the cost of such procedures. One example of “the right thing” was a company I worked for that did not cover abortions, however they deemed it the right thing to cover abortions for families whose babies had rare chromosomal defects such that they would not survive longer than a few months post-birth as it was easier on the families. This decision was made by the Chief Medical Officer (a doctor), Chief Nursing Officer, Chief Financial Officer, and CEO. The costs of these non-standard benefits will almost never be more than 1% of the total premium in aggregate on the base plan.
From there, when an employer group purchases insurance they are usually able to buy insurance riders expanding the items covered. This would allow the group to be able to purchase coverage for infertility, bariatric surgery, etc.
In your case, it seems you do not live in a state that mandates coverage of infertility treatment. Because infertility treatment is a very expensive thing to cover (the treatment itself is expensive, but the more costly thing is the increased likelihood of multiple babies and the increased likelihood of premature babies – which are VERY expensive), the company doesn’t want to be the only one to cover it. If they were, they would not only have to raise premiums compared to their competitors, and not be able to sell as much, but they would also attract everyone who is looking to seek that type of service increasing their risk of multi-million dollar claims in a year (yes, premature babies can be that expensive). Transgender services, whatever that entails, is likely to be such a low frequency claim that it will not impact the premium and is likely covered because one of the executives feels like it should be – or they received pressure from the legislature to cover it (pressure to cover certain services from the state legislature does happen, even without laws).
For determining coverage of new drugs and new technologies, typically a committee consisting of mainly doctors, some outside of the organization, is put together that reviews the literature and studies surrounding the new technology/drug, compares it’s efficacy to previously available technologies, and approves it for coverage if it does one of the following: Significantly improves quality of life over existing technology/drugs, Significantly improves outcomes, Significantly decreases costs while maintaining the same outcomes.
I would think the best way for you to see coverage of infertility services would be to write letters to each of your state legislatures urging them to join the other states that have mandated coverage of infertility services and explain why it would be important to their constituents to do so. Alternatively, discuss with your HR department of where you get healthcare and ask them to purchase a rider covering infertility treatment.
You raise an interesting point here — but I also wonder about whether the failure to pay for fertility treatments isn’t actually about a switch from communal to individual, but rather evidence of long standing bias against women. Patriarchy as opposed to individuality. Policies and plans that address primarily “Women’s issues” like fertility, birth control, family leave, or child care have long been funded far less often that policies that affect “all” people. (As you rightly point out, fertility isn’t just a women’s issue. Nor frankly is paid leave, or child care. Nonetheless, our society continues to see and treat it that way.) To this day, most women pay more for their insurance policies precisely because insurers know they are likely to get pregnant, and require that they bear the brunt of that cost, both physically and financially. So I wonder about your argument that some one gender issues have replaced fertility issues. I’m not sure it’s that. I think gender issues may be have been added to what we as society care about, but not at the expense of women’s issues. Maybe because by definition trans issues have male advocates, they have become everyone’s responsibility. Fertility, alas, remains just for women.
Very interesting alternative interpretation. I hadn’t considered that (there’s male privilege for you), but it certainly seems like a valid reading of the situation. Thank you for sharing, and for doing so in such a thoughtful and articulate way.