Mary Delgado\u2019s first pregnancy went according to plan, but when she tried to get pregnant again seven years later, nothing happened. After 10 months, Delgado, now 34, and her partner, Joaquin Rodriguez, went to see an OB-GYN. Tests showed she had endometriosis<\/a>, which was interfering with conception. Delgado\u2019s only option, the doctor said, was in vitro fertilization.<\/p>\n

\u201cWhen she told me that, she broke me inside,\u201d Delgado said, \u201cbecause I knew it was so expensive.\u201d<\/p>\n

Delgado, who lives in New York City, is enrolled in Medicaid, the federal-state health program for low-income and disabled people. The roughly $20,000 price tag<\/a> for a round of IVF would be a financial stretch for lots of people, but for someone on Medicaid \u2014 for which the maximum annual income for a two-person household in New York<\/a> is just over $26,000 \u2014 the treatment can be unattainable.<\/p>\n

Expansions of work-based insurance plans to cover fertility treatments, including free egg freezing and unlimited IVF cycles, are often touted by large companies as a boon for their employees. But people with lower incomes, often minorities, are more likely to be covered by Medicaid or skimpier commercial plans with no such coverage. That raises the question of whether medical assistance to create a family is only for the well-to-do or people with generous benefit packages.<\/p>\n

\u201cIn American health care, they don\u2019t want the poor people to reproduce,\u201d Delgado said. She was caring full-time for their son, who was born with a rare genetic disorder that required several surgeries before he was 5. Her partner, who works for a company that maintains the city\u2019s yellow cabs, has an individual plan through the state insurance marketplace, but it does not include fertility coverage.<\/p>\n

Years after she had her first child, Joaquin (left), Mary Delgado found out that she had endometriosis and that IVF was her only option to get pregnant again. The news from her doctor \u201cbroke me inside,\u201d Delgado says, \u201cbecause I knew it was so expensive.\u201d Delgado, who is on Medicaid, traveled more than 300 miles round trip for lower-cost IVF, and she and her partner, Joaquin Rodriguez, used savings they\u2019d set aside for a home. Their daughter, Emiliana, is now almost a year old.(Joaquin Rodriguez)<\/span><\/figcaption><\/figure>\n

Some medical experts whose patients have faced these issues say they can understand why people in Delgado\u2019s situation think the system is stacked against them.<\/p>\n

\u201cIt feels a little like that,\u201d said Elizabeth Ginsburg<\/a>, a professor of obstetrics and gynecology at Harvard Medical School who is president-elect of the American Society for Reproductive Medicine<\/a>, a research and advocacy group.<\/p>\n

Whether or not it\u2019s intended, many say the inequity reflects poorly on the U.S.<\/p>\n

\u201cThis is really sort of standing out as a sore thumb in a nation that would like to claim that it cares for the less fortunate and it seeks to do anything it can for them,\u201d said Eli Adashi<\/a>, a professor of medical science at Brown University and former president of the Society for Reproductive Endocrinologists.<\/p>\n

Yet efforts to add coverage for fertility care to Medicaid face a lot of pushback, Ginsburg said.<\/p>\n

Over the years, Barbara Collura<\/a>, president and CEO of the advocacy group Resolve: The National Infertility Association, has heard many explanations for why it doesn\u2019t make sense to cover fertility treatment for Medicaid recipients. Legislators have asked, \u201cIf they can\u2019t pay for fertility treatment, do they have any idea how much it costs to raise a child?\u201d she said.<\/p>\n

\u201cSo right there, as a country we\u2019re making judgments about who gets to have children,\u201d Collura said.<\/p>\n

The legacy of the eugenics movement<\/a> of the early 20th century, when states passed laws that permitted poor, nonwhite, and disabled people to be sterilized against their will, lingers as well.<\/p>\n

\u201cAs a reproductive justice person, I believe it\u2019s a human right to have a child, and it\u2019s a larger ethical issue to provide support,\u201d said Regina Davis Moss, president and CEO of In Our Own Voice<\/a>: National Black Women\u2019s Reproductive Justice Agenda, an advocacy group.<\/p>\n

But such coverage decisions \u2014 especially when the health care safety net is involved \u2014 sometimes require difficult choices, because resources are limited.<\/p>\n

Even if state Medicaid programs wanted to cover fertility treatment, for instance, they would have to weigh the benefit against investing in other types of care, including maternity care, said Kate McEvoy<\/a>, executive director of the National Association of Medicaid Directors. \u201cThere is a recognition about the primacy and urgency of maternity care,\u201d she said.<\/p>\n

Medicaid pays for about 40% of births in the United States. And since 2022, 46 states<\/a> and the District of Columbia have elected to extend Medicaid postpartum coverage to 12 months, up from 60 days.<\/p>\n

Fertility problems are relatively common, affecting roughly 10% of women and men of childbearing age, according to the National Institute of Child Health and Human Development<\/a>.<\/p>\n