Shortly after getting married in 2016, Jordan and Carmella Graham were ready to have kids. The only problem for the same-sex couple: the cost.
To get pregnant, they would need to go through in vitro fertilization (IVF). And a single IVF cycle ‒ a period of about three weeks in which eggs are collected from an ovary, fertilized by sperm in a lab and then transferred to a uterus ‒ can cost upwards of $20,000, including medication.
Even though Carmella’s job in the military offered insurance coverage for some of the necessary medications, most of the procedure would need to be paid out of pocket.
To cover those bills, Jordan picked up extra shifts at her post office job; she and Carmella cut back on their spending; and they committed to the St. Louis clinic despite its distance. Even so, the Grahams had to take out a personal loan and receive financial help from family to cover the costs, they said.
“I remember us feeling stressed because we needed the money,” said Jordan, who now works as a vlogger. “We want to have babies too. We want to have families.”
IVF and other fertility treatments are expensive for most people who want children. But LGBTQ+ couples face even higher financial barriers, advocates say, because state laws and insurance policies can make it more difficult for them to receive fertility coverage. The restrictions make an already pricey process more daunting for LGBTQ+ couples who tend to earn less yet may face the added expenses of needing sperm donors, egg donors, surrogates or gestational carriers.
“We don’t want special treatment. We just want the same benefits as a heterosexual couple,” said Dr. Mark Leondires, medical director of Illume Fertility and founder of Gay Parents To Be, a resource for LGBTQ+ couples.
Leondires said gay couples paying for a surrogate and egg donation can expect to pay upward of $200,000 for one child. Surrogate compensation alone can cost around $55,000, according to the advocacy group Men Having Babies.
The community also faces a record amount of anti-LGBTQ+ bills introduced this year, with some states proposing laws that could jeopardize access to IVF. LGBTQ+ rights advocates say it’s a worrying time.
“Anybody who wants to have a family and wants to bring a child in the world should be able to,” Leondires said. “It shouldn’t be something that is out of reach based on where they live or who they choose to love.”
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What barriers exist
Advocates say LGBTQ + couples face higher hurdles to IVF treatments partly because of how government agencies and state laws define infertility, which influences insurance policies.
Some insurers, for example, base infertility coverage on the federal Centers for Disease Control and Prevention’s definition of infertility which is “not being able to get pregnant (conceive) after one year (or longer) of unprotected sex.” The World Health Organization has a similar definition.
This can exclude same-sex couples since they cannot get pregnant from unprotected sex, according to fertility law attorney Rich Vaughn, founder of the International Fertility Law Group.
Insurance providers are “looking to not cover more than they already have to. Insurance is expensive,” Vaughn said. “If they open this up to a broader interpretation, they’re opening up the number of claims and things that they have to cover. And they don’t know where that’s going to stop.”
Dmitry Kissin, who leads the CDC’s Assisted Reproductive Technology Surveillance and Research Team, said the agency uses that language for monitoring infertility prevalence and trends in the United Statesand it is “not intended to guide any recommendations about the provision of fertility care services.”
Nevertheless, insurance providers like Blue Cross Blue Shield of Illinois have used similar language to define infertility in their policies.
The Chicago-based insurer was sued last year by Kelsey Murphy of Illinois because it offers immediate fertility coverage with no out-of-pocket expenses only to couples who have failed to get pregnant after 12 months of unprotected sex – a definition Murphy’s lawyers say openly discriminates against LGBTQ+ couples. For couples who cannot conceive because of their sexual orientation or gender identity, the policy requires they to pay out of pocket for one year of medically based conception (like artificial insemination) before Blue Cross’s policy kicks in, according to the lawsuit.
Blue Cross and Blue Shield of Illinois, or BCBSIL, said it does not comment on pending litigation but argued that its policies align with the company’s commitment “to diversity, equity and inclusion across our company regardless of race, color, national origin, sex, gender identity, age, sexual orientation, health status or disability.”
Murphy’s lawsuit says the insurance company’s verbiage forced her and her partner to pay about $19,000 out of pocket for one successful pregnancy.
“At best, these individuals incur great costs due to BCBSIL’s Policy language,” the lawsuit claims. “At worst, these exorbitant costs are prohibitive and entirely prevent people who are unable to shoulder them – disproportionately LGBTQ people of color – from becoming pregnant and starting a family.”
When asked for comment on allegations that some fertility insurance policies exclude LGBTQ+ people, America’s Health Insurance Plans spokesperson David Allen pointed to a 2022 comment letter from the trade group, which represents leading health insurers.
“Every American deserves access to high-quality, affordable health care, regardless of race, color, national origin, sex, gender identity, sexual orientation, age, or disability,” the letter reads. “AHIP firmly believes in this commitment, and we strongly support the overarching goal to promote equal access to health care.”
Adoption not always an easy alternative
For LGBTQ+ couples who choose to foster or adopt instead of conceive, other roadblocks exist.
There are 13 states that allow state-licensed child welfare agencies to turn away LGBTQ+ couples if it conflicts with their religious beliefs, according to the Movement Advancement Project, a think tank that researches LGBTQ issues and laws. And adoption can be expensive, ranging from $20,000 to $45,000 for domestic adoption, according to Family Equality, an LGBTQ+ advocacy group.
Leondires said that means biological parenting is sometimes the only path to parenthood for certain LGBTQ+ couples because “there’s still active discrimination against parents-to-be who identify as LGBTQ+,” despite over three decades of peer-reviewed research showing that children are not harmed by having gay or lesbian parents.
‘Not getting their fair shake’
As of May, 21 states have passed legislation that requires insurers to offer coverage to treat infertility, according to Resolve, an infertility advocacy organization. Fourteen of those state laws include IVF coverage.
But many of the mandates are exclusionary and “extremely heterogeneous,” according to a 2022 peer-reviewed paper published in Reproductive Biology and Endocrinology. For example, fertility insurance coverage laws in three states ‒ Arkansas, Hawaii and Texas ‒ say couples must use their own eggs and sperm to conceive, “thus discriminating against couples who do not conform to standards of heteronormativity and traditional gender roles.” The language is also used by the U.S. Department of Veterans Affairs in its medical benefits package.
“There are some populations that still are not getting their fair shake at getting the treatment that they need. The LGBTQ community for sure,” said Tarun Jain, associate professor of obstetrics and gynecology at Northwestern University and one of the paper’s authors. “Some states have very specific language that really excludes that community.”
A statement from the VA said the department currently has limited legal authority to provide assisted reproductive technology to veterans.
And the Hawaii Insurance Division said despite the language, “some health carriers have indicated that they do provide a level of coverage for same-sex couples and unmarried members.”
A statement from the Arkansas Insurance Department declined to comment on the state’s fertility coverage language, noting that the regulatory agency does not write the laws.
Ben Gonzalez, a spokesperson for the Texas Department of Insurance, said the agency can’t speak to why the state’s law on fertility coverage was drafted as it was. But he noted that the law “defines the minimum scope of what must be offered” and only applies to fully insured plans regulated by the Texas Department of Insurance, which account for less than 20% of the market.
“Nothing prevents health plans from offering more generous coverage for in vitro, including benefits for same-sex couples,” Gonzalez said.
Even when states pass fertility insurance coverage laws, the rules don’t apply to self-insured or self-funded insurance plans. More than two-thirds of covered workers were in a self-funded plan last year, according to the nonpartisan health research organization Kaiser Family Foundation.
“It’s really difficult to quantify and varies by state, but it is probably less than half” of employees affected by these fertility laws, said Betsy Campbell, chief engagement officer at Resolve, adding that’s why the patient advocacy group believes it’s important for employees to have conversations about fertility coverage with their employers.
What are the hopes and challenges?
There are efforts being made to expand fertility coverage to the LGBTQ+ community.
President Joe Biden’s 2024 fiscal year budget submission, for instance, included proposed legislation that would expand access to fertility treatment and adoption reimbursement to single veterans, veterans in same-sex relationships and veterans who need donor sperm, eggs or embryos to build a family. The Fiscal Responsibility Act, which ended the debt ceiling crisis, did not include this legislative proposal, but the “VA and Biden-Harris Administration continue to strongly advocate for expanded access to assistive reproductive therapies, including in-vitro fertilization, for Veterans,” according to a statement VA press secretary Terrence Hayes.
House Bill 6617 in Connecticut would require private insurance companies’ fertility coverage to expand to LGBTQ+ and single individuals who need medical assistance to build their families, in addition to people diagnosed as infertile. The bill would also require Connecticut’s Medicaid program to provide fertility care coverage. This year’s legislative session ended without the bill’s passage, but advocates hope to move the bill forward in future sessions.
And California lawmakers have introduced legislation that would require health plans to provide coverage for fertility care, including IVF. The bill covers couples having trouble conceiving, as well as single people and LGBTQ+ couples. (The California Association of Health Plans opposes the bill and argues that the expanded coverage could raise premiums.)
Meanwhile, legislation is in the works that concerns advocates for the LGBTQ+ community, according to Patience Crozier, Director of Family Advocacy at GLBTQ Legal Advocates & Defenders, or GLAD. Lawmakers in 46 states have introduced more than 650 anti-LGBTQ bills so far this year, according to a report by the Movement Advancement Project.
Crozier worries the Supreme Court’s 2022 decision to overturn Roe v. Wade could be a “slippery slope,” with access to assisted reproductive technology like IVF under fire next.
“For LGBTQ families and people who want to build their families, I think it feels like a particularly scary time,” Crozier said.
For the Grahams, IVF was a big expense but successful. Their daughter, Adeece, was born in July 2018. The family has since relocated to Florida but plans to travel back to the clinic in St. Louis this year to get pregnant with their last frozen embryo, which they’ve been paying $600 a year to store.
“It’s just very unfortunate that people like us who love kids and enjoy kids and want to have kids, you’ve got to pay a lot of money,” Jordan said.
You can follow USA TODAY reporter Bailey Schulz on Twitter @bailey_schulz and subscribe to our free Daily Money newsletter here for personal finance tips and business news every Monday through Friday.
