(or why the Quebec Minister of Health should take a flying leap)
On Tuesday Feb. 16, Quebec’s much anticipated Bill 20, first tabled in 2014, was finally passed into law. For those unaware, Bill 20 ended coverage of IVF under the provinces health care system.
The province of Quebec does have an interesting history related to funding of fertility treatments. First, since 2000 and until November 2015, Quebec had a special refundable tax credit for the treatment of infertility. The tax credit was equal to 50% of all eligible expenses to a maximum tax credit of $10,000 (meaning you can claim up to $20,000).
Second, beginning August 5, 2010 Quebec covered, through its provincial medical plan, all medical procedures related to artificial insemination and three cycles of IVF provided through public clinics and some, but not all, private clinics. This coverage was in tandem with a limit on the number of embryo transferred: in exchange for public coverage, a single embryo transfer was required. The goal of this policy was to reduce the incidence of multiple births.
Third in tandem with the public medical coverage Quebec required that all public and private drug insurance plans had to include coverage for associated fertility medications (all private insurance plans must correspond to that of the public plan administered by the Regie de l’assurance maladie due Quebec (RAMQ)).
How successful was Quebec’s coverage of IVF related to the policy goals? The main findings of studies of Quebec’s ART coverage under its medical plan are that: the incidence of multiple births in ART pregnancies declined from 25.6% to 3.7%, the number of ART cycles increased by more than 200%, cost per ART cycle increased by 23%, and the one year post-delivery health costs decreased by $6,155. So the objective of decreased multiple births was indeed observed, but this resulted in increased demand and increased the costs. The end result was the Quebec did not observe the expected savings from the policy and the reduction is multiple births can be more cheaply obtained by simply mandating single embryo transfers.
Part of the cost story relates to age. Quebec did not have an age limit for access and as it turns out that is absolutely essential for controlling costs. A study of the program showed that the cost of a live newborn for women under the age of 35 was only $18,000, but this rose to $43,000 for women over 40 and was more than $100,000 for a 43 year old woman. Not unexpectedly, there are no recorded live births to women any older than that, but the average cost of providing IVF to women over 43 was $600,000. When Quebec first started talking about modifying coverage based on age, there was general moral outrage but you can see why it is important. This was possibly a lesson learned by Ontario, which when it recently announced coverage of one round of IVF, it chose to limit access to women under 43.
The high costs and lack of savings then lead to Bill 20 in Quebec. Bill 20 ends coverage of IVF, though interestingly maintains coverage of artificial insemination. I say interestingly because artificial insemination is still associated with super ovulation and the associated risk of multiple births, it is a very poor treatment choice for many infertile couples, and its efficacy over timed intercourse is questionable.
That aside, Bill 20 continues the requirement of a single embryo transfer for most patients (which is a good thing!), though allowing for the transfer of two embryos if the woman is 37 years of age or older and the quality of embryos suggests the risk of a multiple birth is low. It also modifies the tax credit. The tax credit is still refundable and has a maximum claimable amount of $20,000. But there are some very important changes. First it is now based on family income, providing an 80% tax credit to those with family income under $50,000, and falling thereafter to a minimum of 20% for those with family incomes of $120,000 or more. Second, only those families who have never had a child before the start of the IVF treatment can claim the tax credit. Third, costs claimable are limited to the costs associated with one round of IVF if the woman is under 37, increased to two rounds if the woman is older. All these limitations will limit the cost of this tax credit, further curtailing costs.
However, there were two interesting events this week. First, Quebec’s health minister signaled he was contemplating eliminating the requirement that insurance plans include coverage of fertility medications. Outside of Quebec, few insurance plans include the coverage of fertility medications. In fact, in my search of plans, only the employer plans offered by the federal and select provincial governments extend coverage to fertility medications. As a result, it would not be unexpected to see employers in Quebec eliminating this coverage if the requirement was lifted.
Second , the Quebec health minister said
“The IVF is one thing. To raise a child is another thing. The costs that are involved to IVF are, at the end, closely similar to the cost of raising a child, so if the IVF in itself is an obstacle – the cost is an obstacle to have a child, well, I have something to say, which is raising a child is also a cost.”
This statement is a very unhelpful contribution to the discussion about fertility treatments and coverage. IVF involves large and significant upfront and lump sum costs. Each round of IVF costs, on average, $10,000, meaning that three rounds of IVF, the number of rounds that are needed to garners a 70% success rate, cost an average of $30,000. Outside of private school tuition and catastrophic drug costs, I know of no other case where, as a mother of a young child, I would be expected to shell out that kind of money over a period of several days for one IVF round or several months for three rounds.
Yes, kids are not cheap, but they do not require the same stock of cash as IVF. As it was aptly by an economics student, the minister is confounding income stock with income flow:
@LindsayTedds Seems like more of a liquidity problem then a solvency problem but many people are equating the two.
— Taylor John Wright (@taylor_wright) February 19, 2016
In addition, if what the minister says is true then why can’t we expect those with kids to suck it up and pay for them. Why are we paying to publicly provided day care? Why are we paying benefits to offset the costs of children? Why do we even bother to recognize kids through the tax and transfer system? Kids are expensive and we acknowledge that and provide public support to help offset the costs. Why then not, the costs incurred by some couples to even have them in the first place?
This is not to say that I think IVF should be provided through the public health system. As an economist, I know that something being expensive does not make it worthy of public provision. But we need to have reasonable and rationale discourse about the topic. This is because
- the reported prevalence of infertility has risen from 5% in 1984 to 16% by 2010 (I was unable to locate any newer figures).
- The average age of a first time mum in Canada is nearly 30, the magic age by which female fertility begins its swan song.
- the number of assisted reproduction technology clinics in Canada increased by 50% between 2001 and 2012 (the latest year for which figures are available),
- and the number of ART cycles reported by these clinics increased by nearly 250% over the same time frame.
- Canada has the second highest incidence of multiple births in the world, second only to the U.S.
Fertility treatments are not going away and Canada is, so far, either choosing to bury its head in the sand or fanning the flames with very unhelpful discourse.