Does public funding of IVF make good economic sense?
Debates about public funding of IVF often get stuck. “It's no one's right to have children” or “We can't afford to pay for luxuries like this.” But what if it were in the national economic interest? Would we agree to it then?
Over the years, I've read various arguments for why IVF should be publicly funded. A prevailing rationale in the Canadian debate has been that it would allow policymakers to help reduce the number of multiple births.
That always struck me as spurious. Doctors have an ethical duty, regardless of where their money comes from, to do the right thing. Transferring numerous embryos and deliberately creating twins, triplets and higher order multiples is not good medicine. Doctors who put patients and society at risk should be sanctioned. I'm all stick and no carrot on that one.
Occasionally we also hear that public funding will lead to better data reporting. Again, public money or private, I believe that the government should compel practitioners to share the info that we need to make good public policy decisions. We shouldn't need to induce doctors with public funding to accomplish that.
Personally, I've been much more swayed by the argument that infertility is in many cases a genuine health issue and that in places where we provide universal health coverage, we should provide infertility treatment as part of it. A 35-year-old woman who can't have children because her ovaries have packed it in seems just as legitimate as a 45-year-old marathoner who needs a new set of knees or a 63-year-old heart patient who gets rerouted arteries. But for various reasons, such arguments have not always led to funding.
Last month in BioNews, I read an intriguing opinion piece that framed the issue in a different way: that children are essential to the building a future tax base and even if you have to pay for the IVF that creates them, society will see net gains.
To be honest, I'm a little surprised I didn’t think of this myself. For years, I've been coming at it from the other side, pontificating about how parenting is a public good. Parents donate years of their lives raising the next generation — a generation without which society as we know it would not survive — and parenting is almost entirely volunteer work. It's hard to think of a more profound form of public service.
Now I discover that someone has quantified the value that a mature adult offspring brings to the national coffers. All around us we have people stepping up to be parents, willing to take on this gruelling and often thankless labour ... and we're not willing to chip in a fraction of what we'll eventually recover?
Almost all of the articles over the past decade that propound this view — that paying for IVF makes good economic sense — seem to have one common author, Mark Connolly. He is a former employee of Ferring, a pharmaceutical company that makes, among other things, fertility drugs. He currently heads a company called Global Market Access Solutions, a consulting firm that says it formulates "market access strategies that reveal the full value of healthcare technologies to decision-makers and payers." These disclosures could probably have been made more explicitly in some of the published pieces I read.
That said, I still find the argument compelling, or at least worth contemplating. Below I present a summary of the case.
Should we fund IVF, in the national interest?
Sure babies are cute, but when they're squalling on an airplane or puking on your business suit, it's easy to lose sight of a child's actual value. Its economic value, that is, as a human who will grow up and someday pay taxes. More than merely desirable, like puppies or sunsets, children generate a handsome return on investment. And the good news is that the monetary benefits accrue to all of society, not just to the parents. If anything, the parents gain the least, financially, since they are the ones sinking thousands of hours of their time and tens of thousands of their dollars into what is essentially a public good.
Which begs the question: if parents are so eager to take on this free labour, and bring a potential taxpayer into the world, why don't we enthusiastically foot the bill for people who need help? True, there is no joining fee when children are conceived naturally. But even when you factor in the high startup cost when using IVF, new humans are an excellent economic investment.
So argues Mark Connolly, a health economist, in numerous papers addressing this issue over the years. In "Long-term economic benefits attributed to IVF-conceived children: a lifetime tax calculation," published way back in 2008 in the American Journal of Managed Care, Connolly and his co-authors lay out the economic case for publicly funding IVF. (According to the author disclosures, Connolly was at that time working for Ferring, a drug company that makes fertility drugs. Ferring was also a funder of the study.) The authors point out that although the immediate purpose of assisted reproduction is to simply help people have children, for happiness and fulfillment, the long-term economic impact made by those offspring once they become adults makes funding their conception a sound economic policy. This aspect usually goes unexamined, the authors say.
They examine it. Using data from real life in the US, they estimate how much an average individual can be expected to contribute in federal, state and local taxes over a lifetime. Then they calculate what the average person would consume during childhood in things like tax credits, health care, and education — and in the case of an IVF baby, conception. (This latter is calculated as the cost of the number of cycles that would on average be required to get one live birth; it goes up with maternal age.)
Some might quibble that IVF offspring aren't average. For one thing, because IVF is expensive, they tend to be born disproportionately to the well-off, so they might end up paying more than an average amount of tax. On the other hand, due to high rates of multiples, they have higher rates of disability, so may incur more childhood costs. The authors argue that if IVF were publicly-funded, both of these skews might disappear: people with average incomes would be able to access it, and numbers of excess multiples would go down.
But back to the numbers. People conceived naturally will contribute, the authors calculate, a net $190,515 over their lifetimes, and IVF-conceived people will hand over almost as much, somewhere between $160,540 and $116,240, depending on how old their mothers were at the time of conception. (The older the mother, the higher the cost of the IVF that will result in one live birth.) In short, though, the national pocketbook wins either way. "In vitro fertilization coverage represents a minor component of the net cost for creation of new taxpayers," the authors write. The specific figures are now outdated, but the proposition remains the same.
A 2010 paper in Human Reproduction by Connolly and new co-authors did the same kind of analysis for the UK. (Connolly was now with Global Market Access Solutions.) They found that net taxes from a person born via IVF to a 35-year-old mother would be £109,939 versus £122,127 for a naturally-conceived person. "An investment of £12,931 to achieve an IVF singleton is actually worth 8.5 times this amount to the UK Treasury," they write.
Similarly, the 2010 figures for Europe came out at a €127,000 return on a €15,000 investment, although a task force of the European Society of Human Reproduction and Embryology (ESHRE) called for caution, given that the costs of raising a child to adulthood happen now and the payoff doesn't happen till many years in the future.
Actually, they come almost forty years in the future, according to Connolly's US study. The "breakeven age" — the age at which an individual starts to contribute more to the system than he or she sucked out of it — is 37 years for the naturally-conceived and 40 to 44 years for the IVF-conceived. But lots of investments take time to pay dividends. Think of higher education. Or planting trees.
Contrary to what it feels like, the money we are paying in now isn't just being saved up somewhere for when we need it — to a large extent, we rely on others to pay it when our time comes. Systems like Medicare and Medicaid, the British National Health Service and the Canada Pension Plan all work this way, and everyone benefits from a healthy supply of younger contributors. Connolly et al go so far as to argue that not treating infertility has serious economic costs.
Recently, Connolly wrote on the topic again, this time in BioNews. In this piece he highlighted yet another monetary benefit of children, including, of course, children conceived through IVF. Not only will the offspring born through IVF, as they grow up and pay taxes, be funding their parents' health care needs, they will further reduce the societal costs of eldercare by helping those parents out. "Elderly individuals who have children are less likely to be in nursing homes, receive less funded nursing care, and when they do enter nursing homes, will enter at older ages," he writes. This free labour from child to parent reduces claims by aging parents on public resources. I would like to see the numbers on this, too, but looking around, I sense that it is true.
If Connolly’s arguments check out on further scrutiny, and we still opt not to fund IVF, let's at least be honest about why.
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