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If You're Not a Mom Are You Still a Woman? Fertility Treatments in Israel and in the U.S. in 2014

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The pressure to have children in Israel is so intense that it is palpable. American women may long for babies and feel the weight of the world's judgment when they aren't moms. But childless Israeli women of child-bearing age feel more than longing and more than society's disapproval. Many feel they are not women.

During a recent trip to Israel, I chatted with a beautician in her early 30s in one of Tel Aviv's ubiquitous hair salons. Her personality is guarded. Physically, she is beautiful: perfect figure, pretty face and (not surprisingly) immaculate hair and makeup She loves to do outdoor activities with her husband. The New York City Sex and the City descendent is a few years older than her, and not only doesn't have kids, but may have a stressful, unrewarding job and neither a boyfriend nor a husband. More than 32% of New York City women between 35 and 44 have never been married. To them, the beautician's life seems carefree and fulfilling.

But we all have our crosses to bear. he beautician talked ruefully about one in vitro fertilization (IVF) attempt after another. Her husband emphasized his devotion to her (regardless of whether she bore children). Her cautious personality may be the result of years of disappointment, frustration and fielding one too many "When are you having a baby?" questions.

In Private and Social Incentives for Fertility: Israeli Puzzles (2002), Charles F. Manski and Joram Mayshar identify three incentives that contribute to Israeli fertility patterns: private preferences; desire to conform to society; and the Israeli government's child allowance program.

1.6% of gross national product in Israel is devoted to the child allowance program, reflecting the cultural value placed on procreation. And it is axiomatic that ultraorthodox rabbis encourage fruitfulness and multiplication, and that ultraorthodox women listen to their rabbis. Some posit that post-Holocaust Israeli women (as contrasted with Holocaust survivors) feel a heightened mandate to procreate; others maintain that Israeli children are insurance against Israeli lives lost in war. The Israeli population must be propagated because Jews are needed in Israel to protect Jews all over the world by "standing on a wall" (both via service in the Israeli army and simply by living in Israel).

These factors illustrate why emphasis is placed on procreation. The Health Ministry's IVF subsidization program explains the beautician's plight. Until January 2014, under Israel's socialized health insurance regime, women under 45 with zero or one children were entitled to unlimited state-funded IVF treatments. In accordance with May 2013 recommendations from the National Council for Gynecology, Neonatology and Genetics, there are now treatment limits. According to Ido Efrati's January 22, 2014 article in Israeli newspaper Haaretz,

most women will now be restricted to eight IVF treatment cycles...Women over 42...will be restricted to three IVF treatments in which the embryo failed to implant...[because] the chances of a successful pregnancy occurring after three consecutive failures are near zero at that age.

Interestingly, the Council did not recommend lowering the maximum age from 45 to 44, despite Council chairman Eliezer Shalev's explanation that

[the chances] of a woman of 45 get[ting] pregnant through in vitro fertilization and giv[ing] birth to a healthy child...are zero. At age 44, we're talking about a two percent chance...This leads to situations in which women are hospitalized with psychological problems [because of the stress of trying to conceive children at an age when the chances are minimal to nonexistent].

Shalev's comment reflects a cultural dichotomy: Israeli women may feel shame when they can't conceive, but they need not hide their shame. While IVF subsidies may exacerbate psychological issues in women who keep going back for another "bite at the apple," subsidies also provide relief and hope.

In the United States, IVF coverage is on a far lower order of magnitude under the socialized Obamacare regime (also known as the Affordable Care Act, or "ACA"), effective January 1, 2014. And American women tend to guard their IVF encounters with Fort Knox secrecy. To make a sweeping generalization: childless American women of childbearing age "protest too much" that they don't need to be moms to feel fulfilled.

According to website of RESOLVE: The National Infertility Association, the ACA requires coverage of so-called essential health benefits ("EHBs"). Eight states (Connecticut, Hawaii, Illinois, Massachusetts, New Jersey, Rhode Island, Arkansas, and Maryland) have "IVF mandates" based on benefits which pre-2012 (and pre-ACA) state plans were required to include. So while the ACA itself does not require IVF coverage, it is required in states whose "benchmark plans" require it.

In Presidential elections, "as Ohio goes, so goes the nation"; with respect to the ACA, as goes the state's benchmark plan, so goes that state's ACA requirements. The benchmark plan is a floor. No plan can exclude EHBs offered by the benchmark plan. In Arkansas, one of eight IVF mandate states, the benchmark plan does not cover IVF, so IVF is not considered an EHB and need not be covered by Arkansas ACA plans. In Maryland, the benchmark plan does cover IVF, but there is no IVF mandate, so Maryland ACA plans need not cover IVF. All ACA plans in the remaining six IVF mandate states must cover IVF to comply with EHB requirements.

For women (and families) in these six states who need help conceiving, IVF mandates are good news. But there's plenty of bad news. In the 42 non-mandate states, many plans dropped IVF coverage effective January 1, 2014 because of the financial burdens of the ACA itself. Convincing these states' legislatures to adopt IVF mandates would be an uphill battle indeed.

There is a widespread and pernicious misperception that the ACA made policy coverage "caps" illegal. In fact, under the ACA, the number of IVF cycles and dollar amounts covered may most certainly be limited. And all eight mandate states have pre-ACA benchmark standards, so IVF mandates may soon become obsolete as IVF technology develops. What's more, 2014 and 2015 are ACA "trial" years. Come 2016, states may reevaluate their benefit mandates, which may further undermine IVF coverage.

American women of childbearing age face less negative scrutiny when they don't have children. But infertility is a secret shame, and they often keep their longings and the details of their efforts to conceive under wraps. Relatedly, Obamacare's commitment to IVF is minimal (and may soon dissipate). In Israel, IVF is not a taboo topic, which takes the sting out of the stigma (if not the psychological pressure) that childless Israeli women face. And expansive government IVF programs help Israeli women confront scrutiny.