ASRM Military Families, Infertility, & National Security
Why expanding service members’ access to infertility treatment is easy, affordable, and the right thing to do
A joint white paper by: The ASRM Center for Policy and Leadership Military Family Building Coalition
Executive Summary
Supporting military families is central to keeping our military strong – but for an increasing number of service members, infertility is upending the dream of family- building before it can even begin. Moreover, TRICARE (the military’s health care program) does not even cover infertility treatment for most service members. As a result, many members of the military who struggle with infertility are forced to choose between forgoing parenthood or paying exorbitant out-of-pocket rates for infertility treatments that are financially out of reach for most. These gaps in support for family- building do more than just a disservice to our people in uniform – they undermine the military’s efforts at retention and diversity.
Expanding service members’ access to affordable infertility treatments through TRICARE is an urgent priority that can also bolster retention and enhance diversity. Service members deserve the right to build the families they want regardless of deployment schedules, fertility challenges, or their financial situation. Stronger support for family- building can help retain top talent, especially at the officer level and to boost female leadership. Fortunately, the solution is not only clear – it is also easy, affordable, and the right thing to do.
ASRM has drafted a TRICARE benefit modification to address this issue – and commissioned a Congressional Budget Office (CBO)-style score to estimate the proposal’s cost. The proposed modification would extend coverage for in vitro fertilization (IVF) treatments to any active-duty service member or their spouse struggling with infertility. In the proposed benefit’s first year, the CBO-style model projects an additional budget expense of $260 million – or just 0.5% of the 2021 Defense Health Agency Budget and 0.03% of the 2022 Department of Defense Budget – to meet “pent up” demand. For the remainder of a decade, the model projects an additional recurring budget expense of $144 million – an even smaller share of the projected US military budget.
Expanding access to infertility treatment for members of the military is a cost that the US government can – and should – urgently bear. Over a 10-year period, the total estimated cost of the proposed benefit is just $1.6 billion. Even before considering the benefits to military retention and diversity, as well as service member morale and wellbeing – $1.6 billion over 10 years is a small sacrifice for the people in service who everyday risk the ultimate sacrifice by putting themselves in harm’s way for their country.
Expanding service members’ access to affordable infertility treatments through TRICARE is an urgent priority that can also bolster retention and enhance diversity. Service members deserve the right to build the families they want regardless of deployment schedules, fertility challenges, or their financial situation. Stronger support for family- building can help retain top talent, especially at the officer level and to boost female leadership. Fortunately, the solution is not only clear – it is also easy, affordable, and the right thing to do.
ASRM has drafted a TRICARE benefit modification to address this issue – and commissioned a Congressional Budget Office (CBO)-style score to estimate the proposal’s cost. The proposed modification would extend coverage for in vitro fertilization (IVF) treatments to any active-duty service member or their spouse struggling with infertility. In the proposed benefit’s first year, the CBO-style model projects an additional budget expense of $260 million – or just 0.5% of the 2021 Defense Health Agency Budget and 0.03% of the 2022 Department of Defense Budget – to meet “pent up” demand. For the remainder of a decade, the model projects an additional recurring budget expense of $144 million – an even smaller share of the projected US military budget.
Expanding access to infertility treatment for members of the military is a cost that the US government can – and should – urgently bear. Over a 10-year period, the total estimated cost of the proposed benefit is just $1.6 billion. Even before considering the benefits to military retention and diversity, as well as service member morale and wellbeing – $1.6 billion over 10 years is a small sacrifice for the people in service who everyday risk the ultimate sacrifice by putting themselves in harm’s way for their country.
The Problem
Supporting military families is central to keeping our military strong. Prioritizing and improving quality of life for military families boosts morale and wellbeing for our people in uniform amid the many challenges that come with military life. From childcare to deployment assistance, the military’s strong record of supporting its families also improves retention and ultimately strengthens our national security. As the old adage goes, “the military recruits the member, but retains the family.”
For an increasing number of service members, however, infertility is upending the dream of family-building before it can even begin. From low ovarian egg reserves to poor sperm count or quality, infertility impacts as many as 7.3 million – or one in eight – couples in the United States, according to the American Medical Association. Defined as the inability to conceive after one year of regular, unprotected intercourse, it is a disease that does not discriminate, impacting Americans regardless of race, age, ethnicity, sexual orientation, or economic status. Members of the military may even face additional risk: female service members, as well as female veterans, report higher rates of infertility than women in the general population.
Given the demands of military life, addressing infertility is especially difficult for service members and their spouses. Service members face challenging career demands that can affect family-building, including training cycles, deployment schedules, and frequent separations from partners and families. Women service members have additional obstacles in planning and timing for pregnancy and parental leave. Starting a family while serving in the military is hard enough; undergoing time-consuming, expensive, and emotionally-taxing infertility treatments is doubly hard when one or both partners serve.
Unfortunately, current government policy is not helping. TRICARE – the military’s health care program – does not cover infertility treatment for most service members. For people struggling with infertility, a range of medical treatments offers hope for having children – including cryopreservation (egg and sperm freezing), intrauterine insemination or IUI (the placement of sperm inside a woman’s uterus), and in vitro fertilization or IVF (egg fertilization outside the womb and transfer into a woman’s uterus). Yet under current law, TRICARE only covers comprehensive fertility treatments for active-duty service members whose infertility was caused by an injury sustained in the line of duty.
As a result, most service members are forced to pay out of pocket for infertility treatments, which is financially out of reach for many. While the costs vary substantially by type of treatment, 67% percent of infertility care patients report spending $10,000 or more to build their families. The average cost of an IVF cycle is about $15,000 in the United States – and many patients require multiple repeated cycles until a successful pregnancy is achieved. A recent survey found that women 25-34 years old accrued, on average, around $30,000 of debt after undergoing fertility treatment. Such costs put fertility treatment out of reach for a significant share of service members.
Gaps in family-building support do more than just a disservice to service members – they undermine the military’s efforts at retention and diversity. To recruit, retain, and promote top talent, the military must provide its members with whatever support they need to thrive on and off the battlefield – including the resources to address family- building challenges like infertility. This is especially true at the officer level, when service members may be ready to start a family, and for the promotion of female leadership – an area where the military has long struggled. Likewise, making infertility treatments more affordable for all service members offers an important opportunity to redress existing racial and ethnic disparities in the US healthcare system and the military.
Our people in uniform face many challenges due to their service – but having children should not be one of them. Service members struggling with infertility should not have to choose between their jobs and having a family, but right now, many do. Expanding support for military family-building is an urgent priority – so service members can build the families they want regardless of deployment schedules, fertility challenges, or their financial situation. Fortunately, the solution is not only clear – it is also easy, affordable, and the right thing to do.
For an increasing number of service members, however, infertility is upending the dream of family-building before it can even begin. From low ovarian egg reserves to poor sperm count or quality, infertility impacts as many as 7.3 million – or one in eight – couples in the United States, according to the American Medical Association. Defined as the inability to conceive after one year of regular, unprotected intercourse, it is a disease that does not discriminate, impacting Americans regardless of race, age, ethnicity, sexual orientation, or economic status. Members of the military may even face additional risk: female service members, as well as female veterans, report higher rates of infertility than women in the general population.
Given the demands of military life, addressing infertility is especially difficult for service members and their spouses. Service members face challenging career demands that can affect family-building, including training cycles, deployment schedules, and frequent separations from partners and families. Women service members have additional obstacles in planning and timing for pregnancy and parental leave. Starting a family while serving in the military is hard enough; undergoing time-consuming, expensive, and emotionally-taxing infertility treatments is doubly hard when one or both partners serve.
Unfortunately, current government policy is not helping. TRICARE – the military’s health care program – does not cover infertility treatment for most service members. For people struggling with infertility, a range of medical treatments offers hope for having children – including cryopreservation (egg and sperm freezing), intrauterine insemination or IUI (the placement of sperm inside a woman’s uterus), and in vitro fertilization or IVF (egg fertilization outside the womb and transfer into a woman’s uterus). Yet under current law, TRICARE only covers comprehensive fertility treatments for active-duty service members whose infertility was caused by an injury sustained in the line of duty.
As a result, most service members are forced to pay out of pocket for infertility treatments, which is financially out of reach for many. While the costs vary substantially by type of treatment, 67% percent of infertility care patients report spending $10,000 or more to build their families. The average cost of an IVF cycle is about $15,000 in the United States – and many patients require multiple repeated cycles until a successful pregnancy is achieved. A recent survey found that women 25-34 years old accrued, on average, around $30,000 of debt after undergoing fertility treatment. Such costs put fertility treatment out of reach for a significant share of service members.
Gaps in family-building support do more than just a disservice to service members – they undermine the military’s efforts at retention and diversity. To recruit, retain, and promote top talent, the military must provide its members with whatever support they need to thrive on and off the battlefield – including the resources to address family- building challenges like infertility. This is especially true at the officer level, when service members may be ready to start a family, and for the promotion of female leadership – an area where the military has long struggled. Likewise, making infertility treatments more affordable for all service members offers an important opportunity to redress existing racial and ethnic disparities in the US healthcare system and the military.
Our people in uniform face many challenges due to their service – but having children should not be one of them. Service members struggling with infertility should not have to choose between their jobs and having a family, but right now, many do. Expanding support for military family-building is an urgent priority – so service members can build the families they want regardless of deployment schedules, fertility challenges, or their financial situation. Fortunately, the solution is not only clear – it is also easy, affordable, and the right thing to do.
The Solution
ASRM has drafted a modification to the current TRICARE infertility benefit that would cover IVF services for any active-duty service members, or their spouses diagnosed with infertility. The proposed benefit is designed to mirror TRICARE’s current IVF coverage for service members whose infertility was caused by an injury sustained in the line of duty: up to three rounds of IVF (including egg extraction, associated medication, and single-embryo transfer), initial cryopreservation of embryos, and up to three years of embryo storage.
The proposed benefit would expand eligibility for comprehensive IVF coverage to all active-duty service members and their spouses. Like the current TRICARE infertility coverage, the proposed benefit would cover 100% of the benefit cost, with no cost- sharing to the beneficiary, and would cover care at military treatment facilities (“MTF”) as well as civilian care settings. It would require an infertility diagnosis, which can only be achieved after one year of attempting to conceive naturally.
To establish a credible estimate of the reform’s cost, ASRM commissioned a Congressional Budget Office (CBO)-style score for the proposed benefit. After conducting extensive research to identify the relevant inputs and make reasonable assumptions, NORC at the University of Chicago constructed a model that mirrors the rationale and analysis used for previous CBO scores of comparable infertility benefits (and conforms to CBO and the Joint Committee on Taxation rules on dynamic scoring). NORC’s analysis includes two important assumptions:
NORC used the CBO-style model to calculate the estimated costs of the proposed benefits, using the most recently available demographic data published by TRICARE and the Department of Defense. NORC estimated that 2.1 million service members and their spouses would be eligible for the proposed benefit in its first year. To accurately project the costs of providing the new benefit over a 10-year period, the model has two key estimates:
Over a 10-year period (FY2022-FY2031), the total estimated cost of the proposed benefit is just $1.6 billion. NORC estimates that 22,416 TRICARE beneficiaries would take advantage of the new benefit over this period.
The actual cost of expanding family-building to all service members would likely be even lower, as the CBO-style model includes a number of conservative assumptions. While NORC’s cost estimates are consistent with prior CBO scores of similar TRICARE benefit proposals – namely S. 131: Women Veterans and Other Health Care Improvements Act of 2013 and H.R. 1735: TRICARE Coverage of Infertility Treatment of 2015) – the model is likely conservative in three ways:
Expanding access to infertility treatment for members of the military is a cost that the US government can – and should – urgently bear. Even before considering the benefits to military retention and diversity, as well as service member morale and wellbeing, $1.6 billion over 10 years is a small sacrifice for the people who everyday risk the ultimate sacrifice by putting themselves in harm’s way for their country.
The proposed benefit would expand eligibility for comprehensive IVF coverage to all active-duty service members and their spouses. Like the current TRICARE infertility coverage, the proposed benefit would cover 100% of the benefit cost, with no cost- sharing to the beneficiary, and would cover care at military treatment facilities (“MTF”) as well as civilian care settings. It would require an infertility diagnosis, which can only be achieved after one year of attempting to conceive naturally.
To establish a credible estimate of the reform’s cost, ASRM commissioned a Congressional Budget Office (CBO)-style score for the proposed benefit. After conducting extensive research to identify the relevant inputs and make reasonable assumptions, NORC at the University of Chicago constructed a model that mirrors the rationale and analysis used for previous CBO scores of comparable infertility benefits (and conforms to CBO and the Joint Committee on Taxation rules on dynamic scoring). NORC’s analysis includes two important assumptions:
- The CBO-style model accounts for cost variations between military treatment facilities (MTFs) and civilian care settings. The average estimated cost for comprehensive IVF coverage is $45,900 at MTFs and $76,832 in civilian care settings. Further, the model assumes that beneficiaries would choose their care provider in a way that mirrors the choices of TRICARE beneficiaries receiving obstetric care: 67.4% of beneficiaries will pursue care at an MTF and 32.6% will pursue care at civilian care settings.
- The model estimates the full cost of the proposed benefit to TRICARE, including additional neonatal and labor and delivery costs associated with new births. The average estimated costs for neonatal and labor and delivery services are $19,930 at MTFs and $33,575 in civilian care settings. These costs are already covered under the standard TRICARE benefits.
NORC used the CBO-style model to calculate the estimated costs of the proposed benefits, using the most recently available demographic data published by TRICARE and the Department of Defense. NORC estimated that 2.1 million service members and their spouses would be eligible for the proposed benefit in its first year. To accurately project the costs of providing the new benefit over a 10-year period, the model has two key estimates:
- Estimated cost in year one: $260 million for 4,134 beneficiaries. NORC’s model assumes that active-duty service members and spouses with existing infertility diagnoses will seek IVF treatment during the first year that the service is offered. Using 5-year infertility prevalence rates published by the Military Health System and the National Survey of Family Growth, NORC estimates that there are approximately 62,877 eligible beneficiaries with existing infertility diagnoses – less than 3% of the total eligible TRICARE population. Of these, NORC projects that 12.5% or 4,134 beneficiaries will seek IVF treatment during the first year of the reform, resulting in additional budgetary spending of $259.7 million – or just 0.5% of the 2021 Defense Health Agency Budget and 0.03% of the 2022 Department of Defense Budget.
- Estimated annual cost thereafter: an average of $144 million per year for 2,033 beneficiaries. NORC’s model assumes that in future years, those who pursue the benefit will be active-duty service members and spouses who have yet to receive an infertility diagnosis. Using the same sources for infertility prevalence rates, NORC projects that approximately 2,033 eligible beneficiaries per year will receive infertility diagnoses, resulting in additional budgetary spending of $130.2 million in the second year and increasing to $158.1 million by the tenth year, accounting for estimated inflation and beneficiary population growth (derived from the Centers for Medicare & Medicaid Services National Health Expenditure projections and TRICARE enrollment projections, respectively).
Over a 10-year period (FY2022-FY2031), the total estimated cost of the proposed benefit is just $1.6 billion. NORC estimates that 22,416 TRICARE beneficiaries would take advantage of the new benefit over this period.
The actual cost of expanding family-building to all service members would likely be even lower, as the CBO-style model includes a number of conservative assumptions. While NORC’s cost estimates are consistent with prior CBO scores of similar TRICARE benefit proposals – namely S. 131: Women Veterans and Other Health Care Improvements Act of 2013 and H.R. 1735: TRICARE Coverage of Infertility Treatment of 2015) – the model is likely conservative in three ways:
- The majority of TRICARE beneficiaries are young service members (18-23 years old) who will likely leave the military before they begin family-building. Members of this younger demographic are less likely to use the coverage offered under the proposed benefit, which can only be used by service members or their spouses who receive an infertility diagnosis (after 1 year of attempting to conceive naturally).
- Many eligible beneficiaries with an infertility diagnosis may become pregnant through a less expensive treatment, such as IUI, without needing to pursue comprehensive IVF treatment. These less expensive treatments were not included in the model, due to a lack of data about these non-IVF procedures and an effort to avoid over-complicating the analysis.
- The model assumes every eligible couple will take advantage of the full three- year cryopreservation benefit, but some beneficiaries may not choose to use the full duration. Couples that successfully conceive on the first round of IVF, for example, may not choose to preserve unused frozen eggs for three years.
Expanding access to infertility treatment for members of the military is a cost that the US government can – and should – urgently bear. Even before considering the benefits to military retention and diversity, as well as service member morale and wellbeing, $1.6 billion over 10 years is a small sacrifice for the people who everyday risk the ultimate sacrifice by putting themselves in harm’s way for their country.
The American Society for Reproductive Medicine (ASRM) is dedicated to the advancement of the science and practice of reproductive medicine. The Society accomplishes its mission through the pursuit of excellence in evidence-based, life-long education and learning, through the advancement and support of innovative research, through the development and dissemination of the highest ethical and quality standards in patient care, and through advocacy on behalf of physicians and affiliated healthcare providers and their patients.
The Military Family Building Coalition is a non-profit organization committed to supporting military families build the families they want by: educating active duty service members and their families about the current military health care fertility and adoption landscape and helping them navigate their path to a family; educating the American public about this hole in our care and support for military families and what we can do to heal it; seeking out resources for current military families who are seeking treatment, fertility preservation before a deployment or adoption assistance to relieve some of their financial burden; and partnerships with organizations who are pushing for policy change.
The Military Family Building Coalition is a non-profit organization committed to supporting military families build the families they want by: educating active duty service members and their families about the current military health care fertility and adoption landscape and helping them navigate their path to a family; educating the American public about this hole in our care and support for military families and what we can do to heal it; seeking out resources for current military families who are seeking treatment, fertility preservation before a deployment or adoption assistance to relieve some of their financial burden; and partnerships with organizations who are pushing for policy change.
