The politics of healthcare funding

Since Quebec first offered tax credits for in vitro fertilization (IVF) in 2000, the use of public funds to pay for IVF treatments has been political and controversial in Canada. Over the last two decades, amongst much political debate, both Ontario and Quebec have established—then cut—then established again—programs to support IVF. Only recently, the topic was brought up by Alberta’s governing Conservative party, who are facing a May election, when Premier Danielle Smith said she wanted to open up the discussion on funding IVF. The ongoing debate around IVF funding has some arguing that public funds should not be used to pay for treatments that are seen as a lifestyle choice, while others say that infertility is a medical condition that should be treated. Some are concerned that public funding of IVF treatments could lead to parents having more children than they can afford. Others point out that eligibility for public funding of IVF is usually conditional on the practice of single embryo transfer, which reduces costly high-risk multiple births. Plus, funding IVF can also help address health equity concerns, as it ensures access to the treatment is not determined by a patient’s ability to pay. Dr. Alykhan Abdulla sees the issue through a lens of funding for the greatest good. “The benefit-to-cost ratio is low for IVF. Socialized medicine should support the largest number of Canadians with the limited number of resources that are available,” said Dr. Abdulla, an FP in Manotick, Ont., and member of the Ontario Medical Foundation board. “Why are we investing in expensive low-yield procedures? Should we not invest our limited resources on lower-cost high-yield procedures instead?” Dr. Ginevra Mills, a reproductive endocrinologist based in Victoria, says infertility is a medical diagnosis just like any other. “So it seems a little bit exclusive in our universal healthcare system to have a medical condition for which a treatment is not available,” she said. Funding and costs The cost of one IVF cycle is between $10,000 and $15,000, and according to the Canadian Fertility and Andrology Society, in 2018, (the latest year for which data is available), 16,852 IVF cycles were performed. Out of those cycles, there were 2,438 pregnancies. Seven provinces offer financial assistance for infertility treatments, including IVF, IUI and medications. British Columbia, Alberta, Saskatchewan and the territories do not provide coverage. Manitoba and Nova Scotia provide a tax credit equal to 40% of the cost up to $20,000 annually, with N.S. this year extending that to surrogacy services. Ontario and Quebec cover the cost of one IVF cycle for women up to age 42 and 41, respectively. Prince Edward Island offers reimbursement of up to $10,000 based on family income. Newfoundland and Labrador provides a $5,000 per cycle up to three times. New Brunswick offers a one-time grant of 50% of costs up to $5,000. Dr. Mills says she thinks the lack of funding is unfair to those facing infertility. “There are a lot of reasons people can’t get pregnant. We talk about age-related fertility decline, but that’s not the only realm. You could say, ‘Oh, well people have delayed childbearing, they waited too long. That’s not a public health problem.’ A lot of people with endometriosis can’t get pregnant. Somebody who’s got scarring in their tubes because they had a ruptured appendix when they were eight years old and now can’t get pregnant—this is a medical diagnosis, completely out of the control of the patient.” At least half of Dr. Mills’ IVF patients have some private insurance for IVF, but many of the others struggle given the lack of funding in B.C. “Most of my patients who don’t do IVF don’t do it for financial reasons and they end up doing other treatments that are less effective and less likely to be successful. Usually, it’s intrauterine insemination. The outcomes of that are either there’s not a huge increase in pregnancy rate or they’re significantly increasing the risk of multiple pregnancies. Up to 30% or more of people will have twins or possibly triplets, high-risk pregnancies or pre-term babies that end up needing long stays in ICU, stressing the healthcare system in another way. And this is all because patients are trying to grasp straws and trying to find ways to get pregnant within their means.” Dr. John Crosby, a family physician in Cambridge, Ont., said that while he is sympathetic to individuals facing infertility, “It really is a first-world problem. There are so many things lacking funding. We have 12-hour waits in emergency, a shortage of nurses who are not getting raises. Dieticians and social workers and psychologists are not covered. There are needs ahead of IVF.” There are many other services also ahead of IVF, said Dr. Abdulla. “We have not optimized primary care services for basic needs like a family doctor for all, dental care, affordable medications, reducing obesity, improving health literacy and self-care, improving physical fitness, optimizing vaccinations, ensuring safe drinking water, and ensuring access to food, housing, mental health supports and other services. It costs $10,000 to try for a child (with IVF). How much preventative care services can you get for that $10,000?” Dr. Mills says that while she respects that opinion, “there are a lot of inefficiencies in the healthcare system and there are a lot of places where potentially we could look at tightening up or defunding things that in my opinion might not be as important or things that have existed for a long time and now don’t make sense.” Dr. Mills acknowledges that IVF is, by necessity, a very expensive process. “The reason it’s so expensive is because of the embryology lab. We’re talking about millions of dollars’ worth of equipment and scientists trained to do some really complicated procedures. If we don’t have a good embryology lab, it’s sort of a waste of money. You’re not doing patients any favours.” Dr. Mills goes even further to say that where there is provincial funding, it is often inadequate and doesn’t allow for the fact that some cycles do not work. “We know that healthcare, in general, is chronically underfunded and doctors in general are pretty under-compensated for what they do. And so if the government says, ‘OK, we’re going to fund IVF but our version of funding IVF is we’re going to pay up to $15,000 per patient per cycle.’ It’s not a one-size-fits-all situation and funding one cycle per person is not always ideal.”

The politics of healthcare funding

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