The Biden-Harris Administration Must Treat Fertility Treatment as a Matter of Reproductive Choice

President Biden and Vice President Harris have a rare opportunity to unite the newly Democratic House and Senate to expand health care access, including revisiting the ACA and Medicaid. Here’s what that might mean for people affected by infertility in the U.S.— the “would-be” mothers.

The Biden-Harris Administration Must Treat Fertility Treatment as a Matter of Reproductive Choice
The March for Science in Portland, Maine, in April 2017. (Paul VanDerWerf / Flickr)

This article is about health care access, infertility, President Biden, and the big business of fertility preservation and IVF in the United States.

But first, a disclaimer:

In December 2018, I was diagnosed with Hodgkin’s lymphoma. It took a month of testing, prodding and scanning to confirm, but a biopsy finally revealed that stealthy stalker—cancer. I was 24 and in my first semester of graduate school.

Days later, I met my oncologists. I nodded robotically as we discussed treatment, survival rates, chemotherapy, nausea, hair loss. Then my oncologists caught me off guard: Did I want to freeze my eggs?

Between 20-70 percent of those undergoing cancer treatment experience infertility, yet only a handful of states mandate that health insurance companies cover the exorbitant fees for in vitro fertilization (IVF). Many of these mandates do not apply to those with cancer or other chronic illnesses. The Affordable Care Act (ACA), despite expanding access to health care, also fails to mandate fertility coverage federally.

Those faced with the harrowing decision to pay out of pocket for fertility treatment—especially transgender folk, queer folk, the chronically ill and Black women, who are at greater risk of infertility—can experience severe physical, emotional and psychological harm as a result.

My oncologists told me that I could undergo precautionary egg preservation. Yet my health insurance company, unsurprisingly, did not insure egg freezing, so I would have to pay the $12,000 sticker price up front. I had nowhere near $12,000 to spend, but with the immense privilege of family and community financial support, I decided to go through with the procedure.

After one month of injecting myself with hormones and feet in stirrups, I was able to harvest 35 eggs before chemotherapy—my own insurance policy on motherhood. Unfortunately, even with a generous subsidy from the Livestrong Foundation, that “insurance policy” cost $5,000 plus a shocking $1,000 annual storage fee—in fine print, of course.

Eggs on Ice: An Opportunity for Equitable and Affordable Fertility Treatment

Fast forward to 2021, and the U.S. has entered a historic political transition. I am in remission but still pay for my eggs. I read news articles applauding President Biden for appointing women and people of color to his Cabinet, and I dare to think: Could this be the moment to bring fertility to the forefront?

Of course, being a woman does not feminist policies make. Much has, for example, been made in public debate about Supreme Court Justice Amy Coney Barrett’s status as a mother, but she has remained cryptically quiet and hard to read on the issue of California v. Texas (the current Supreme Court case seeking to repeal the ACA) and her confirmation sounded the alarm on the future of Roe v. Wade. The American Society for Reproductive Medicine uncharacteristically warned that a Barrett confirmation could put fertility treatment in “peril.”

But President Biden’s “Agenda for Women” has set a promising tone on health care issues that would appear to genuinely back up his record-shattering Cabinet. It promises to build on the ACA, “tackle maternal mortality,” expand contraception. Equitable health care access is listed as a top priority, drawing an important link between challenges too often considered separately—gender, poverty, and health care. In a 2019 Democratic debate, Vice President Harris echoed this tone, defending Roe and celebrating choice.

Yet “equitable health care” goes far beyond abortion and contraception. It goes beyond affordable health insurance for women. A health care “Agenda for Women” must also include fertility treatment—a too-often ignored reproductive issue—as a matter of women’s choice and agency.  

Motherhood Will Cost You: The ACA, Medicaid and Fertility

IVF and fertility preservation are big business, mostly supporting (and advertising to) white, wealthy, middle-class women. This is why feminists must be clear that advocating for affordable fertility is as much a reproductive issue as a social equity issue. The path to motherhood for many low-income women, queer women, Black women, the chronically ill, and myriad other would-be mothers is far from clear. Expanding the ACA and providing more affordable health care options to women is one way to ease the burden of fertility treatment.

How? The ACA is not a perfect policy, but it was what I needed when I sat in the chemotherapy chair for the first time, hooked to a tangle of IV lines. It allowed me to remain on my family insurance and maintain some financial flexibility to shell out for fertility treatment. It is a step—albeit an imperfect step—in the right direction for would-be mothers. By making health care less expensive, it allows women a bit more fertility freedom. But just a bit.

Federally mandating the ACA and Medicaid to cover fertility treatment is one vessel for President Biden to more dramatically expand women’s access. Understanding the obstacles to fertility treatment for Black women and LGBTQI+ folks highlights the opportunity at hand.  

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Understanding the Racial Impact

Expanding affordable access to fertility is a racial justice issue. Sixty-five percent of white women facing infertility seek IVF, compared to 44 percent of Black women and 39 percent of uninsured women. This is rooted in “class-based ideas” about who “deserves” motherhood.  Health care providers routinely discourage poor, often Black, women from having children at all. They have done so while also sidelining low-income women for whom “intensive mothering” in the style of the do-it-all “supermom” may remain out of reach.

The U.S. health care industry has historically compelled Black women, as Mikki Kendall writes in the excellent Hood Feminism, to “put their reproductive capacities into the service of their wealthier sisters” while also sanctioning forced sterilization. If that is not enough, some medical conditions to which Black women are more prone—such as obesity—can increase their likelihood of infertility. This has posed additional barriers to Black women having children on their own terms.

As the Biden-Harris administration has already recognized, Black women are also statistically more likely to die in childbirth than white women. The majority of these deaths could be prevented by expanding the ACA, Medicaid, and social programs such as fair housing. Racialized views of family planning and Black fertility are nothing new. Yet that does not make cheapening Black motherhood less harmful. Black women must be able decide what motherhood looks like for them—where, when, and how. Affordable fertility treatment is an essential piece of that puzzle.  

Fertility and Choice: LGBTQI+ Communities

It is also crucial to acknowledge the effect that “big fertility” may have on LGBTQI+ people.

In 1998, the Women’s Health and Cancer Act mandated insurance coverage for breast reconstruction for breast cancer survivors. Yet no such law has been passed for fertility preservation for those facing cancer or other medical challenges. This begs the question: Why insure breasts and not eggs? Fear of setting a precedent for queer folks offers one potential answer.

Fertility remains a challenge for same-sex couples seeking IVF and for transgender folk undergoing transition. The gender-affirming hormones that some transgender folks take in order to transition can cause infertility. Under President Obama, Section 1557 of the ACA prohibited discrimination based on gender identity and sex stereotyping. Donald Trump has since eliminated this definition, severely curtailing rights for transgender people.

It goes without saying that President Biden must reverse President Trump’s elimination of Section 1557 immediately, and his “Agenda for Women” protects gender confirmation surgery. Yet he should also consider how expanding affordable fertility preservation is a human rights issue for transgender folks and those facing cancer. No one should have to choose between infertility or a critical medical procedure. By enshrining insurance coverage for elective fertility preservation—whether through the ACA, Medicaid, or a broad federal mandate—no one would have to.

A Call for Solidarity, A Call to Action

The Biden-Harris Administration Must Treat Fertility Treatment as a Matter of Reproductive Choice
“I read news articles applauding President Biden for appointing women and people of color to his Cabinet, and I dare to think: Could this be the moment to bring fertility to the forefront?” (@kamalaharris / Instagram)

Have President Biden and Vice President Harris made the connection between choice, health care access, fertility and motherhood? It is impossible to say with certainty. Yet there is no doubt that the current big business of fertility treatment has a gatekeeping effect. This gatekeeping suggests, however implicitly, that some mothers are fit to thrive and some to die—some to choose childbirth, and some to be denied that choice because they cannot access affordable fertility treatments. The politics of motherhood and family planning are grounded in racialized, homophobic fear, threatening a diverse group of would-be mothers. The Biden-Harris administration has an opportunity to recognize and rectify this, by treating fertility treatment as a matter of reproductive choice.

As his first 100 days in office begin, President Biden has an unprecedented opportunity to make expanding access to affordable fertility treatment a cornerstone issue in the “Women’s Agenda.” Ensuring fertility treatment for all would-be mothers—regardless of race, sexuality or pre-existing condition—must become a pillar of U.S. health care policy. Would-be mothers, it is time to stand together and make our stories known. I, for one, hold on to the hope that more equitable family planning policies will follow.

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Madison Chapman recently graduated with her Master of Arts at The Fletcher School of Law and Diplomacy at Tufts University. She researches gender and forced migration, with a focus on how cash-based humanitarian aid can help protect refugee women. Her work in Latin America with The Journeys Project has highlighted the role of gender and identity in transnational migration. She has worked both in the non-profit world and in the U.S. Department of Justice, where she was a paralegal on a major health insurance merger case. She is also a proud young adult cancer survivor. She received her undergraduate degree, Phi Beta Kappa, from the University of California, Berkeley. You can learn more about her on LinkedIn or Instagram, and email her at