Recently, while I was having dinner with friends, one asked me about the topic of the book I was writing at the time. I explained that I was focusing on the inequities in our current family-planning program—that government is supportive when low-income families need assistance controlling their fertility, but it offers no support for low-income, infertile couples who want to have children. I told them I thought that needs to change. Those at the table seemed surprised that I would suggest that government should support low-income men and women having children (or more children). They asked what possible justification I could have for recommending such an outlandish idea.
I described health equity as the goal, or purported goal, of U.S. government-sponsored family-planning programs, implying that all social classes should have access to contraception. If we use health equity as our decision rule, it makes sense that we have contraception coverage. However, regarding infertility support, we do not seem to be following that rule. Since the mid-1980s, more and more states have mandated infertility supports for private health insurance, and within these states, coverage has grown over time. On the public side, however, we have not observed any change in this form of coverage. In fact, there is legislation to prevent the use of Medicaid funds for infertility medications. Where there is health equity for infertility support, it occurs in states where neither low-income families nor middle-income families have access through their health insurance.
I explained that if we want health equity across the nation, we must offer infertility services in the 22 states that have private-health-insurance mandates for them. I also mentioned that the Inter-Agency Working Group on Reproductive Health in Crisis and the World Health Organization define family planning to include both options to control and enhance fertility, so we are out of alignment with the goals of some big international institutions. Finally, I explained that if we did not start to publicly provide support for assisted reproductive technologies (ARTs) with genetic testing, then, as expensive fertility technologies advance, only the most affluent Americans will have access to the advantages these technologies generate.
Why do we support contraception but not fertility treatments? Government-sponsored family-planning programs, and more generally all of our population policies, are currently shaped by some of the most insidious thinking of the last two centuries. Even where the policies’ intents are not malicious, they remain shaped by, and limited by, forces of malevolence from earlier eras. The United States does and should continue to legislate to support family planning, but its policies should be reconsidered and designed to increase wantedness.
What do I mean by wantedness? We are better off as a society when all parents have children intentionally—that is, when they think they are ready financially and emotionally, which includes preparing for children prenatally. Wantedness as a goal brings clarity to the design of and proposed changes to our family-planning programs (to all population policies, really). If we used wantedness as a decision rule for family planning, no one would be surprised by my suggestion to add infertility supports.
Many population policies are not well thought out. They are the result of the preferences of leadership at the time they were passed. They are created piecemeal, and we end up with policies that are incomplete, narrow, or contradictory. This haphazard approach to family planning, which was motivated at various times (and with different levels of emphasis) by eugenic or health equity arguments, explains why government-sponsored family-planning programs today focus on limiting fertility, while never considering infertility support. If policies were written around wantedness, it is likely the United States would have a family-planning program that has both a fertility limiting component and a fertility augmenting component. Wantedness is the defining feature that should guide family-planning programs and really any population-oriented policy. Once one moves to the wantedness mindset, offering infertility support seems a lot less unusual.
There are multiple reasons infertility support should be added to our current family planning programs, including creating true health equity, reducing cost barriers, and improving social cohesion. Again, health equity has always been a justification for family planning. In the past, it has largely involved providing the same contraception supplies and services that middle- and high-income women can afford. Today, however, while many affluent women can afford infertility supports, all low-income and most middle-income women cannot.
The United States does and should continue to legislate to support family planning, but its policies should be reconsidered and designed to increase wantedness.
Recently, the government provision of infertility support has made its way onto the political agenda. Shortly after being sworn in as vice president, JD Vance claimed that he wanted to see more babies born in the United States, and pronatalism has been a focal point of the Trump administration. Current data show that about 8.6 percent of women in this country are infertile. In February 2026, the administration launched Trump Rx, which provides access to discounted medications, including several ovulation stimulating drugs. However, as is the case with our existing programs, these medications are not available to low-income people. Individuals must pay cash to receive benefits; those who rely on government-provided health insurance, such as Medicaid, are ineligible. Thus, Trump Rx can help middle-class families with a small portion of their infertility costs; however, low-income men and women are excluded. As was the case in the past, the principle of health equity is not being applied to this new government-sponsored family planning program. If we want to justify contraception provision with health equity arguments, we must also provide infertility treatments to low-income families, making them as available for them as they are for Americans higher in the income distribution.
It is not unreasonable to believe that if someone cannot afford children, the government should help them avoid childbearing. However, there are a large number of people who can afford a child but cannot afford the price of infertility treatments, many of which require large payments upfront. In fact, the initial high costs of infertility treatments, such as IVF, not only prevent low-income Americans from having children, but they also stop many middle-income adults from gaining access as well. In addition, using them does not guarantee success. Many couples who use IVF, for example, have to undergo many cycles before they become pregnant, if they ever do. Asking a potential parent to put up tens of thousands of dollars for a medical procedure with a high likelihood of failure keeps many would-be parents from making the investment. Government support of infertility treatments could help many people overcome this barrier.
In fact, for this reason, I would argue that government should make infertility support universal. Not only would government provision of infertility support create efficiencies that should drive down costs, but doctors would also feel less pressure to produce a pregnancy and could reduce the number of transferred embryos each cycle. Multiple embryo transfers often lead to multiple birth pregnancies, which are associated with poor health outcomes for both mothers and children.
Finally, we should be concerned that lack of access to birth technologies will create greater polarization in the United States. Today, some wealthy families use IVF with preimplantation genetic testing (PGT). PGT reveals genetic anomalies in the embryos, thereby allowing doctors and their patients to implant those with preferable genetic compositions, eliminating the transmission of genetic diseases like Huntington’s, cystic fibrosis, and Tay-Sachs disease. However, these options are cost-prohibitive for the majority of the population. Failure to provide infertility support in our family planning to low- and middle-income families will advantage the children of affluent families even more over time. It will be difficult for those without resources to compete with families that have designed their children to have greater health, an option available today, and potentially other genetic advantages going forward. This difference in access will create more social stratification between the haves and have-nots, further dividing our nation and limiting the opportunities for those who do not have the resources to consider these technological advancements. For all of these reasons, government-supported infertility assistance makes sense in our family planning programs.