Let’s switch from statutory interpretation to policy – since, whether Morrissey is right or wrong as to the former, rejecting it as to the latter would call for legal change. I would argue that there is a compelling case for mandatory government-provided insurance coverage for ART for dysfertility, as well as infertility.
This obviously starts from mid-conversation, so far as government-provided health insurance coverage is concerned. I state it as generally as that to extend the sphere past income tax deductions for medical expenses to the realm of Medicare, Medicaid, single-payer, the mandated scope of universal health insurance coverage, etcetera.
I’d put the starting point for the argument as follows. From behind the veil regarding one’s own particular identity within our society, one should recognize that it’s very common to have a very strong desire for a biological child, or as close to it as possible, as a joint project with one’s partner . One should further recognize that, again from behind the veil, one doesn’t know whether one will be one of the people for whom this turns out to be relatively easy – i.e., a fertile heterosexual individual with a fertile heterosexual partner. From this perspective, both infertility and dysfertility are risks – partly converted by modern technology into financial risks, insofar as one can pay a lot of money for workarounds that did not always exist – against which it is rational to want to insure.
But why mandatory government insurance? This requires a market failure that the government can address better than private insurance firms. The most obviously relevant one here is adverse selection – widely recognized now as a key reason for favoring government provision in the healthcare arena, whether it be via the current ramshackle U.S. methods, single payer, or something else. It’s very plausible that the government’s superior ability to address adverse selection with respect to dysfertility – the risk of which gets affected by knowing one’s own sexual orientation and partner preferences – creates a strong enough case to support the intervention.
The other classic issue in government vs. private insurance analyses is moral hazard. Here there is a difference as well. From the perspective of a private insurer, moral hazard is at work if people use ART coverage to do things that they wouldn’t have done if forced to bear the full freight financially. But for the government this is not so clear. To a benign government, it’s not just financial “waste” if motivated prospective parents get to have children with a particular desired relationship to themselves. (Yes, the fate of children in need of adoption is also part of the larger policy picture, but it’s not clear that shutting off other routes to raising a child is part of the optimal response to that.)
2) Beyond dysfertility? – What about ART expenses incurred, say, by heterosexual couples that are neither infertile nor dysfertile? An administrative advantage of not requiring infertility or dysfertility is that one need not demand an inquiry into either when people incurred ART expenses. But this admittedly would come at a fiscal cost that would raise issues of moral hazard, insofar as one thinks these expenses might have been incurred out of a preference for neither going through pregnancy (even when feasible) nor adopting. But I’d be inclined to say the expenses should be covered even without either infertility or dysfertility. Going through pregnancy is a pretty huge thing, with significant potential health costs, impact on one’s career and long-term earnings, etc. But I am leaving aside here questions of whether we are uneasy (e.g., for Handmaid’s Tale-type reasons) about the extent to which surrogacy becomes a go-to. These are certainly beyond the scope of my expertise.
3) Why run ART expenses through section 213? – As a long literature discusses, income tax deductions for medical expenses are a bizarre way to increase overall government health insurance coverage, relative to what it would be if one simply repealed the provision without changing anything else in the legal and policy landscape. Medical deductions come with an adjusted gross-income related deductible, followed by a marginal tax rate-related co-pay, without its being obvious why this form of government insurance is being interacted with the income tax’s general provision of ability insurance / under-diversified human capital insurance.
Even taking the use of section 213 as given, I suppose one might want to treat ART and adoption expenses in the same bucket, although to really do this right one might also want to throw in the marginal healthcare expenses that result from being pregnant, if these could be separately identified. And conceivably one would treat things in this bucket differently than other stuff, just as a well-designed health insurance schemes might vary the deductible, the co-pay, the cap if any on covered outlays, etc., based on the characteristics of particular areas.
4) The paper’s proposed solution – Rather than discussing statutory changes that might directly address ART expenses, the paper proposes modifying section 213 in more general terms, so that it focuses on “inherently medical services” and on allowing taxpayers to “restore or approximate typical human functioning.” This raises further interesting issues, although I won’t explore them here, regarding, for example, the technology-driven rise of “inherently medical” procedures that might allow people to go way above the median (a la the use of human growth hormone by someone of average height who wants to become 6’5″).