How hard would you fight to change a law? What if you’d already had five miscarriages and that law was making it even harder for you to become pregnant?

For one Phoenix woman, the answer is very hard.

Elizabeth Marshall struggles with infertility; her body doesn’t produce enough progesterone — a steroid hormone that is critical to conception and maintenance of pregnancy. Marshall needs progesterone treatment before conception, but as she told the Arizona Capitol Times, her insurance company will only cover treatment after she’s already pregnant. 

This presents her with a catch-22 — without getting the progesterone treatment prior to conception, Marshall has only a 20% chance of carrying a pregnancy to term.

Infertility is categorized as a disease by the World Health Organization and the American Medical Association, but insurers rarely treat it that way and can often deny coverage for infertility treatments.

Arizona is one of 33 states that does not require insurance companies to cover infertility treatment, but Marshall has spent the last three years trying to change that.

About 137,000 Arizonans currently struggle with infertility issues, according to RESOLVE, a national infertility association that has worked with Marshall. And because there is no state law mandating insurers cover fertility treatments, Arizonans are often forced to pay out of pocket for the often prohibitively expensive treatments.

Marshall, an accountant at a small firm in Mesa, worked with her boss to add infertility coverage to her company’s insurance plan but discovered that insurance companies only allow businesses with 100 or more employees to include fertility coverage. Because Marshall and her husband, who works at a Gilbert auto manufacturing company, both work for small businesses, they’re not eligible to receive the coverage.

This meant that Marshall had to pay out of pocket when she decided to undergo a cycle of in vitro fertilization (IVF) — a procedure in which eggs are fertilized outside the womb and then placed into a woman’s uterus. 

In order to pay for her treatment, Marshall and her husband had to forego making a down payment on a house — money they did not get back when Marshall’s IVF treatment ended in a miscarriage. 

And still, Marshall is among the lucky ones who could even afford IVF; the average cost of an IVF cycle in the United States is approximately $23,000, according to the Center for Human Reproduction. Progesterone alone costs about $120 a month, Marshall said. 

The prohibitively high cost of treatment means that roughly 25% of Arizonans affected by infertility cannot afford treatment, according to RESOLVE. The result is that people affected by infertility frequently have to give up on their dreams of having children. 

Marshall is fighting to change that. Working with RESOLVE, Marshall persuaded State Sen. David Bradley (D-Tucson) to sponsor a bill in 2018 to address the issue. 

Bradley’s bill would have required insurers to cover medically necessary tests and procedures for the diagnosis and treatment of infertility. It also would have covered artificial insemination and up to three cycles of IVF.

“I just see this as a right that couples have that if they want to have a child, they should have the opportunity,” Bradley told the Arizona Republic in November 2018.

The bill was opposed by the Center for Arizona Policy, an influential conservative lobbying group and was eventually blocked by Republican leadership in the state legislature. 

Cathi Herrod, President of the Center for Arizona Policy, told the Arizona Republic that she doesn’t think government should dictate what insurance companies should over. “For the government to mandate insurance coverage on IVF is a concern for those who hold a pro-life position,” Herrod said. 

Despite the setback in 2018, Marshall has persisted, and she and Bradley hope to once again introduce their proposal in 2020.

Arizona state law requires anyone introducing legislation that would affect insurance coverage to submit a report detailing the social and financial effects of such a change to the Joint Legislative Audit Committee. Marshall submitted her report and JLAC referred it to the Senate Finance and House Regulatory Affairs committees earlier this month, the Arizona Capitol Times reports. The committees are likely to hold hearings later this fall,

Marshall knows that because Republicans control the legislature, gaining their support will be crucial. She told the Capitol Times that Sen. Heather Carter (R-Cave Creek) and Rep. Regina Cobb (R-Kingman), have been receptive to her plan.

“This is an issue that many families are faced with, and I think we should at least have a conversation about it in the Legislature,” Carter told the Capitol Times.

Marshall and Bradley’s plan would increase premiums by about $1.37 per month, according to the report Marshall submitted. 

Herrod says her group will wait to see the full bill before deciding whether to oppose it again. 

Marshall’s proposal may face long odds, but she remains dedicated to the fight. 

“No one really likes a mandate, but this is the one disease that’s allowed to be discriminated against by insurance,” she told the Capitol Times.

If Marshall succeeds, that discrimination would no longer be allowed, and for the tens of thousands of Arizonans with fertility issues, they could see their dreams of having children renewed.