Title : The REFRAME Index: A composite policy framework for evaluating fertility care access and reproductive health equity in the United States
Abstract:
Our poster presentation will discuss how inequities in U.S. fertility-care access have been compounded by growing state-level divergence in reproductive health governance following the 2022 Dobbs v. Jackson Women's Health Organization decision. Following Dobbs, insurance regulation, eligibility standards, publicly financed coverage, reproductive legal risk, and the geographic distribution of fertility services vary substantially across states, with consequences for historically underserved populations already facing barriers to care. Despite this multifaceted nature of fertility-care access, recent evaluations have relied almost entirely on whether a state has enacted an insurance mandate. Such comparisons offer an incomplete account of the factors that shape access to care. To address this gap, the MIT Health Equity Research Group developed the REFRAME Index (Reproductive Equity Framework for Resource Access Mapping & Evaluation), a multidimensional state-comparison framework grounded in Reproductive Justice and Universal IVF Justice that evaluates how coverage, affordability, legal context, and access infrastructure collectively shape fertility-care access. To build it, we’ve conducted a comparative, cross-sectional policy analysis across ten significant states representing variation in the framework's four evaluated domains: fertility coverage and eligibility, public coverage and affordability, legal risk, and access infrastructure. The framework followed composite-indicator principles for theory-based indicator selection, normalization, weighting, aggregation, and robustness assessment. Evidence was drawn through public statutes, regulations, regulator guidance, payer policies, legal materials, and fertility-clinic access sources using standardized coding and source-verification. Indicators include IVF-mandate scope, inclusivity of infertility definitions and family-formation eligibility, ERISA-limited mandate reach, public insurance coverage, fetal/embryonic personhood risk, and fertility-clinic distribution. At the Global Public Health conference, we plan to present the initial ten-state application results. Thus far, comprehensive mandates are associated with lower ART discontinuation, higher IVF utilization, fewer embryos transferred, and lower multiple-birth risk, but mandate states still vary substantially in scope, eligibility, implementation specificity, and realized access. This divergence is illustrated by Massachusetts and Louisiana: Massachusetts is consistently recognized as a comprehensive IVF-mandate state, while Louisiana mandates only fertility-preservation coverage for iatrogenic infertility. Yet both received the same Medicaid score, because Massachusetts Medicaid covers only diagnostic infertility services, as does the non-mandate state Louisiana. Additionally, we’ve discovered that access differs because state mandates do not reach many self-funded employer plans and often exclude publicly insured populations, leaving low-income patients under covered. Furthermore, restrictive reproductive policy environments increase travel and cost burdens. Geographic and social barriers further stratify access, especially for BIPOC and LGBTQ+ populations. Our presentation also identifies statutory ambiguity, rapidly changing legal conditions, and incomplete public reporting in restrictive states as sources of evidentiary uncertainty requiring documentation and adjudication. In conclusion, the presentation will showcase the novel REFRAME Index, which provides a transparent, multidimensional standard for comparing state fertility-care environments beyond mandate status alone. By integrating coverage design, public affordability, legal context, and access infrastructure, the initial ten-state application supports reproductive health equity research, policy surveillance, and future scaling to all 50 states while remaining centred on populations most affected by structural exclusion.
