In a classic example of good intentions crowding out judicious reasoning, President Clinton is on the verge of requiring Medicare, Medicaid, and federal employee health insurance programs to pay for mammograms for women aged 40 to 49. Currently such coverage is limited to women over 50, and following the President’s lead, the 46 states that now require health insurance to pay for mammograms in women over 50 will surely extend that mandate to women in their forties.
As health care policy, these are moves in the wrong direction. Mandates that insurance pay for routine medical services change insurance from a system that spreads the costs of unexpected serious injuries and illnesses over a large population to a prepayment scheme for routine medical services. Heaping those mandates one on top of another with their hefty administrative costs drives up health insurance premiums, pricing insurance beyond the financial reach of some small companies and their workers.
As health care policy, the mandate is bad enough. But it is even more outrageous because politics has obscured the reality that the medical community has serious misgivings about the value of mammograms for women in their forties.
In the last few months, three expert groups have issued three different opinions about the desirability of mammograms for women age 40 to 49. The woman’s age is important because breast tissue changes with age. Although mammography fails to detect only about 10 percent of serious cancers in women over fifty, it misses about 25 percent of such cancers in younger women. Some experts warn that these "false negative" results can cause women and their physicians to ignore lumps detected through manual exams.
Moreover, the National Cancer Institute estimates that 3 women out of every 10 who have annual mammograms in their forties will have at least one "false positive" result that indicates the presence of a tumor when there is none. Every false positive has to be investigated by more tests, biopsies, or surgery with the attendant anxiety, pain, and costs.
While mammograms can detect cancer, mammography has little or no measurable effect on death rates from breast cancer in women 40 to 49. In the absence of data showing any positive effect of screening women in their forties and considering the monetary costs of that screening as well as the emotional stress associated with false positives, in January the NIH Consensus Panel did not recommend mammograms for women in their forties.
The second recommendation came early last week from the independent American Cancer Society. The ACS recommendation that all women in their forties have annual mammograms caused little reaction except for some comments that it differed from NIH’s.
The National Cancer Institute released the third recommendation on March 27. NCI recommended mammograms for women in their forties, but at one- and two-year-intervals because of the questionable benefits of annual tests. The NCI recommendation raised questions about the role of politics in mammography policy, triggered a White House press conference, and unleashed demands for insurance coverage.
Did politics play a role in the change between the NIH recommendation against screening in January and the NCI recommendation for it in March? It depends on who you ask. NCI Director Dr. Richard Klausner said the institute had received pressure from all directions. The chairperson of the NCI panel, Dr. Barbara K. Rimer of Duke University, said that the panelists had received a handful of letters from Congress and advocacy groups, but that they "stepped back and looked at the science." Senator Arlen Specter (R-Penn.), responding to reports that he threatened to have Dr. Klausner removed if he did not move quickly on the mammogram issue, said, "I did not say Dr. Klausner ought to resign or be replaced, but I did raise a question about whether they are using their funds properly." Coming from the chairman of the subcommittee that oversees NCI’s funding, Senator Specter’s question could have been very weighty.
While medical experts may be uncertain about the benefits of mammography, Secretary of Health and Human Services Donna Shalala is not. Appearing at the White House news conference to announce the NCI recommendation, she said, "Years of confusion have been replaced by a clear, consistent, scientific recommendation for [mammography tests for] women between the ages of 40 and 49." Her conclusion brushed aside Dr. Klausner’s observation that different groups of scientists had interpreted the data differently. Why does Shalala need a scientist-physician, such as Dr. Klausner, to head NCI when she can rely upon her own scientific acumen?
President Clinton, at the same news conference, went beyond NCI’s recommendation. He announced that he would work to make sure that Medicare, Medicaid, and federal employee health plans pay for annual mammograms. The displacement of science by politics was complete, and increases in taxes and insurance premiums are on their way.
Given the bipartisan support for screening women in their forties, pity the insurance company president who decides not to pay for such tests in exchange for offering lower premiums. Democrats and Republicans in Congress will race to CNN to grandstand about how the company is depriving women of a life-saving test. States will almost certainly mandate coverage, and if President Clinton succeeds in making federal employee health plans pay for the tests, companies that don’t offer that coverage will cut themselves off from that market.
Currently, a woman in her forties and her physician can weigh the possible benefits of a mammogram against the risks of a false positive and consider whether the test is worth the cost. If politics produces the expected mandates, the possible benefits and risks will still have to be weighed with a small difference--the tests will be "free"--except for higher taxes and insurance premiums.