What's not being reported about the screening benefit in the Affordable Care Act

One part of the health care law that took effect this week is widely reported as “establishing a menu of preventive procedures, such as colonoscopies, mammograms and cholesterol screening, that must be covered without co-payments.” For example, one of my local papers, the Star Tribune, wrote, “Some people will no longer have to pay for copays, coinsurance or meet their deductibles for preventive care that’s backed up by the best scientific evidence.” (emphasis added)

That phrase should always include a huge asterisk, like the one hung on Roger Maris’ 61st home run. The best scientific evidence according to whom?

Time magazine reports, “Procedures, screenings and tests that are considered ‘preventive’ will be determined by the U.S. Preventive Services Task Force, the Centers for Disease Control (for vaccines) and the Health Resources and Services Administration.”

As written, that is incorrect and inaccurate at worst and misleading at best.

The Associated Press came closer to the truth, reporting: “Of note to women: Those in their 40s and at average risk for breast cancer can get a mammogram every one to two years as part of the free preventive care. That’s in line with American Cancer Society advice. But it’s more generous than the Preventive Services Task Force, which says most women don’t need mammograms in their 40s.” However, the AP fell into the same un-asterisked trap, leading with the line, “New health insurance policies beginning on or after Sept. 23 must cover — without charge — preventive care that’s backed up by the best scientific evidence.”

Don’t forget: independent experts volunteering on the US Preventive Services Task Force last November stated:

“The decision to start regular, biennial screening mammography before the age of 50 years should be an individual one and take patient context into account, including the patient’s values regarding specific benefits and harms.”

The task force’s “Grade C” recommendation means it recommends against routinely providing the service. “There may be considerations that support providing the service in an individual patient. There is at least moderate certainty that the net benefit is small.”

The task force page has a little box at the bottom that reads:

The Department of Health and Human Services, in implementing the Affordable Care Act under the standard it sets out in revised Section 2713(a)(5) of the Public Health Service Act, utilizes the 2002 recommendation on breast cancer screening of the U.S. Preventive Services Task Force.

In other words, the 2009 review was ignored because special interests and politicians didn’t like it. So a review done 7 years prior was used instead because it was more politically acceptable.

This appears to be a clear political concession on the part of the Department of Health & Human Services to people like Senator David Vitter of Louisiana, who boasted on his website:

December 3, 2009
Senate Approves Vitter Breast Cancer Amendment

(Washington, D.C.) – U.S. Sen. David Vitter today announced that the U.S. Senate approved his amendment to the Senate health care bill that would prevent the new United States Preventive Service Task Force recommendations from restricting mammograms for women. In November, the USPSTF released a series of recommendations that stand in stark contrast to common-held cancer prevention practices.

Politics won.

Expert analysis by members of the USPSTF was ignored, disregarded and overruled.

You are free to disagree with the USPSTF. But it is wrong to say that the new law’s recommendations are based on the USPSTF recommendations – without including a line like “based on only some of the USPSTF recommendations” or “based on older USPSTF recommendations in the case of mammography” or “based on the more politically acceptable USPSTF recommendations.”

Some news organizations – and probably many Americans – may still not understand what happened. But there’s an obligation to report the facts – whether you like them or not.

It is particularly ironic that the day before the law’s changes went into effect, a study was published in the New England Journal of Medicine that was reported in the New York Times, for example, under the headline, “Mammograms’ Value in Cancer Fight at Issue.

More evidence.

But the law – driven by politics and special interests – went in a different direction.

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Comments (6)

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Gilles Frydman

September 24, 2010 at 12:38 pm

Thank You, Gary!
Important details that most journalists won’t report adequately, unfortunately.
Like you I payed close attention to the newest study published in NEJM.
Sometimes details end up being very important. It looks at least possible and could easily become probable that routine mammograms are really not even one of the major elements in the better survival of many women diagnosed with breast cancer. If that end up being the case, we will collectively wonder for many, many years why so many women accepted blindly some voodoo science results that impacted negatively both their quality of life and their ultimate ability to understand the real science behind breast cancer treatments.


September 24, 2010 at 12:56 pm

Excellent points. Each individual’s circumstances should be taken into consideration for any such screening. I would also add that calling these “free” is misleading. We are paying for these, just indirectly. If you doubt that, wait until you see your premiums:) Even if the government “pays” it’s our taxes paying for this “free care.”
This type of “free preventive care” is endorsed by people who think it will encourage many more people to actually get the preventive care. We’ll see. The really unhealthy poor will still avoid it.
Preventive care isn’t even the root of the health care cost problem. The problem is the 15% or so of people who are extremely ill and need lots of expensive intervention. More preventative care makes perfect sense, for you, the individual. But it’s not going to lower health care costs overall. It will raise them.
Many of these screening procedures are not without side effects. When we “guarantee” payment for a procedure, it encourages the unscrupulous to start pushing these procedures even on patients for whom they are unsuitable. The result is many tragic stories. A man I know who was at very high risk for stroke died when an eager provider pressed the patient to get a routine colonoscopy for no other reason than “you’re at the right age.” That is an extreme example, but it was a horribly sad incident. The patient was elderly and deaf, and just walked the plank. Exposure to unneeded radiation is a growing problem in America too.
I strongly advise patients to talk with their physicians about what preventive health measure make the most sense for them, individually.
But people don’t want to hear this. All they want to hear is “Someone else will pay for your health care.” right? If we could change that mindset, and make health care “affordable” then we could bring costs down.

SM Fitzgerald

September 28, 2010 at 6:27 pm

Agreed — “free” preventive care is anything but. And I’m getting REALLY tired of Pelosi et al accusing insurers of spreading false information about HCR when her crew is doing such an excellent job of the same.
We won’t be able to reduce costs and improve health until we stop interpreting “preventive” as “procedure” and start thinking of it as diet and lifestyle coaching.
When people — including doctors — are exposed to the real cost of care, they make different decisions. I had insurance with a cap on annual preventive screenings — couldn’t get both a PAP and a mammo in the same year, without paying more out of pocket. So my doctor suggested alternating, since I wasn’t particularly at-risk. Said I didn’t really need them both each year. SO — when was she going to tell me THAT?
As long as we have this “it’s covered” mentality, little will change except premiums will keep going up and we’ll be blaming the wrong party, the one paying our bills.