Health reformers emerged from the darkness of the hallowed congressional committee rooms to pull off a highly celebrated though razor-thin 220-to-215 victory in the House of Representatives last month, bringing transformative change halfway home. But the hastily called Saturday vote took a big bite out of women's hard-won reproductive rights, as they were traded away for some 10 votes deemed essential to the bill's passage. The rules of the new government health insurance exchange, which is slated to provide the uninsured and small-business employees with a wide choice of insurance policies, would now forbid any participating insurer to offer a woman a policy with abortion services (except in dire circumstances like rape or incest) if her premiums are subsidized with even one government penny.
Why should such a fundamental right to choice, won 40 years ago, be singled out, one might ask? The answer: It isn't. The bill takes all sorts of choices out of patients' and doctors' hands. Even mammograms and prostate-specific antigen tests would be similarly restricted by the government for millions of people, and they actually serve as better examples of what happens more broadly to personal medical decision making in the new system.
The ground is being laid already, with the announcement by the U.S. Preventive Services Task Force, a government-appointed body, of new guidelines for mammograms just days ago. Such a board of experts, composed mainly of primary care, prevention, public health, and epidemiology experts, would recommend the list of preventive services covered in the post-health-reform insurance plan that all would have no choice but to buy. Until now, the government's task force has been one voice among several medical groups issuing sometimes conflicting prevention guidelines, leaving room for patient-doctor choice. But in an elevated role under health reform, the federal preventive task force's declarations would carry greater force and have an economic impact on everyone.
Women have been told for years with some unanimity that they should have mammograms faithfully from age 40 on, and they have dutifully responded. The task force now advises women that they can hold off until they turn 50 and be screened just every other year from age 50 to 74, not yearly. The group also withdraws its recommendation for women to have mammograms after 74. Moreover, a woman shouldn't, and neither should a doctor, examine her breasts for lumps or bumps, the task force says; that can lead to unnecessary testing.
No one questions that screening saves women's lives, reducing cancer mortality for women 40 years of age and older. And aggressive screening is a big reason that the United States leads the world—yes, leads—in breast cancer survival. Nor does anyone question the imperfection of screening, given that about 8 percent of women face false readings of possible cancer that lead to repeat studies. About 1 percent of women screened undergo biopsies, with about half of them showing cancer. Going through the false-positive ordeal creates persistent anxiety in a few patients. But the bigger concern is the cost of unnecessary procedures, including treatments of the earliest in situ stage of cancer, which turns into invasive disease in only 10 to 20 percent of women over 10 years.
Too many screens, too many biopsies, and too much unnecessary surgery. This sounds pretty wasteful to some at a time when exploding healthcare costs seem to have trumped cancer as Public Health Enemy No. 1. More vigorously disallowing payments to Medicare and Medicaid for tests not recommended by the government's own task force and using these new guidelines in everyone's mandated benefits package would reap buckets of savings. But at what cost?
With the same facts, there are sharp differences in interpretation. Many health experts and economists in armchairs wearing green eyeshades are willing, say, to accept a 20 percent reduction in cancers found if costs are cut in half. But doctors see before them the mothers and grandmothers, sisters and daughters who benefit from early detection of cancer; they see the husbands who still have their wives, the children who still have their moms. They do know the science and statistics, and they know when to pull back and respect a patient's wishes not to have a study or treatment. But they're all too aware that early therapy is easier and more likely to bring a happier outcome.
And how can those "old" women over 74, who have two to three times the chance of a cancer lurking as do women in their 60s, be categorically dropped as a group worthy of early detection? Forgive me, but it borders on the cruel. Sure, there are some women who don't want to be screened; there are others unlikely to live for five or 10 more years who doctors know will draw no benefit. But these are not the typical 70-somethings we see out and about every day. Cooling off their interest in mammograms, while it may save Medicare a bundle, might not serve them well. It wasn't so long ago, in the era before cancer screening, when older women pretty regularly showed up in the emergency room with oozing, fungating masses on their breast, and bones and brains riddled with cancer. I still have visions of such a time from my early years in medical training. Just as vividly, I remember the desperate young women butchered by back-alley abortionists before women won their reproductive freedom.
But loss of personal choice is not an issue for women only. Look at PSAs. As the pioneering prostate cancer surgeon Patrick Walsh of Johns Hopkins points out, a European randomized trial showed that PSAs saved lives. In the United States, there has been a 40 percent reduction in prostate cancer deaths since testing began in the early 1990s. Yet prostate screening arouses many of the same concerns as does breast cancer screening: too many follow-on studies, too many biopsies, and surgery on slow-growing tumors that may never have harmed the patient. The government task force claims that there's insufficient evidence to make a recommendation for routine screening of men younger than 75 and is firmly against screening in men older than that. The American Urological Association's position is the polar opposite: Baseline PSAs should be offered to men at age 40, and the frequency of subsequent testing should be determined by doctor and patient choice.
With all the disparagements of screening, Walsh worries about the future for men who would have benefited by early attention. "Who is going to be their advocate?" he asks. As things are going, doctors might be losing the ability to play that role—a healthcare transformation that to me would be a tragedy.
[Related slide show: 11 Screening Tests You Should (and Shouldn't) Consider]