"A government panel that didn't include cancer specialists says women shouldn't receive mammograms until age 50...If government takes over health care, recommendations like these could become the law for all kinds of diseases."
Americans for Prosperity on Tuesday, March 16th, 2010 in a TV ad
Ad claims if health reform bill passes, government panel could make laws that limit preventive services like mammograms
A new TV ad from Americans for Prosperity, a group opposing the health reform bill, suggests that screening mammograms for women under 50 would be in jeopardy if the bill passes.
The ad, running in 18 key congressional districts through March 18, 2010, features an appeal from breast cancer survivor Tracy Walsh of North Augusta, S.C.
"I was diagnosed with breast cancer when I was 43," Walsh begins. "My mother died of cancer. But early detection saved my life. Now a government panel, that didn't include cancer specialists, says women shouldn't receive mammograms until age 50. That saves money, but could cost your life. If I had followed the new government guidelines on mammograms, my cancer would have spread undetected, and my chances of survival would have been reduced. If government takes over health care, recommendations like these could become the law for all kinds of diseases."
There's an awful lot of misinformation and distortion packed into to these few sentences, and we'll have to take them one at a time.
But first, some background. In November 2009, the U.S. Preventive Services Task Force issued controversial recommendations regarding breast cancer screenings, including one that challenged the long-standing convention that women between the ages of 40 and 50 should get routine mammograms.
Specifically, the task force dropped the need for regular mammography screenings for women between 40 and 50 from a Grade B to a Grade C. Grade B means there is "high certainty that the net benefit is moderate or there is moderate certainty that the net benefit is moderate to substantial" and therefore the screening is recommended. Grade C, however, means that there is "at least moderate certainty that the net benefit is small." As a result, the task force recommended against routinely providing the screening unless "other considerations support the offering or providing the service in an individual patient."
Enter the Senate version of the health care bill (which is largely the working bill for now). It would create a health care exchange for people who do not get their insurance through their employer. Among other intended benefits, it would allow people in the so-called individual market to get group rates. Private health insurance companies that wish to compete for business in the exchange would have to offer a minimum package of coverage described in the bill. And among those minimum standards, they'd have to cover the entire cost of "evidence-based items or services that have in effect a rating of 'A' or 'B' in the current recommendations of the United States Preventive Services Task Force."
That's the underpinning of the argument from Americans for Prosperity.
Now, to unravel some of the distortion.
First and foremost, the task force did not say women shouldn't receive mammograms until age 50.
Diana Petitti, former vice chair of the task force, said the report has been wildly misrepresented on this point.
"The report says that when you hit 40, you should start having conversations with your physician about whether you want to have a mammogram," she said. "There is no reason they shouldn't get a mammogram if they decide to get a mammogram. There is nothing in it that attempts to deny or affect the coverage for mammograms for women aged 40 to 49."
The report found there was insufficient backing to support the idea that routine mammograms should be automatic for all women 40 to 50, but it noted that there were many women for whom they would be appropriate, and that "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."
Among those who should get routine mammograms under 50? Women with a history of cancer in their family, like Walsh, Petitti said.
Dr. Petitti also takes umbrage at Walsh's claim that the panel didn't include cancer specialists. She is the former vice chair of the Institute of Medicine National Cancer Policy Board and vice chair of an Institute of Medicine committee that issued a report, "Beyond Mammography." Dr. Allen Dietrich is director of Population Sciences at an NCI-designated Cancer Center at Dartmouth-Hitchcock medical center. And Dr. Sanford Schwartz has also published on the topic of mammography, she noted. In addition, she said, the recommendations were reviewed by oncologists, including a preventive oncologist, and by radiologists.
The task force was established to provide an "independent voice" and "sound, evidence-based recommendations for preventive services," said Alina Salganicoff, vice president and director of women's health policy at the independent Kaiser Family Foundation.
As for Walsh's comment that not providing mammograms "saves money, but could cost your life," we note that cost-effectiveness was not one of the criteria considered by the task force. It only analyzed the benefits -- early detection of cancer -- against the potential downsides of screening -- mainly stress caused from false-positive test results and the risk of exposure to radiation -- regardless of cost. In short, the panel concluded that based on the evidence, "For biennial screening mammography in women aged 40 to 49 years, there is moderate certainty that the net benefit is small."
Walsh calls the task force recommendation "new government guidelines on mammograms." That's also wrong. The task force is an independent panel convened by the government's Agency for Healthcare Research and Quality. But their recommendations carry an important disclaimer: "Recommendations made by the USPSTF are independent of the U.S. government. They should not be construed as an official position of the Agency for Healthcare Research and Quality or the U.S. Department of Health and Human Services."
In fact, when the task force released its recommendations, Health and Human Services Secretary Kathleen Sebelius promptly issued a press release stating, "There is no question that the U.S. Preventive Services Task Force Recommendations have caused a great deal of confusion and worry among women and their families across this country. I want to address that confusion head on. The U.S. Preventive Task Force is an outside independent panel of doctors and scientists who make recommendations. They do not set federal policy and they don't determine what services are covered by the federal government.
"There has been debate in this country for years about the age at which routine screening mammograms should begin, and how often they should be given. The Task Force has presented some new evidence for consideration, but our policies remain unchanged. Indeed, I would be very surprised if any private insurance company changed its mammography coverage decisions as a result of this action."
Health and Human Services guidelines regarding mammograms did not change. Medicaid still covers the full cost of mammograms for women over 40.
And Sebelius was correct that it did not affect private insurance companies' policies regarding mammography coverage.
"Our providers continue to provide coverage (of breast cancer screenings) when that is a decision reached between the doctor and patient (even when they are under 50)," said Susan Pisano, a spokeswoman for America's Health Insurance Plans.
She said she "doesn't have any reason to believe the health bill is going to change" their policy. "Quite the opposite," Pisano said, "we even do outreach to encourage women to do screenings. We will continue to focus on screenings and prevention. That's something we very much believe in."
But back to the Senate bill.
There are a few other reasons that Walsh's claims about its limits of mammography are misleading. For one, the bill talks about minimum requirements for policies offered on the exchange.
"That's the floor in terms of preventive benefits," said Salganicoff, of Kaiser. "Furthermore, there is nothing that stops anyone from covering diagnostic mammograms for women of any age."
The Senate bill makes it clear that plans may offer services well beyond the minimum requirements, including mammograms or any other services.
"Nothing in this subsection shall be construed to prohibit a plan or issuer from providing coverage for services in addition to those recommended by United States Preventive Services Task Force or to deny coverage for services that are not recommended by such Task Force," the bill states.
And if all that weren't enough, legislators went out of their way to ensure that mammograms for women aged 40 to 50 would be covered.
Sen. Barbara Mikulski, D-Md., added an amendment that requires, when it comes to no-cost preventive services offered to women on the exchange, in addition to the services recommended by the U.S. Preventive Services Task Force, they also must include services "provided for in comprehensive guidelines supported by the Health Resources and Services Administration." And those HHS guidelines say you've got to cover mammograms for women over 40.
Asked in an interview with National Public Radio whether task-force studies like the breast cancer recommendations would be the basis for restricting coverage on the health care exchange, Sebelius said it is the secretary of health and human services — not the advisory panels — who would be have final say on what must be covered.
According to NPR, "Asked whether she would be willing to pledge that as long as she remains secretary of health and human services, she will make sure that every plan offered on the exchange will give coverage for annual mammograms for women over 40, Sebelius responded: 'Well, yes. I think that is an important service. It's a determination that we've made.'"
Sen. David Vitter, R-La., offered an amendment (which passed) that made it even clearer. "For the purposes of this Act, and for the purposes of any other provision of law, the current recommendations of the United States Preventive Service Task Force regarding breast cancer screening, mammography, and prevention shall be considered the most current other than those issued in or around November 2009."
In other words, ignore the November task force ruling altogether.
Phil Kerpen, vice president of policy at Americans for Prosperity (which spent $750,000 on the ad) called that a "temporary fix" and said "if the task force upholds that again in its next recommendations (as expected) that will no longer be operative."
How worried is the American Cancer Society that Kerpen's scenario might lead to insurers not covering mammograms for women under 50? Not at all.
"We're comfortable with the final language and that women 40 and above will continue to have access to mammograms as appropriate," said Stephen Finan, senior director of policy at the American Cancer Society Cancer Action Network.
The HHS guidelines include mammograms for women over 40, he noted, so "as of now, if everything in the plan today was law, women over 40 would continue to be covered by their insurance."
In addition, he noted, 49 states have laws that require mammograms to be covered. The rules vary from state to state, but most require private insurers to pay 100 percent of the cost of mammograms for women over 40.
"The fact is, most group plans today provide it anyway as essential, good preventive service," Finan said. The number of plans that don't cover it is very small, he said, and is relegated to "junk plans."
One last point: Without any context provided, Walsh's comments leave the impression this issue applies to all Americans. It doesn't. As Kerpen confirmed, she's talking only about people who participate in the health insurance exchange, not people who get their insurance through their employer. The independent Congressional Budget Office estimated that if the health bill passes, four out of five people would continue to get their insurance through their employer. Walsh was covered through her husband's employer, so this whole issue doesn't even apply to her.
To review: The task force did not say women shouldn't receive mammograms until age 50. The task force did include experts on cancer screening. It did not factor in cost. The recommendations are not the new government guidelines (in fact, the government guidelines remained the same).
In short, this is a bogus issue. If the bill passes, preventive services recommended by the task force would become the bare minimum insurance companies in the exchange would be required to cover. And with regard to mammograms, specifically, they would be covered for women over 40.
Americans for Prosperity got the wrong messenger. With a mother who died of cancer, Walsh is practically a poster child for the kind of person who the task force believes ought to get a mammogram before 50. And she gets her insurance through her husband's insurance. Nothing in the health care bill would change how she (or the four out of five Americans like her) would have received care through employer insurance. More importantly, Americans for Prosperity seized on an issue -- free mammograms for women between 40 and 50 -- that was specifically taken care of with not one, but two, Senate amendments. We rule this claim Pants on Fire!