Mammograms, Money, and Medical Power Plays

Why should government decide when mammograms are appropriate?

As the health care debate wore on, a tempest flared up when a committee which had been examining the results of decades of examining women's breasts for cancer reported that women were being given too many mammograms.  The New York Times quotation of the day for October 21, 2009 was:

We don't want people to panic. But I'm admitting that American medicine has overpromised when it comes to screening. The advantages to screening have been exaggerated.

- DR. OTIS BRAWLEY, chief medical officer of the American Cancer Society.

Cancer screening had been touted as offering "early detection."  The plausible-sounding idea was that the earlier a cancer could be detected, the more likely it was to be cured.

A side effect of early detection was that the medical establishment could claim that "survival rates" for cancer patients were getting better.  Since "survival" starts when the cancer is first detected, earlier detection starts the clock earlier and makes it seem that cancer research is having positive results even if cancer treatment has no effect at all.

As with many intuitive-sounding ideas, earlier detection doesn't always work as well as people had thought.  One reason is that mammograms expose women's breasts to radiation, the very same radiation that's produced by (gasp) nuclear power plants.  It's suspected that accumulated doses of radiation can make it more likely that a woman will get cancer that she would not have gotten without the mammograms.

On the other hand, the New York Times reports that some cancers grow so slowly that there's no point in detecting them:

... mammograms can find cancers that grow so slowly that they never would be noticed in a woman's lifetime, resulting in unnecessary treatment.

Some would say "waste of money" instead of "unnecessary treatment."  The committee that made the recommendations says that having mammograms every other year cuts the harm from radiation in half without reducing the benefits very much.  The fact that paying for half as many mammograms would save a great deal of money didn't enter their heads, of course.

Ignoring Cancer?

The thought of not treating slow-growing cancers is not new, of course.  Prostate cancers can be divided into two categories, slow and fast.  If a man in his 70's or even 60's has a slow-growing prostate cancer, it's often best just to ignore it because he'll die of something else before the cancer kills him.

However, being encouraged to ignore breast cancers doesn't sit all that well with most women who've been following years and years of articles about "early detection" and "aggressive treatment."

The mammogram controversy, as with just about all issues involved in the health care legislation, boils down to money.  Current medicare rules require Medicare to pay for annual mammograms, but those rules could easily be changed.

All states of the union except for Utah require health insurance programs to pay for annual mammograms for women in their 40s.  The insurance companies, of course, are also required to pay to treat any cancers found by the mammograms, regardless of their speed of growth or the likelihood of their causing problems in the future.

Controversy is Unavoidable

The committee claimed that they'd made the best possible judgment given the available data.  Perhaps they did; but we'll never know, because their conclusions immediately entered the realm of politics.

Republicans claimed that the committee's recommendations would lead to women being denied coverage for mammograms.  Democrats accused Republicans of scaremongering because the recommendations didn't have the force of law.

In this case, the Democrats were being disingenuous.  While their point was true that at this moment - current law does not require that the committee's recommendations take effect immediately - their own pending health-care law gives such recommendations the force of law in the future.  All insurance companies will be required to cover whatever treatments the federal government deems "necessary" and won't have to cover anything else.

To be fair to the committee, any medical study is going to generate controversy because people have become used to someone else paying for medical treatment.  The Times reports that the National Football League has suspended its study of how concussions sustained during a player's active career affect life after retirement.  Concussion is a far simpler condition than breast cancer and the NFL medical records are far more complete - their players are so valuable that they always get first-class medical treatment.

Nonetheless, the NFL was criticized for funding the study because there was no way to eliminate conflict of interest.  Our medical system has become so politicized at all levels that it's not really possible to conduct objective studies anymore - or, even if you did, nobody would ever believe you.

A Lobbyists' Dream

Given most people's reluctance to spend their own money on medical treatment, getting on the list of medical conditions which must be covered by insurance can make or break a medical specialty.  Under current law, lobbyists for each medical specialty have to schmooze individual state legislatures to have their specialty included in the list of medical conditions which must be covered by insurance in that state; somehow, the mammogram industry missed out on Utah.  Under the new law, they can ignore the states and lobby the feds instead, which is a lot easier.

As with most political controversies, it all boils down to money.  Under the new rules, the federal government will decide what's covered and what's not covered.  Bureaucrats are not noted for being able to make subtle judgments; the new rules will tend toward one size fits all.

I have a friend whose daughter became very ill with Lyme disease.  At one point, her symptoms seemed to come back.  Her doctor called the Center for Disease Control and was told, "She's had the treatment.  It works.  Whatever she has now, it isn't Lyme disease."

Under current rules, her doctor was free to ignore the CDC.  He treated her again, and the second time, managed to clear up the disease.  That wouldn't be allowed under the proposed legislation.

I have a friend who doesn't feel pain in his legs.  When he's suffering from a condition that should cause pain, his mind is not conscious of the pain, but the trauma affects his body by causing stress, even leading to hallucinations.

When he had recent leg surgery, his doctors fitted him with all kinds of instruments that measure the effects of pain.  They couldn't ask him how much pain he was feeling and adjust his drug dosage accordingly, they had to look at blood pressure, which spikes when the pain hits, blood composition, and other surrogates for the patient telling them about the pain.

There are very few people who have this unfortunate pain-free existence, perhaps 15,000 in the entire world, so there are no specifically-approved rules for treating them.  His doctor used his general medical knowledge to deduce a potential therapy that, in the event, turned out to be helpful.  Under the new rules, it would not be permitted to monitor him in this way and they'd have to simply guess how many pain killers he needed.

It's All About Power

Medicine is too inexact for bureaucratic rules to apply and most of our legislators know this.  They aren't worried - they're keeping their taxpayer-funded medical program which will give them pretty much anything they want, but the rest of us will have to beg for treatment if we have anything at all unusual.

It's not enough that the Federal government has enough power over highway spending that politicians like Hillary can get campaign contributions from people who want roads routed near shopping centers they own.  Now they want enough power over health care to be able to get campaign contributions from sick people who need treatment.

That's truly sick - in the head and in the heart, but that's their Christmas gift to the nation for 2009.

Will Offensicht is a staff writer for and an internationally published author by a different name.  Read other articles by Will Offensicht or other articles on Bureaucracy.
Reader Comments
I don't believe that private insurance programs would be told by the Feds that they can't provide coverage for a particular need. Which would be why private health care providers could continue to exist.

I don't have any first hand knowledge of the bill to back up my belief but simply find it difficult to believe that they would include language like that in the bill.
January 7, 2010 2:49 PM
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