The Controversy About Insurance Coverage for Breast Cancer Screening

By Sondra Forsyth

On January 11^th 2016, the United States Preventive Services Task Force (USPSTF) published what were called “final” recommendations on screening for breast cancer.” The recommendation statement, which is published in Annals of Internal Medicine, is made up of several recommendations addressing different age groups and screening methods, and is accompanied by an editorial on how its findings converge with guidelines from other organizations. A release from the American College of Physicians reiterated earlier recommendations that we reported here on thirdAge.com on October 20^th 2015:

• Women ages 50 to 74 should be screened regularly.
• For women in their 40s, the Task Force found that mammography screening every two years can also be effective and recommends that the decision to start screening should be an individual one, taking into account a woman’s health history, preferences, and how she values the potential benefits and harms.
• Women in their 40s who have a mother, sister, or daughter with breast cancer may benefit more than average-risk women by beginning screening before age 50.
• The Task Force concluded that evidence is insufficient to determine the balance of benefits and harms in three important areas: the benefits and harms of screening women age 75 and older; adjunctive screening in women with dense breasts; and the effectiveness of 3-D mammography for the detection of breast cancer.
• Due to this lack of evidence, the Task Force is unable to make a recommendation for or against these services. The Task Force strongly encourages additional research in these areas and notes that women should speak to their doctors to determine what is best for their individual needs.

That said, the release goes on to emphasize that “it’s important to note that the Task Force does not make recommendations for or against insurance coverage; coverage decisions are the responsibility of payers, regulators and legislators. Legislators recently extended a guarantee that women who have private insurance, beginning at age 40, will not have a co-pay for their screening mammogram. The role and mission of the Task Force is to provide all people with the best available information about the current science of prevention to empower them to make informed decisions about their health and health care.”

However, on January 19^th 2016 Georgetown professors issued a release saying that Congress made “scientific judgment for which it is distinctly unqualified.” The professors contend that a section of the recently passed Congressional spending bill effectively undermines science and the health of women. Their JAMA Viewpoint, “A Public Health Framework for Screening Mammography: Evidence-Based Versus Politically Mandated Care,” was published online.

A release from Georgetown states that at issue is the FY 2016 Consolidated Appropriations Act (H.R. 2019), passed in December, in which Congress requires private insurers to follow “outdated scientific guidance” for breast cancer screening coverage, say Lawrence O. Gostin, JD, and Kenneth Lin, MD, MPH.

The professors remind us that on January 11th 2016, after a rigorous review of scientific evidence, “the U.S. Preventive Services Task Force recommended, as it did in 2009, mammography screening every other year for average-risk women beginning at age 50. There was no screening recommendation for women younger than 50. In 2002, the Task Force had recommended screening every one to two years beginning at 40.”

The release goes on to say that under the Affordable Care Act, private insurers are required to follow the recommendations of the Task Force, which is comprised of independent, volunteer experts. However, language in the recent spending bill overrides the ACA by directing insurers to follow the 2002 recommendations for mammography screening.

The release quotes Gostin, Georgetown University Law Professor and faculty director of its O’Neill Institute for National and Global Health Law, as saying, “The Task Force reviewed thousands of research studies over the past decade. Yet legislators with no medical or scientific education decided that the rigorous work carried out by the Task Force was all wrong, and that they have better advice for women. Congress is sowing public distrust in the integrity of science.”

The release also quotes Lin, a family medicine physician at Georgetown University School of Medicine and an expert on cancer screening in the primary care setting, as saying, “By insisting on referring to the 2002 recommendations, Congress is in fact making a scientific judgment. This action strikes at the Task Force’s credibility by saying it was right 2002, but was wrong in 2009 and is wrong now.”

Prior to the ACA, insurers had discretion to determine what screening, counseling and vaccinations to cover. Under the ACA, insurers provide cost-free access to preventive services based on modern evidence of effectiveness, as determined by groups such as the Task Force.

But when Congress required insurance coverage to link to “outdated public health guidance, it was making a scientific judgment for which it is distinctly unqualified,” Lin and Gostin write.

“The public’s health is best served when women’s personal decisions about screening are informed by evidence rather than political considerations,” they write. “Rather than benefiting women, political interference with science can discourage shared decision-making, increase harms from screening, and foster public doubt about the value and integrity of science.”