Who Decides if Breast Tests Are Best?

Patients, not bureaucrats, should make choices about mammograms.


The United States Preventive Services Task Force "recommends against routine screening mammography in women aged 40 to 49 years." This simple statement, published on the website of the U.S. Department of Health and Human Services by the Agency for Healthcare Research and Quality, ignited a firestorm of protest in November.

"This recent recommendation…is dangerous because it suggests that women lay down their best weapon in the fight against breast cancer, which is early detection," declared Janelle Hall, founder of the National Breast Cancer Foundation. Bernadine Healy, the first woman to head the National Institutes of Health, urged women to ignore the new recommendation, "because unequivocally this will increase the number of women dying of breast cancer." The American Cancer Society (ACS) immediately announced that it "continues to recommend annual screening using mammography and clinical breast examination for all women beginning at age 40."

The ACS also pointedly stated that the task force "is essentially telling women that mammography at age 40 to 49 saves lives; just not enough of them." A USA Today poll found that 76 percent of women say they disagree or strongly disagree with the panel's recommendation. In the face of the public anger, a rattled Health and Human Services Secretary Kathleen Sebelius disavowed the federal panel's recommendation, declaring that the task force does "not set federal policy and they don't determine what services are covered by the federal government."

Thank goodness that someone stepped in to stop federally appointed experts and bureaucrats from making health care policy and deciding which patients will get what treatments, right? Actually, no. A federal bureaucrat, namely Sebelius, did decide which patients will get what treatments. She simply rejected the panel's clinical cost-benefit analysis for mammography in favor of her own political cost-benefit analysis.

The fury and confusion among competing bureaucrats over the new mammogram recommendations is a timely reminder that the proper person to make medical treatment cost-benefit decisions is the patient. Forty-nine states mandate that insurers cover routine mammograms between ages 40 and 49. But instead of mandates and instead of potential regulations limiting access to mammography, why not let women choose for themselves? If a woman is comfortable with the new recommendations, she should be able to buy a less expensive health insurance policy that does not cover annual mammograms. If she believes that routine mammograms will give her greater peace of mind, she should have the choice to purchase a policy with more extensive and expensive coverage.

The patient choice principle extends beyond the mammogram controversy. One way to encourage consumers to more carefully balance health care risks and benefits would be to allow them to choose less expensive high-deductible insurance policies combined with health savings accounts. In such a situation, patients, not politicians, could decide for themselves how much screening tests such as mammograms are really worth to them. (By the way, the task force also concluded that "the current evidence is insufficient to assess the balance of benefits and harms of prostate cancer screening in men younger than age 75." I nevertheless choose to get a prostate-specific antigen test every year.) A quick check with the New Choice Health consumer website finds that mammograms in the Washington, D.C., area cost between $140 and $340.

Sebelius' ruling shows how politics overtakes decisions about what constitutes appropriate medical treatment as the government assumes ever greater responsibility to pay for health care. As Washington debates sweeping changes to American medicine, the controversy should encourage us to do some cost-benefit analysis of our own about increased government interference with our health.