Who Decides If Breast Tests Are Best?

Patients should make their own choices about mammograms, not bureaucrats.

"The USPSTF [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 last week by the Agency for Healthcare Research and Quality, ignited a firestorm of protest.

"This recent recommendation by the USPSTF 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 up the National Institutes of Health, advised, "I'm saying very powerfully ignore [the new recommendation], because unequivocally this will increase the number of women dying of breast cancer."

The American Cancer Society immediately rejected the federal panel's recommendations: "The American Cancer Society continues to recommend annual screening using mammography and clinical breast examination for all women beginning at age 40." The ACS also pointedly noted, "With its new recommendations, the USPSTF is essentially telling women that mammography at age 40 to 49 saves lives; just not enough of them." A new USA Today poll finds 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 (HHS) Kathleen Sebelius immediately disavowed the federal panel's recommendation, declaring that the USPSTF 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. The HHS secretary simply rejected USPSTF's clinical cost-benefit analysis for mammography in favor of her own political version of 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. Currently, 49 states mandate that health insurers cover routine mammograms between ages 40 and 49. But instead of mandates or potential federal 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. 

And the patient choice principle extends beyond a resolution for the mammogram controversy: One way to encourage consumers to more carefully balance health care risks and benefits would be by allowing them to choose less expensive high-deductible health insurance policies combined with health savings accounts. In such a situation, patients, not politicians, could decide for themselves how much screening tests like mammograms are really worth to them. (By the way, the USPSTF also has 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." Nevertheless, I choose to get a prostate-specific antigen test every year.) For the record, a quick check with the New Choice Health consumer website finds that mammograms in the Washington, DC, area cost between $140 and $340.

Sebelius' ruling is an example of how politics will overtake decisions about what constitutes appropriate medical treatment as the federal government assumes ever greater responsibility in paying for health care. As health care reform legislation moves through Congress, this controversy should encourage the public do some cost-benefit analysis of its own about increased government interference with health care.

Ronald Bailey is Reason's science correspondent. His book Liberation Biology: The Scientific and Moral Case for the Biotech Revolution is available from Prometheus Books.