The Government's New Recommendations for Breast Cancer Screening, Part 2:
Bipartisan complaints with ironic consequences
21 Nov 2009 in Regulatory Economics, Regulatory Policy
The US Preventive Services Task Force recommendation that women without any risk factors for breast cancer obtain mammograms less frequently has elicited furious complaints by both Republican and Democratic Members of Congress. We blogged on the report when it was released.
Among Republicans, those quoted appear to be unified in opposition. From Associated Press writer Laurie Kellman:
Republicans are seizing on this week's recommendations for fewer Pap smears and mammograms to fuel concern about government-rationed medical care -- and to try to chip away support by women for President Barack Obama's proposed health care overhaul.
"This is how rationing starts," declared Jon Kyl of Arizona, the party's second-in-command in the Senate, during a news conference. "This is what we're going to expect in the future."
Said Sen. Lisa Murkowski of Alaska: "Those recommendations will be used by the insurance companies as they make a determination as to what they're going to cover."
From Stephanie Condon of CBS News:
"This is how rationing begins. This is the little toe in the edge of the water," said Rep. Marsha Blackburn (R-Tenn.) at a press conference on Capitol Hill. "This is when you start getting a bureaucrat between you and your physician. This is what we have warned about."
...
Rep. Candice Miller (R-Mich.) called the recommendations "a huge step backward" that puts the nation on a "slippery slope" to discouraging screening for other diseases based on cost rather than medical need. The Democratic health care plan would particularly encourage this, the lawmakers said.
"Women in particular may lose a great deal of clout in decision making," said Rep. Michele Bachmann (R-Minn.). "We don't know how far government will go in this bureaucracy."
Republicans, Bachmann said, "want to empower women... We want to have all the data on the table so individuals can make the best decision they can."
In contrast, Democrats are divided. Condon reports that some have defended the Task Force report, saying that it empowers patients:
To rebut the Republican criticisms, Democratic Rep. Rosa DeLauro (Conn.) released a statement saying that the task force recommendations do just that -- give women more information with which to make decisions.
"If we can cut through the Republicans' political gamesmanship on this issue, the new breast cancer recommendations, as always, were an attempt to put the best possible evidence in the hands of women and their doctors, so they can assess their own risk and benefit," DeLauro said.
Kellman also quotes Democrats also saying that health effectiveness research of this type would not empower the government as health care gatekeeper:
Senate Finance Committee Chairman Max Baucus said the Senate health care bill he authored "doesn't do one single thing to change current law related to the way coverage decisions are made."
"Those decisions will be based only on science and thorough review, just as they are today," said Baucus, D-Mont. "Research comparing the effectiveness of different treatments for different patients cannot be used for rationing care."
The White House also denies that research such as this Task Force report could be used as Republicans claim:
"Under health insurance reform, recommendations like these cannot be used to dictate coverage," said presidential spokesman Reid Cherlin.
But other Democrats dislike the Task Force report. Kellman writes:
Democrats said the recommendations had nothing to do with the big health care bill. And besides, they said, the recommendations, especially one that women start mammograms at 50 rather than 40, were deeply flawed.
"It's entirely possible that this panel got it wrong, and I think they did," said Illinois Sen. Dick Durbin, the vote-counting Democratic whip. Fears that the government is going to run health care have not come up during negotiations for Saturday's crucial procedural vote, Durbin added.
Claims that the government would not (or could not) use health effectiveness research to make coverage decisions are inconsistent with the legislative text. Both the House-passed bill and Senate majority leader Harry Reid's amalgam bill include extensive provisions for health effectiveness research. They do not include language prohibiting CMS or the proposed new Health Choices Commissioner from deciding the conditions under which insurance would cover mammography.
This gives Republicans an additional, and analytically more accurate, line of attack. Condon writes:
Rep. Jean Schmidt (R-Ohio) said today that she feared health insurance companies would change their policies. Furthermore, she said, she feared that such studies would be used to set policy in the national health insurance exchange that would be set up and run by HHS if Democrats are able to pass their health care bill.
"The rules of what will be required to go into the exchange have yet to be written," Schmidt pointed out. The nonpartisan Congressional Budget Office has estimated about 30 million Americans could receive their coverage through the exchange.
And on this point, Democrats are not united. Sen. Barbara Mikulski (MD) "said she would introduce an amendment that would limit the costs of the breast cancer tests for women 40 and older." If the Republicans are wrong and health effectiveness research such as this Task Force report could not lead to rationing, there would be no need for such an amendment.
Complaints on both sides are mostly instrumental, by which we mean that they have less to do with the quality of the Task Force report than with how it can be used as leverage for other purposes. The report and its recommendations are caught up in the polarized debate over health care legislation. Soon, if not already, its medical value may be destroyed by this politicization.
There are strange ironies at work. Republicans allege that the report is part of a plan to ration health care (almost certainly false) and that proposed legislation would lead to more health effectiveness analysis that the government would use to ration care (almost certainly true).
Democrats deny that the Task Force's recommendations are politically motivated (almost certainly true) but that they are technically incorrect (highly unlikely to be true) and, in any case, would never be used to ration care (almost certainly false).
Perhaps the greatest irony of all is that this incident exposes in stark relief how controversial health effectiveness research likely would be if it is enacted in legislation, and thus how politically difficult in practice it would be for the government to actually use it to ration care. As we noted in our first post, the Task Force's procedures required it to base its recommendations on tallying benefits from early detection and subtracting costs of misdiagnosis -- all from the perspective of patients, not the government or private insurers.
Neither the House nor the Senate bill restricts the research methodology this way, and that would make health effectiveness research extraordinarily more controversial.
