Archive for July, 2012

ObamaCare and Mammography – October 2013 Update – Bad News and Good News

July 23, 2012

Note :  This is a popular, but long post.  If you just want to know whether ObamaCare allows mammograms for women over 40, the answer is “Yes,” for now, provided your Doctor agrees.  I urge you to talk to your Doctor soon about this – it may save your life.  This post tells the story of how women’s access to mammography has been saved by staring down a disastrous ObamaCare decision… a decision that, despite being discredited by experts, has still resulted in 54,000 fewer mammograms per year among women between 40 and 49 years of age!  My source?  No less than the Mayo Clinic – you can read about their study here orst/6958.html  or here (a survivor’s report on the Mayo study)


In November, 2009, an obscure Government-appointed panel, the USPSTF (United States Preventive Services Task Force), did what it had been doing for many years – it evaluated a diagnostic procedure and classified it.  The unusual aspect of this decision, was that this time a new bill, the Affordable Care Act (ACA), also referred to as “ObamaCare,” would, upon enactment, specifically give this USPSTF decision the force of law in determining insurance coverage for all Americans.

The procedure evaluated by USPSTF was mammography for the detection of breast cancer.  In its decision, the USPSTF now classified a mammogram as a “Class C” procedure for any woman between 40 and 49 years of age.  Under section 2713 of the ACA,  only Class A and Class B procedures were required to be covered by public or private insurance.  A “Class C” rating meant that insurers could legally “co-pay” mammograms out of reach for hundreds of thousands of women.   With this one bureaucratic ruling, the USPSTF had provided a frightening glimpse of just how ObamaCare could empower and transform an obscure panel of experts effectively into a “death panel.”

How much death?  Senator Barbara Mikulski estimated the toll at 40% of women in this age group who have breast cancer, reflecting the overall reduction in mortality since regular mammograms became common practice.  A more modest estimate by the Health Resources and Services Administration (HRSA)  is that mammography, by itself, is responsible for about a 10% reduction in mortality from breast cancer.  Since the number of women 40-49 currently getting mammograms is estimated at around 800,000, this would still amount to potentially hundreds of dead women per year, every year!

Update – October 2013: These previous estimates of mortality due to lack of screening may be underestimates.  In a new study “…71 percent of the (breast cancer) deaths were among women who had never had a mammogram or it had been more than two years since their last screening. The study found half the deaths were women younger than 50 …” This study has caused a new furor amongst the mammogram “deniers” because it indicates a higher death rate among younger women who were not screened than was previously suspected. You can read about this study in a recent Chicago Tribune story (click here). 

Inside the beltway, panicky lawmakers were blindsided by this double system failure because most hadn’t even read section 2713, or heard of the USPSTF! This was a double system failure because firstly, too much authority was concentrated in one small, isolated group that has no specific expertise in the area being classified, and because, secondly, there were no downstream safeguards built into the system to monitor impacts and overturn a bad decision.

Many tried to portray this major system failure as a minor bureaucratic glitch that had no impact. On television, Secretary Sebelius tried to whitewash the problem saying that the USPSTF decision would not change policy (later on, she would discover that DHHS was already bound to this decision!) In December, 2009,  in an effort to reassure shaky  ObamaCare supporters, Senator Mikulski proposed an amendment to void the USPSTF ruling, and guarantee that women would receive all necessary health procedures.

Although it passed, this amendment did nothing to change the bureaucratic paradigm and reasoning employed by the USPSTF, or their unchecked authority under the ACA.  The amended wording of section 2713, voiding the USPSTF decision, is vague, referring only to decisions reached “in or around November 2009,”  thus avoiding any admission that any mistake had been made.   Also, the amendment validates the sole authority of the USPSTF to set these criteria, merely reinstating by default the most recent previous USPSTF decision from 2002.  Any lessons learned? Evidently not.

Unfortunately, this time-specific voiding leaves open the possibility that USPSTF could revisit mammography in the future, and, once again, restrict women’s access to this procedure in a new decision.  Because no systematic safeguards have been added, such as a requirement to show equivalence to recommendations from other recognized expert groups (such as ACOG, ACR etc.), or a requirement to forge consensus recommendations with such groups. or a requirement for true experts to sit on the USPSTF panel, or a requirement to maintain vigilance over outcomes after issuing a new guideline, etc. etc.  it is quite likely that a future USPSTF panel would  reach the same disastrous conclusion as that reached in November, 2009, with the same disastrous results!  Only the next time, politicians may not be so eager to “fix” a bad decision. By then, the ACA will be firmly in place, and totally unpopular anyway, so there will probably be no fevered rush to try to get public opinion in favor of  the program like there was at the end of 2009.

Please understand, the USPSTF has never admitted any mistake in their analysis or conclusion regarding mammography, despite the Mikulski Amendment and attendant outrage.  Early on, the American College of Radiology (ACR) called on USPSTF to rescind their decision.  They never have.  Incredibly, many true believers and Government health care advocates still defend the USPSTF methodology and conclusion on this issue!  Today, you can go on the internet and find these “expert” apologists claiming that mammography is ineffective, too costly, and even dangerous.

One academically prestigious site I visited, gleefully proclaimed that mammograms were no longer the gold standard and could, in fact,  increase the risk of cancer in women under 50.  The induced cancer rate for digital mammography was estimated at 1 in 100,000.  However, the risk of not testing is estimated by some HMOs as one death  per 2000 mammograms not performed.  I’ll do the math for you – the risk of getting cancer from a mammogram may be about 50 times less than  the risk of undetected cancer due to not getting a mammogram!

These advocates of Government health care are counting on you not knowing this, and there are hordes of them out there.  Please pay attention to this folks – this is the hallmark of Government-mandated health care – the Bureaucracy has never, ever, ever made a mistake.  If ObamaCare persists, all such failures of the system will be denied and/or covered up by the expertocracy.

What is the motivation for all this deception and misuse of science, when reliable information of the real value of mammograms is readily available right at the Health Resources and Services Administration (HRSA) website and many, many other sources?  The late Dr. Bernadine Healy (former head of NIH) shed some light on the possible motivation for these mammography “deniers” in her excellent commentary on the USPSTF guideline.  Dr. Healy wrote that the USPSTF diminished mammography screening program of 2009 would accomplish “…roughly 80 percent of the survival benefits of the intensive program in exchange for an estimated 50 percent of the costs.”  So, basically, ObamaCare was prepared to sacrifice about one in five survivors for the sake of saving money (actually redistributing it to other patients deemed more worthy).  I believe mammography “deniers” are trying to confuse the Public so they will not reach Dr. Healy’s grim dollars and cents conclusion.  After all, if they can convince you that mammography is ineffective,  then you will think that no survivors will be lost if we don’t provide mammograms.

The “Bad News” (very bad indeed) is that the bureaucracy’s failure to rescind the USPSTF decision and come out forcefully, and quickly, in favor of annual mammograms, may already have affected Public Health, perhaps even costing lives.  The Mayo Clinic believed that the USPSTF decision, and the confusion it caused among doctors and patients, could have depressed mammography rates among women between 40 and 49, and so they performed a study.  Sure enough, the preliminary results of the Mayo study, released on June 26, 2012, indicate that mammography rates have indeed declined by about 6% in this age group subsequent to the USPSTF decision.  This amounts to about 54,000 fewer mammograms per year in this age group, despite the ObamaCare amendment that was supposed to ensure access.  You can read about the Mayo Clinic study here or

Further update – October 2013: Another study has found a decline in mammography rates among older women. This study was reported by Dr. David Levin at a meeting of the Radiological Society of North America. Using Medicare data, Dr. Levin found a decline in mammograms of over 4% in 2010 – the year after the USPSTF guideline was issued. The data seems compelling because, in the four previous years, a consistent increase of about 1% per year was observed. The 4% decline effectively wipes out all the previous progress and puts the mammography rate back at 2005 levels. You can read about this study in this story (click here).

So an outlier position, taken by a task force of contract bureaucrats who are not experts in this field, has still managed to reach out, long after having been discredited, and put a large number of women at risk.  Some of these women will die unneccessarily as a result of the confusion caused by this decision.  Is this the real “War on Women,” soon to be the “War on Patients?”  Is this the shape of ObamaCare to come- endless bureaucratic decsions made in ivory towers having devastating consequences on patients’ lives out there in the real world?  Decisions that are difficult to overturn and which are endlessly defended by entrenched bureaucrats and their fans?  After 100 years of trying to fix ObamaCare, will we wind up with a system that isn’t nearly as good as what we originally had, but which is tremendously more expensive?

Because of the Government refusal to take responsibilty and admit to what was a truly disastrous failure, we have had to look to official pronouncements by various independent medical organizations to counteract the damage caused by USPSTF.  Hopefully, if enough organizations with enough credentials contradict the USPSTF decision, mammography rates will return to normal, and the USPSTF will be unwilling to face the firestorm of criticism that would result if they imposed further restrictions on mammograms.

The first good news came in March 2010, when Senator David Vitter, and others in Congress, complained to the Department of Health and Human Services (DHHS) that their website still posted the 2009 Guidelines, causing confusion to doctors and patients.   The problem was that the ACA was not yet in effect, therefore amended section 2713 was not yet applicable, and the 2009 USPSTF decision was not yet voided!  Roused out of her “this won’t affect policy” denial, Secretary Sebelius tasked DHHS to develop and publish its rationale for departing from the new USPSTF guideline. In September 2010, DHHS finally, formally adopted the National Cancer Institute (NCI) guidelines and the previous USPSTF guidelines from 2002. This reversion to the old guidelines means that, currently, until further notice, women over forty are covered for a mammogram if their physicians approve of the  procedure.  

Sensing the precarious state of  mammography coverage, the “real” experts began to weigh in.   In 2011, the American College of Obstetrics and Gynecology (ACOG), in a position endorsed by the American College of Radiology (ACR), contradicted the USPSTF decision, and issued a recommendation for annual mammograms after age 40.  Additional good news has continued in 2012 with the American Medical Association (AMA) formal policy announcement of June 19, 2012, that women over the age of 40 should receive annual mammograms, if agreed to by their doctors.  This strong position was accompanied by a statement urging insurers to factor in annual mammograms for women 40-49 into their coverage.  Smackdown, USPSTF!! AMA goes over the heads of the bureaucrats and directly tells insurers to ignore USPSTF and pay up! The AMA policy statement was endorsed by the ACR, and other imaging groups.

According to Dr. Van Moore, a radiologist who testified to the AMA delegates, the 2009 USPSTF  decision to not cover mammograms for women less than 50 years old was reached in a bureaucratic vacuum. “None of the recognized experts in the field were contacted, to the best of our knowledge,”  Van Moore stated.

Unfortunately, that policy is exactly intentional.  The USPSTF intentionally had no oncologists on the panel reaching this decision! The thinking of many true believers in Government health care is that specialists cannot be trusted to impartially rule on areas in which they are experts.  Since the principal  goal of ObamaCare is to rein in Government expenditures, specialists are an enemy because A) they tend to favor using health care resources for their own specialty and B) they tend to favor expensive interventions  (procedures and tests aimed at root causes) rather than palliative and relatively cheap “pill medicine.” So, unless drastic changes are made, the USPSTF will continue to avoid including appropriate specialists on any panel classifying a preventive procedure.

This bureaucratic monster is still on the prowl, make no mistake.  In the last year, USPSTF has ruled that routine PSA screening to detect prostate cancer in men, should not be covered.  So far, Secretary Sebelius has done nothing to soften this decision.

In 2012, the USPSTF has also continued its ‘war on women’ by classifying various screening tests and procedures as not covered by ObamaCare.  The USPSTF would now deny women access to chlamydia testing, HPV testing, cervical cancer screening( for women over 65), and digital mammography screening.  Denial of digital mammography screening shows how cost-driven ObamaCare is since digital mammograms are more effective at detecting agressive cancers and produce significantly lower doses of x-rays than film mammograms thus reducing the risk of causing cancer with the screening.  The only reason to not cover digital mammography is cost.  Read more about these denials of women’s access to routine procedures in this New York Post article: ObamaCare v. Women

I have been warning folks about the rationing structure built into ObamaCare long before the Democratic Party coined the term “War on Women,”  but incredibly, the Public seems to have forgotten (or never understood in the first place) the nightmare scenario ObamaCare created regarding women’s access to mammograms.   We seem to be in denial of the possibility that our Government might purposely seek to deny access to health care resources for millions of Americans in order to reallocate those resources to more “worthy” uses under some grand bureaucratic scheme. This denial carries great risks for our society as we move forward toward the future.  Unless we learn from this example, I fear we are doomed to many more bureaucratic health care disasters, because they are effectively hardwired into the ObamaCare patchwork of arbitrary boards and rules.

Senator Mikulski, Senator Vitter, ACOG, ACR, and now the AMA deserve our thanks because they have saved the lives of thousands of women, but the underlying problem still remains – it is the wrong-headed notion that isolated, task-focused, Government expertocracies are wiser than a dynamic, interconnected medical community that is based on centuries of science, and custom, and ethics.

Unfortunately, this notion undergirds all of ObamaCare, and is written into many sections besides section 2713.   It is a monster that is only waiting for another ill-informed decision by USPSTF, or some other bureaucratic entity, to spring off the page and into your doctor’s office!  And there will be no Senator there with you in the office to nullify the decision – you will face this monster alone…

The only effective way to stop this monster is to proactively repeal ObamaCare and replace it with something centered around patients and doctors – NOT BUREAUCRATS!!!

the Sceptic


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