Could Mammogram Brouhaha Stymie Health Care Reform?

Nov. 21, 2009— -- Opponents of health care reform are coming out against new government panel recommendations to limit breast cancer screenings, saying that this kind of health care cut back could be a sign of things to come if proposed health care legislation is passed.

The new mammography guidelines, released by the U.S. Preventive Services Task Force Monday, suggest fewer mammograms for those 50 and older and no routine mammograms at all for those younger than 50. For those opposed to the health care bill going before the Senate this Saturday, the guidelines have become a rallying cry against comparative effectiveness -- which, simply put, means the comparison of different medical approaches to determine which one delivers the best balance of benefits with the fewest possible downsides.

Critics of health care reform are calling the new measures health care rationing.

"Of course this connects directly to comparative effectiveness and it how it will be used and is being used to limit access to technologies," said Bob Goldberg, vice president of the Center for Medicine in the Public Interest. "Quite a mess. And of course no one has even asked if this exercise saves money or improves health."

"If it were my money and my life at stake, I would forget the committees and the politicians and listen only to the one person who knows me best. My own doctor," said Greg Scandlen, senior fellow and director of the advocacy group Consumers for Health Care Choices.

Most health policy experts agree that the health care rationing rhetoric does not truly reflect what comparative effectiveness is all about. But they worry that such perceptions could sway public opinion against health care reform measures. And now, as the Senate prepares to vote on health care reform today, health care policy experts worry that the controversy could be a new stumbling block for government backers of health care reform -- even though the new recommendations came not from the government per se, but rather from an independent panel.

"This can't be good for the health care reformers, regardless of... whether it bears any relationship to what a comparative effectiveness research operation would do," said Joe White, Luxenberg family professor of public policy, at Case Western Reserve University in Cleveland, Ohio. "The uproar just shows how hard it will be to do anything with a new comparative effectiveness research operation."

Supporters of reform bemoaned the timing of the controversy.

"I think that the timing for releasing these new recommendations was lousy and may well hurt the health care reform efforts," said Jerry Jarvik, director of Comparative Effectiveness, Cost and Outcomes at the University of Washington. "This is not a question of great government involvement, but rather greater involvement by decision makers using the best available evidence."

Could Debate Affect Public Perception of Health Care Reform?

The controversy created by these guidelines is also being used by opponents of the bill to sway public perception of health care reform, experts say.

"There is clearly a view in the U.S. that more care is better care," said Marthe Gold, chair of the department of Community Health and Social Medicine at CUNY. "Now, in the form of breast cancer, the people who do not want fundamental health care reform have been given quite the vehicle."

It is a vehicle, noted Dr. David Orentlicher, co-director of the Hall Center for Law and Health at Indiana University that could serve to polarize those who until this point have been on the fence in the debate.

"Critics of the bills have had some success in mobilizing opposition on the ground that the government should not be making health care decisions," he said. "The revised cancer screening guidelines can easily reinforce the public perception that government will be too quick to compromise patient welfare for budgetary reasons."

Ironically, members of the task force have insisted that cost control had nothing to do with their recommendations -- a point that some outside experts have also cited.

"[They] attempt to balance benefits and harms, not reduce costs [and are] supposed to focus on clinical, not economic value," said Richard Hirth, associate professor of health management at the University of Michigan in Ann Arbor.

"Such evaluations of the risks, costs and benefits of screening... are what medical science and policy analysis does and should do," noted Ted Marmor, professor of public policy and management, at Yale University.

But the notion of cost control has already given rise to worries over health care rationing among some -- a gross misconception, said White.

"The story itself has been badly misunderstood," he said. "The report does not in any sense call for 'rationing' [as some opponents have claimed]...all the report says [is that] physicians should exercise judgment."

But applying cost concerns to the nation's health and wellbeing provokes controversy, Orentlicher says, and "it is very difficult for the public to accept efforts to eliminate the excesses in the U.S. health care system."

Nonetheless, issues of cost cannot be ignored says Dr. Aaron Carroll, director, Center for Health Policy and Professionalism Research at Indiana University:

"We spend about $2.5 trillion a year on health care... and that's simply unsustainable. But if every attempt [to reduce health care spending] is immediately viewed in political terms, then it's hard to imagine how we will ever succeed in containing costs."

Others agree. "In the false world of some politicians, it's okay to trick people into believing that they can have all the health care that any doctor, anywhere, might be willing to provide--and all the care that someone else is willing to pay for," says Alan Sager, director of the health reform program at Boston University.

"Back in the real world, every family knows they have a budget, and wasting money on things we don't need means that we can't afford what we really need."