This week, the U.S. Preventive Services Task Force recommended that most women begin regular mammograms starting at age 50 instead of 40. Days later, the American College of Obstetricians and Gynecologists revised its guidelines on cervical cancer screening: Now it suggests women receive their first Pap smears later than previously recommended and, depending on certain risk factors, get them less frequently. The move to reduce unnecessary screening has some critics of health care reform suggesting that America is moving headlong toward rationing care. In a Facebook notetoday, Sarah Palin wrote, "We need to carefully watch this debate as it coincides with Capitol Hill's debate and determine whether we are witnessing the early stages of that rationed care before the Senate bill is rushed through as well." After chief political correspondent John Dickerson sent Palin's note around, Slate staffers began debating what, exactly, rationing is; the value of screening; and the relationship between patients and the medical community. An edited transcript of the discussion is below.
Daniel Engber: This is crazy. What incentive would the American College of Obstetricians and Gynecologists—or any other doctors' group—have for controlling costs? Healthy women go to the doctor more often than healthy men, so there's a gender-weighted market for unnecessary screening procedures.
John Dickerson: Another thing here that's obvious but seems newish is that Palin and the rest of the conservative base making these claims about rationing are turning everyday debate in the medical community over care into signs that rationing is inevitable. Any finding that suggests more treatment might not be great or a certain kind of treatment might not be great = rationing. This seems rather powerful (and potentially pernicious). It hooks up people's general view that medical advice is always shifting and unknowable, which is merely irritating, and turns it into a government-fueled plot to deny them health and, ultimately, their lives.
Palin's Facebook posting echoed from an e-mail I just received from a conservative organization:
Health care rationing getting less subtle almost by the day. Now ACOG recommendations for less frequent pap smears on the heels of the HHS recommendations on mammograms that got breast cancer advocates up in arms. This is all straight out of the UK rationing playbook. In the UK, no mammograms until age 50, and as for pap smears here's CPR's vignette with Katie Brickell who asked Britain's National Health Service for a pap smear at 19, was told to come back at 20, came back and was told the minimum age had been changed to 25, and then she contracted cervical cancer. Interviewer is former CNN anchor Gene Randall:
This seems ripe for one of you who actually knows about science and medicine and facts and stuff.
William Saletan: It's the mirror image of the Democratic rants about HMOs and evil insurers. Everybody wants cheap health care without cost controls.
Rachael Larimore: How did the task force possibly not think this was going to happen? It's an organization whose guidelines are often followed by Medicare and insurers. In the middle of a huge national debate about the role government plays in health care, it comes out with guidelines that almost mirror the British NHS, which has been a favorite target of Conservatives for Patients' Rights and other health care skeptics. How is that not going to be seen as rationing?
Torie Bosch: It was a no-win situation. Had they sat on this until after the health care reform dust settled to make the announcement, the task-force members would have been accused of letting politics influence their recommendations.
Engber: A main selling point for reform is that preventive care = better care = lower costs. Now we've got this screening stuff, which breaks the equation both ways: preventive care = worse outcomes = higher costs.
Emily Yoffe: For years there has been a growing chorus that it's a mistake to go looking aggressively for cancers. Spiral CT scans for smokers were supposed to be the way to find lung cancer tumors early, before they became deadly. It turns out when you do mass screening for lung cancer, you find lots more tumors, but given the actual incidence of lung cancer deaths, it turns out the technology picks up tumors that would never progress. This isn't just "anxiety"—this is finding real cancer that you then have to treat but that you probably should not have looked for. That's why it's too bad this mammogram recommendation will be so politicized when we really need rational, thorough discussion and analysis of how much screening is a good idea. The Republicans have turned this into the harbinger of British-style health care rationing. But Obama has been touting the "preventive care" mantra—so now he's stuck. Witness the administration cave on the task-force mammogram recommendations.
Engber: Forget screening—shouldn't we be having a rational discussion of whether Obama's "preventive care" mantra makes any sense? If it's bullshit, then reform will be a lot more expensive than we've been led to believe.
Yoffe: Why forget screening? Isn't that a major part of preventive care? Taking out screening, what's meant by preventive care? Annual checkups? Everyone on cholesterol medication? Lectures about diet and exercise? I agree we need a discussion of what these things are and whether they're effective.