Opening the Screening Door
Slatewriters and editors discuss whether new cancer-screening guidelines should be considered a harbinger of health care rationing.
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.
Saletan: I don't think screening is what the cost-containment advocates are talking about when they talk about preventive care. But to the extent they do (presumably to exploit women and families with cancer), this is a good opportunity to kick them in the ass.
Larimore: I think it's fascinating that we're figuring out that there are cancers that won't progress, and I liked the "XX Factor" post saying we need a Pap-like test for breast cancer. (At least until they start rationing those! Kidding.) But until we know more and until there are better tests, it feels like we're reducing our best methods for preventative care without anything to replace them.
Emily Bazelon: But the thing is, these aren't our best methods. That's what the evidence-based findings show. They're just the methods we're used to. And the reason the federal task force was taken by surprise is that politics isn't what it was designed for when it was set up back in 1984.
Hanna Rosin: If you were going just by the science, you would do a lot less screening. Mammograms are a perfect example. The mammogram's utility should be judged by how well it prevents deaths in a large population. Instead, we judge it by how accurately it picks up cancer in one individual. The former would, in fact, be an argument for rationing. The latter leads everyone to want a mammogram, though it is irrational and unhelpful. Ditto for prostate screenings.
Bosch: The problem is bridging the divide between the push for science-based medicine and the way patients are encouraged to be their own advocates—from marking your thigh with a Sharpie before surgery to ensure the surgeon amputates the correct leg to questioning the medication dosages your doctor prescribes. We've backed away from the idea that every doctor is omniscient, but we seem to have gone too far in the other direction. The patient-as-advocate model is also what's partially responsible for "adjusted" vaccination schedules, overprescribing antibiotics, etc. The shift in power has thrown things off-kilter.
Bazelon: Why do many women seem susceptible to the fear-mongering? Why is it hard to see that the costs of overscreening can outweigh the benefits of early detection? These recommendations ask us to give up a couple of myths we hold dear. The first is that saving one life is worth any amount of trouble or money. "One life out of 1,904 to be saved," Sen. Kay Bailey Hutchison said of the stats about getting mammograms in your 40s. Right, and the point should be, that's not much bang for the buck. But what if it's your life, your bang? We seem frozen on that question, unable to have the deeper discussion that should follow from it.
The second myth we've grown attached to is that more tests and screenings equal more control. If you get regular mammograms and Pap smears, then you're protecting yourself. It's a kind of talisman: You won't get cancer, or at least you won't die of it. Cut it out early and fast! Now we have to absorb the idea that some slow-growing cancers are better left alone. We have to let go of the illusion that testing guarantees wellness and confront the far less reassuring reality that false positives lead to unnecessary interventions that can hurt us—biopsies and radiation treatment and removal of relatively harmless growths. Remember the adage that the cure can be worse than the disease? It's unsettling. But also true.
Saletan: Well said. Cost control means some people will die, and medicine without cost control is financially unsustainable. Palin is just playing to Americans' age-old denial of this reality.
Dickerson: There's not a lot of cost containment that comes from preventative care in the bills we're talking about. The Congressional Budget Office scores preventative measures as costing money, I believe. So there aren't claims being made about the power of preventive care to save big money. When Obama talks about preventive care, he's talking about how it's better to have an annual checkup to find out that you have diabetes than waiting until you're so sick you have to go to the emergency room.
In terms of prevention, he also lists mammogram screening—not because he's got a particular jones about the science but because his plan tries to give people access to whatever the basic set of preventive measures are as an act of fairness. If those measures change over time, fine. That's the whole point of comparative effectiveness, the other thing that the president talks about and that critics immediately claim is rationing. Presumably, if doctors decided that what was once considered preventive is now expensive and full of false positives and bad health outcomes, a well-functioning comparative-effectiveness system would spread the word so that doctors could make intelligent decisions with their patients based on the latest research. This comparative-effectiveness scheme would guard against a mindless mantra in favor of or against preventive measures and base decisions on actual studies, ultimately leaving the decision to the doctor and patient. Critics, of course, claim that spreading information about studies immediately equals rationing.
And here comes the White House on this topic.
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