Rationed health care, when it comes, will not come all at once. It will creep in stealthily, measure by measure. At first few will object.
Because at first, a charismatic politician will tell us of blue pills that work better than red pills costing twice as much.
Then, a government sponsored panel of experts – none of them oncologists – will tell us that mammograms for women in the 40-50 year old cohort simply don’t save enough lives to justify the “false positive” rate. Because under the previous recommendation to start screenings at age 40, only two in one thousand women discovered that they had breast cancer.
(According to US Census Bureau statistics for 2008, the 40-50 year old female population in this country is 22,346,000. If all of those women received mammograms every year, the number of “true positives” would be 44,692. That’s about ten times the number of soldiers who have died fighting the nations wars since 2001.
Every year.)
Predictably, medical insurance companies – while they last – will remove red pills from their schedule of treatments, and in time mammograms may no longer be insured for women under 50. In their defense, insurance companies may point to the recommendations of government empaneled health care experts. This will save money that would have otherwise been reimbursed for screenings, which are not terribly expensive, and for cancer treatments for those 44,692 women whose lives might have been saved by early detection.
Cancer treatments are very expensive.
The new guidelines will help to “bend the cost curve” of medical care, which we all have agreed is a public good.
It will all be cool, rational and analytic. The best science will back it up. Of course, many more women may die than otherwise would have done, which would be a shame.
But over time the system will be much fairer, much more egalitarian. And this will help the president reduce the budget deficit.
All those women would have eventually died in any case.
I hear ya. My ex- had breast cancer at age 44. It was caught early enough that she survived and is a seven-year survivor as of this writing…
Forgot to add my daughter-in-law: diagnosed at age 39. Also a survivor.
Lex,
I suppose you have a good point there:
“All those women would have eventually died in any case.”
And you’re pretty well backed up by a quote from John Maynard Keynes when he said:
“In the long run, we’re all dead.”
In so far as both quotes are factual as far as I can determine, perhaps the current administration’s perception is that as our time is limited, why should we waste so much of it at the doctor’s office, getting tests, squandering it on (ultimately) futile treatments, etc.?
No doubt a wonderful side benefit will be that funds otherwise consumed by health care can be put to far better use organizing communities, repaying the world for the horrible things our nation has done, or providing bonuses to ‘investment’ bankers.
My maternal grandmother died of breast cancer at age 47 a few years before I was born. I’d have liked to have gotten to know her, but I doubt there was much practical treatment back in the late 1930s. As the administration would likely point out, you can’t miss what you don’t know. I disagree.
Very interesting take Lex. Brings to mind the image of the frog in boiling water, except here we’re talking about our mothers and grandmothers.
Another little issue the new guidelines neglect to consider is that pre-menopausal breast cancer tends to be the more aggressive kind. My mother didn’t catch it early. Thirteen operations and three years later, she succumbed at age 43, leaving 3 small children and a devastated husband behind.
Part way through her treatment, the insurance company dropped her coverage. Her hospital bill was over half a million dollars by the time she died (1965 dollars). The hospital threatened that they could have us kids taken away from my father if he didn’t pay the bill. I won’t go into all the details, but suffice it to say that a gun and a very kind nurse kept that from happening.
Regular mammograms weren’t recommended back then. Would she have survived if they had been? It’s hard to say, but the relative cost would seem to make a pretty compelling case for the $1,000 a year cost.
You just made a great argument for public health insurance.
Hardly. Fast forward Kate’s situation to today under public health insurance. She may well have been refused any treatment at all given the aggressive nature of the cancer – palliative care only. Bringing about her death much sooner and leaving 3 even younger children behind.
It’s working out pretty well for English cancer patients.
On the contrary, Alos, she just made a great argument for having a gun.
Because, you see, when denied coverage by the New Improved government employee what are you going to do? You can’t sue them. Maybe you can organize a candlelight vigil or perhaps write a letter to your Congressman which will be opened by an intern, read by a staffer, and responded to with a form letter! Now *that’s* being aggressive!
With a private insurer I can argue, I can appeal, I can sue and eventually I can walk into the office of the SOB who denied a claim and we can hash it out.
Try getting to meet your local congressman with a complaint. You’ll die of old age before that happens.
On the plus side, for you at least, unless you pay taxes you’re getting an unearned benefit. So you have that going for you. Which is nice.
– Max
Yeah, and by the time you get through appealing, suing and eventually walking into the SOB’s office … something tells me that chances are good you won’t still be standing. Or breathing.
A gun and a kind nurse? Kate, you can’t leave us hanging like that!
Lex you are spot on. And of course the recommendation re mammograms was also no mammograms for ladies over 75. Grandma is going to die anyway and breast cancer takes a few years to kill etc. Even if they find a cancerous tumor in a lady aged 77, why she might die of heart failure at age 80, and the cancer wouldn’t have killed her until 82.
The British commission that makes these rationing choices for the National Health Service goes by the acronym “NICE”. One of their ways to evaluate whether treatment is “worth” giving is to look at the “quality adjusted years of life” versus cost. If you look at it that way, denying mammograms to 40 year old women is particularly stupid. If you catch it and prevent it in a 42 year old woman, she’ll likely live on for another 40 years.
But the reality is that health care rationing will be upon us no matter what happens. You’ve got “Y” pot of dollars to take care of “X” number of people. You can increase the size of the pot, but ultimately you run up against limits. I accept the idea and necessity of rationing. What I don’t accept is the hypocritical blather emanating from the cave of winds on Capitol Hill and from 1600 Pennsylvanis. Lying bloviation is never fun to see or hear.
Yes, get ready for reduced quality at higher costs.
That’s not the worst of it.
You can bet your bottom dollar that your health care priority will depend on your political affiliation…and how much you contributed to your Congressgangster’s reelection fund.
This is tinfoil hat stuff.
Prove it.
Alos/ Tinfoil hat stuff???? I suppose it t’was the merest of coincidences that under the Chrysler bailout the vast majority of dealerships ordered closed by the government (yes the Govt via the appointed panel) were those who had contributed heavily to Republicans–even tho many were far more profitable and financially sound than most of those allowed to remain in business, most of whom-mirabeau dictu–just happened to be big contributors to the Donkey Party. Naw, couldn’t be–just my fevered imagination.
Mike: Where do you find that info? To be honest, I have a hard time believing you. Since my Congressgangster gets $0.00 from me, my access health care will be restricted? How do you figure?
Well, jpr, why don’t you check out Solzhenitsyn’s account of the wonderful healthcare he received as a dissident under the benevolent state-run system of the Union of Soviet SOCIALIST Republics.
You’re either dishonest or a black-hole of stupid.
In ANY system of government provided anything, the service you get is partially based on who you bribe. Call it baksheesh or rent-seeking or campaign contributions, doesn’t matter. The only way to avoid it is to keep the government out of everything possible to reduce the motivation for bribery.
In my experience, jpr is neither dishonest nor stupid and the tone you’re using here does not comport with local standards. It’s possible to disagree without being disagreeable.
lex,
Your site, your rules. Please delete my comment as you see fit.
After getting enough arguments like jpr’s (which have to fit in one of those two categories, since no one with any historical knowledge can deny the truth that government based systems only function with favorable treatment for the Party faithful) my sense of humor has gone out for a smoke.
Oh, heavens, Lex, cancer treatment won’t be rationed! No, no, no — they’re transformed by Hope! and Change!
Instead, under our New National Health Plan everyone diagnosed with cancer will have the pleasure of receiving the letter that insurers in the States of Washington and Oregon already send out. Which says, (summarizing here): “Since your cancer can’t be provably cured to guarantee you will be alive in five years, we will not pay a dime for any treatment. However, we are thrilled to tell you that we are going to cover the costs to snuff you. We wouldn’t want you to suffer, after all!”
Not urban legend — this is already going on.
JAS … The truly evil thing that these professionally “compassionate” Democrats are including in their universal health care bills is that private citizens, who have been careful enough and prudent enough to save their own money for health care, will be forbidden from negotiating with their doctors for procedures and medications which they will pay for themselves. The doctors will be fined large amounts if they provide the treatments and procedures — at least $10,000 and maybe more. This provision in both bills was confirmed by my own physician when I had my annual physical this week. So Nasty Nan and Clueless Harry will have you coming and going.
Ready to pick out your coffin now? I’m not, dammit!
Marianne
And now the American College of Obstetricians and Gynecologists or ACOG now say women younger than 30 should undergo cervical cancer screening once every two years instead of an annual exam. And those age 30 and older can be screened once every three years. At least this is from a medical society rather than a group of government ninnies.
X-boss: actually that would be pretty horrendous. The new standard is over age 21 with annual screenings. The recent change in mammogram procedures indicated one mammogram every 2 years.
Kris, I agree. This is just another sign of rationing health care, one step at a time. IIRC, didn’t the AMA support one or more versions of the bill? Guess they now feel compelled to do their part and suggest some ways we can cut back.
And the AMA / AARP etc were duly rewarded with government grants in the proposed new health care bills.
But I thought (one of)Lex’s points was that the mammogram decision was made by gov’t bureaucrats as opposed to the appropriate medical specialty. Doesn’t seem to fit here.
And today it was announced that screening for cervical cancer should start after the age of 21, rather than before. Despite the fact that, in the same article, it stated that cervical cancer cases have fallen by half due to screenings.
I worked with someone diagnosed with cervical cancer at age 20. By today’s new screening standards, she’d be dead.
Like many others, I know several women who are or have battled breast cancer. All of them, save one, were diagnosed in their late 30s/early 40s. The exception was 78. By these new standards, all of these women would likely be dead, leaving at least 6 children without a mother and 4 grieving husbands. Today – only one of these women is no longer with us; she died at age 92 of heart failure, not cancer.
Early detection is the only way to treat these cancers. A woman without a family history isn’t exempt from the need for screening in her 40s for breast cancer (and teens for cervical cancer). All of the women I mentioned above had zero family history of either cancer.
My insurance company already tells me the blue pills work better than the red pills.
Oh, wait, I’m active duty. So why was the effective medication I used to use dropped from the formulary and I am now compelled to use Brand X? I can do the online renewal option and pay additional for the old blue pills. Is it worth it? Maybe.
Ever wonder why British teeth are so bad? Not a small part of it is that Brits have to pay for most of their dental care, while their routine medical care is all paid for. If they paid for their medical care directly, would they be as stingy as they are with their teeth, or would they recognize the value of the care, the price tag of which they don’t see right now? Like me and the blue or the red pill.
This is all insane. I don’t comment here very often but I simply must say that limiting women’s access to screening will result in death. The very idea that “false positives” cause “anxiety” and there for must be eliminated is absurd. I know many women that have died from breast cancer and many others that have survived it. Had the survivors not gotten early screening thay would be dead now.
I actually think that this is the gov’t placing the cost of health care on the individual (with tax dollars).
You want cervical or breast screening? Pay for it yourself.
The majority of the comments and arguments given here so far are exactly why health insurance rates will never go down – the underlying costs that insurance is paying for will never decrease. Between the latest technical and pharmacological advances, and demands for treatment That Will Not Be Denied, there is no way the portion each insured has pay for both sharing the risk of catastrophic medical treatment or the time shifting/person shifting of “routine” screening and exam costs will come down. You want the latest, it costs, you want frequent services, it will cost.
On another note, what’s so special about mammograms age 40? Aren’t we “condemning some women to death” by not routinely screening at 35? 30? At what point do you draw a line? Are there “Cadillac” health care plans that reimburse for screening at those ages, for those who feel the need and are willing to pay the commensurate premiums?
While you are correct that adding more screening will not push the costs down, nor will not denying compensation to those who are found to need treatment, you’re forgetting the economy of scale. For example, at one point in time detecting cancer was a tough process full of blood work and X-rays and the like. Diabetes is another disease that has become easier, and less costly, to detect. Both diseases are less costly to treat if detected early, so there is your cost savings. Kind of like detecting a cavity in your tooth in time for a $20 filling vs a $2K crown or denture, early detection means shorter, more effective treatment and we can screen a boatload for the same costs as treating 1 later-term detection.
According to current medical thought colonoscopies are not needed until 50. I seem to recall certain folks who have had them regularly as a part of their regular checkup.
If the checkup were so costly, why would a screening be wished for instead of a diagnosis?
– Max
Wow LJ, do you really feel that mammograms at age 40 are cadillac plans?I am blown away by your prespective. I don’t even think I can reply as your point of view is so off the track.
Do you not know anyone that has had breast cancer?
Babs:
No, not at all. At age 35 or 30.
But then, one of the goals of health care “reform” is for those types of plans to go away.
And regrettably, I do know several. It killed my Great Grandmother. Struck a very accomplished Naval Aviator of my very close personal acquaintance.
The second paragraph is not a perspective, but rather an object point about the screening discussion. Why start at 40? Buck gives us an anecdote at age 39 in the second comment this evening. My friend was significantly below that age 40 threshold. Shouldn’t she have had the benefit of starting annual screening earlier, in order to have had a chance at earlier discovery and the probability that she might have had a less invasive course of treatment?
I believe part of NPR’s coverage today noted that a similar analysis of the data 15 or so years ago reached the same conclusion, that screening was not generally effective until age 50, but the outcry was so great Congress mandated screening stay at 40.
I use “mandate,” even though I don’t recall what the exact decision process was, because that is effectively what we have at this point from the public.
And I concur with part of Lex’ point, that you shouldn’t have your options taken away from you, which is what the health reform program is really all about. The statistics say that money is better spent screening starting at age 50. You want to start your screening earlier, I very much want you to be able to be able to choose a plan that provides that coverage. But I would also like you and the others who want that to cover the added cost. Ranges of options for ranges of people with ranges of need.
My wife was pulling a shift at USC Univ. Hosp. (not LA/USC COUNTY) yesterday and one of her patients–a Mexican plumber with only a HS education said of the whole affair: “So it’s started (the rationing) already, hasn’t it?”
“You don’t have to be a weatherman to know which way the wind blows.”
That is a lot of women to be considered expendable. How do Democrats sleep at night?
Because they make sure women can kill their babies… tradeoffs, you know.
Anyone who things whatever rationed care will be doled out to lucky recipients will be FREE is sadly mistaken.
Remember, military promises of free healthcare for life for those who retired after 20 years are not being honored. Think of the money spend on CHAMPUS/TRICARE supplemental insurance and all the minimums and copays and the like.
And, when you turn 65, you MUST enroll in Medicare to get TRICARE for Life benefits. Guess what? Medicare cost the retiree and spouse about $100 per month each, so about $2,400 to get that “FREE” care we were promised.
Now, does anyone really believe that they will not drastically increase the cost for Medicare per month? The system is bankrupt already and they want to chop nearly $500 billion from Medicare spending over the next 10 years. DOctors and staff will be getting slave wages (if not forced into slavery for the government) while the cost for a huge uncaring bureaucracy to run the FREE healthcare system will suck up untold sums.
We are seriously screwed if this thing passes. Even if we can throw out the rotten SOBs who pass it in 2010, the change may be irreversible. At a time when inflation is sure to be soaring and taxes increasing.
Pitchforks- buy early and avoid the long lines sure to come.
Concerning mammograms and pap tests. In general, if you don’t know what you are talking about, one might want to be careful of running your mouth. Make sure you understand the natural history of the disease, the state of current treatment regimens, a good dose of epidemiology and then try to understand what the USPSTF is talking about. Make sure you understand what screening is. Make sure you know what survival of cancer is (5 years from date of diagnosis, regardless of what is done) The decision years ago about mammograms was purely political, moving screening from 50 to 40. The science at the time did not back it up, but at the time women were feeling undercared for by the medical system. Amazing since they outlived men by 7 years at the time and saw a provider twice as often. Cervical cancer is an STD, caused by a virus. Chew on that one for a while. Finally, please remember that whatever decision you make (the collective you) dollars spent on studies that don’t change outcomes are dollars that are not available for spending on things that do. Seems that folks are happy to talk about evidence-based care until it’s their grandma. I don’t have all the answers but getting hyperventilated does not contribute to the debate. Just sayin’
And you don’t think this sudden change in mammograms from age 40 to 50 isn’t political? Since the USPSTF is appointed and funded by the government… My friends Cindy, Deb and Lori don’t really care about the politics. They care about getting care that is appropriate, since all of them were in their early 40s when a routine annual mammogram revealed their breast cancer.
And you imply that because cervical cancer is caused by an STD that somehow means screenings for that aren’t important because it’s possible someone brought in on themselves? My friend Lisa says gee, thanx. At age 20 she was diagnosed with cervical cancer – had 2 more recurrences before it finally went into remission.
I’m all for reformed healthcare, just not like what we are seeing.
Kris, please don’t read additional things into what I wrote. Of course, political concerns play a part of it. Who, for many of us, is paying the bills now? The government. The folks who divide up the money we have for buying these services are politicians, so I assume there is a political aspect. There are those professionals who believe that in many respects we don’t know what the natural history of some cancers is because we can’t study what would happen if you did nothing. Not a very ethical study and I’m sure no one would consent to being a part of it. Breast cancer in a 20 year old woman is usually different than in a 50 year old woman. The older one is more likely to survive it (5 years beyond diagnosis, regardless of treatment). On the cervical cancer, be certain of what you’re saying. A woman with a pap at 20 years old with low grade intraepithelial lesion (LGSIL) is told to repeat the pap in a year. Why? Because most of them will clear without any additional therapy. LGSIL is not the same as a carcinoma, yet. My point is, one should be careful about what we get excited about as there may actually be some attempt at good science behind it.
Bill you said: Cervical cancer is an STD, caused by a virus. Chew on that one for a while.
What else should someone read into a statement like that? Chew on what exactly…that the cancer is caused by an STD? Because that’s what it sounds like you said, giving the impression that the person who gets that kind of cancer may … um … deserve it? Or at least be treated differently because of it.
If I’m wrong, I apologize.
My grandmother was diagnosed with Breast Cancer at age 43. My father was in his 3rd year at the Naval Academy. A radical mastectomy and the prophylactic removal of the other breast saved her life. Mastectomies then were not what they are today. They were far more invasive.
I am 44 and have been having mammograms and breast ultrasounds since the age of 36. They’ve already found things they don’t like… every year since the age of 40. I don’t think I’ve been through a year since 40 when something didn’t raise alarm. So far it has been benign, but considering my family history, nobody is taking chances.
I don’t like the thought that I am being denied something that could save my life. It pisses me off. Yes, I’ll pay for it out of pocket anyway, but quite frankly, it’s not right. And thankfully, I have a good job where I can afford to pay for it. But it’s not right. And no, I’ve never done the BRAC tests to see if truly am high risk. I can’t chance it with the insurance companies.
Actually, Babs, it IS right. That the government interferes at all with the health care market is abominable and no small part of the ridiculous policies your physicians and yourself must contend with. There wouldn’t be the eight-dollar aspirins on the hospital bill if the consumer always paid directly, the consumer would fight back. Nor does government involvement protect you from the insurance company that decides that your best interests and its own are not the same. If anything, it hinders your ability to fight the insurance company, which is almost always operating within the confines of some government bureaucratic regime.
What’s worth noting is that you still have the option to pay for your own testing. When access to the diagnostic tools are denied you because you’re not part of the system, then you’re well and truly screwed. But at least for now, it’s not accurate that you’re being denied anything.
And I know a woman diagnosed with Cervical Cancer at age 43. She had missed her annual appt with her ob/gyn for three years. That is only three years she missed… no STD, and she is now playing cancer whack a mole. She has had it for two years now and it will ultimately kill her. The cancer pops up at will throughout her body. You don’t want to know how much she beats herself up for not taking the time to get screened for something so easily tested… for she will leave behind two children and a grieving husband. It will not be long before people like her will be dying because of the government. Personally, I’d prefer the burden of my own fate over that of the government’s for me.
Ugh, this just kills me.
I’ve been an occasional reader here for a few years. I’m also now a rather older than average first year med student in Britain. Over here, there has been a significant clinical debate about the benefits/harms of mammography after the publication of this article in the British Medical Journal: http://www.bmj.com/cgi/content/full/338/jan27_2/b86. The standout points relevant to this situation are:
If 2000 women are screened regularly for 10 years, one will benefit from the screening, as she will avoid dying from breast cancer
At the same time, 10 healthy women will, as a consequence, become cancer patients and will be treated unnecessarily. These women will have either a part of their breast or the whole breast removed, and they will often receive radiotherapy and sometimes chemotherapy.
As I understand it, the body making these recommendations in the US is not tasked with cost control and doesn’t seek ban provision of mammograms, but rather to make them elective and ensure that patients understand the potential downsides of screening, which can be considerable.
Tom, this doesn’t make sense to me. Mammography itself does not prove the presence of cancer, so why would the ten “false positives” (not sure what’s false, the mammography found an unexplained lump) suddenly move on to mastectomies and radiotherapy? Would there not be subsequent testing to identify what the mammography found?
Also, your brief summation doesn’t mention the ages of the tested 2000 women, and I understand that, as others have noted, age is a significant factor in both the rate of occurence and the lethality of breast cancer.
Zane, sorry for the confusion, I forgot to add quote marks around my middle paragraph, which was a direct excerpt from the paper, rather than intended as a summary. I’ve also realized that bmj articles which appear as open access through my institution’s network may not be available to everyone due to subscription issues, sorry if thats so. In case it should be, I’ve pasted in a chunk from this editorial below(BMJ 2009;339:b1425). British spelling I’m afraid.
“Overdiagnosis refers to the detection of abnormalities that will never cause symptoms or death during a patient’s lifetime. Overdiagnosis of cancer occurs when the cancer grows so slowly that the patient dies of other causes before it produces symptoms or when the cancer remains dormant (or regresses). Because doctors don’t know which patients are overdiagnosed, we tend to treat them all. Overdiagnosis therefore results in unnecessary treatment.
With the advent of widespread efforts to diagnose cancer earlier, overdiagnosis has become an increasingly vexing problem. Overdiagnosis is a widely recognised problem in prostate cancer screening, and it has also been reported in other cancers, including neuroblastoma, melanoma, thyroid cancer, and lung cancer. Some degree of overdiagnosis is likely to be the rule rather than the exception in cancer screening.
Jørgensen and Gøtzsche’s results are consistent with a growing body of observational evidence that screening mammography is associated with sustained increases in the incidence of breast cancer in women of screening age, with little or no subsequent decrease in incidence in older women. One cohort study concluded that some invasive breast cancers detected by screening must spontaneously regress.7″
(Split in two: didn’t want to hog space.)
Here’s a cochrane review on the matter (http://www.ncbi.nlm.nih.gov/pubmed/17054145?ordinalpos=1&itool=PPMCLayout.PPMCAppController.PPMCArticlePage.PPMCPubmedRA&linkpos=5) which should be open access.
Your point about age is well taken: I can’t work out the age parameters from that article I posted. Here women are routinely invited for triennial screening between their late 40′s and 73 (although risk factors such as family history or just plain requests will of course change that). So if overdiagnosis is a problem in this middle aged to elderly testing group, I can only imagine that its more significant a problem the lower the population wide risk.
I certainly don’t want to claim any special knowledge off the back of one semester of med school and i’m no knee-jerk defender of my nation’s health care practises – it just seems to me that the suggestion the U.S. Preventive Services Task Force made (that screening be discussed in terms of harm/benefit rather than being automatic in this age range)is a sensible response to the evidence for tangible harm from overdiagnosis that is accumulating.
Tom, thanks for the thoughtful response. I’m on the move to the UK in two weeks, may I ask where you’re studying?
Thanks, and likewise. I’m at Edinburgh. Where is your UK trip taking you?
late, don’t know if you’ll see this. Down near Peterborough, but have family in Newcastle (South Shields). Perhaps a trip across Midlothian and I’ll buy you a beer.
I don’t object to having recommendations for care modified. What I do object to is the government deciding what treatments I can and cannot have even if I am footing the bill. The people making these decisions are not my doctor and the decisions they make will not impact their lives, only mine. Most of them have no medical background either, they are bean counters not medical professionals. Their ultimate goal is not health care or even health insurance, it is control.