When the federal government’s Preventive Services Task Force recommended in November 2009 that most women under age 50 should stop having regular mammograms and that women 50 to 70 should cut back to one screening every other year, it ignited a huge controversy with some critics complaining that women were being patronized and short-changed on essential preventive health services and others claiming the move foreshadowed the carnage that might arise under Obamacare death panels. Indeed, many Obamacare advocates hailed the recommendations as the kind of evidence-based medicine we needed to adopt if we were ever to get escalating health care costs under control. And they railed on HHS Secretary Kathleen Sebelius for “caving in” to political pressure and disavowing the recommendations made by her own department.
Two other studies published last year suggested just the opposite, though, finding small but significant reductions in the risk of dying from breast cancer among women who began annual mammograms at age 40. The American College of Obstetricians and Gynecologists had been splitting the difference, advising women age 40 to 50 to get a mammogram every other year. But the organization has updated its guidelines, now recommending that “mammography screening be offered annually to women beginning at age 40.”
Of course, the debate isn’t over. The subject of when otherwise healthy women with an average expected risk of getting breast cancer should begin regular screenings has been a hot topic for well over a decade now. And plenty of different scientific research organizations have staked out scientifically-justifiable but conflicting positions on the procedure. Perhaps the only clear conclusion we can draw from all the hubbub is that figuring out exactly when a medical intervention is or is not justified, is or is not cost-effective, and is or is not superior to a different intervention is pretty damn difficult.
This is relevant to public policy because our governments have long taken it upon themselves to pay for much of the health care we receive and to mandate or forbid private parties from contracting to deliver or pay for various health services. In a July 2009 interview, President Obama vastly oversimplified the kinds of choices government should be entitled to make by saying, “If there’s a blue pill and a red pill, and the blue pill is half the price of the red pill and works just as well, why not pay half price for the thing that’s going to make you well?” But, as I wrote at the time, “patients and their ailments vary, so the choice is rarely that easy.”
For many conditions and treatments, from cancer and cardiac care to asthma medicines and antidepressants, the appropriate prescription for an individual patient requires a delicate balance of the benefits and risks. Moreover, measures of effectiveness in populations may not reflect what will happen in particular individuals: For example, two drugs to treat heart failure might both be effective in 40% of patients, but in a different 40%. Even if one of those medications were significantly more expensive than the other, it would be unwise to block its regulatory approval or reimbursement for its use.
That’s worth remembering now, as Congress debates whether it should repeal the Independent Payment Advisory Board, a feature of the Obamacare legislation designed to implement the President’s blue pill-red pill cost-cutting theory.