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Wednesday, November 18, 2009

The future of health care, as seen in... mammograms?

A seemingly innocuous statement about recommended medical treatment has inadvertently exposed Americans to the risk of a government-run health care system. The U.S. Preventive Services Task Force now recommends less frequent mammograms to monitor for breast cancer. The new guidelines suggest that only women with risk factors get screened at 40, and two years between mammograms is fine for women in their 50s. The reason for these changes is that the false positives outweigh the early detections. Of course, home examinations can and should be continued as normal.

Understandably, many women are upset with this recommendation. Any woman whose early breast cancer was discovered by a mammogram would feel as if the early detection saved her life. "I wouldn't be here today if these guidelines were in place." (Some would have survived even with a later detection, of course.) Some fear these guidelines may be used by government and private insurers to set which medical procedures are covered.

In the current U.S. health care system, there is nothing to be afraid of. Some insurers may change their policies, but I don't think most will. Private insurance widely covers preventative care, normally at 100%. It may make theoretical sense for all insurance to exclude annual preventative care, like physicals and mammograms and prostate exams, because it's more expensive to pay with insurance's overhead than just paying out of pocket. But health insurance is not sold to homo economicus, the theoretical creatures that economists work with, who make perfectly rational economic decisions. In the real world, covering preventative care encourages utilization of preventative care (which can help discover problems early, though the actual economic cost/benefit analysis is extremely complicated) and is attractive to consumers. As long as the price remains reasonable, people won't mind over-pre-paying. As long as there's strong interest in this type of coverage at a
reasonable price, insurers have a financial incentive to offer this coverage.

However, put only one entity, the government, in charge of health care, and these type of recommendations may become enforcements. The absolute extreme case is a complete ban on mammograms before 50 for women without risk factors. The more reasonable extreme case is a system where almost all care is provided by government-paid and government-regulated doctors, who would have a prohibition on providing these mammograms, and only the very rich would be able to see doctors who operate outside the public sphere. In either case, being willing to pay for the peace of mind of an early mammogram would not be an option.

The larger issue, of course, is increasing health care costs, partly because people want care that is of limited or no benefit. They want antibiotics to treat the flu. They want the latest generation drug when an earlier, now generic drug might work as well. They want health screenings that are very unlikely to uncover a disease. Anecdotal evidence will uncover some who benefited, but practically, we do need to recognize that some risk will remain in an ideal system. We could virtually eliminate traffic fatalities by restricting automobiles to running no faster than 20 mph, but we accept those risks to get the benefits of being able to travel faster.

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