A Project of The Annenberg Public Policy Center

Mammography and the ACA, Redux


Get ready for another round of misleading claims about the government interfering with women’s ability to get mammograms.

Lawmakers of both parties have already claimed that draft recommendations from the U.S. Preventive Services Task Force put the government, or “bureaucrats,” in charge of health care choices, differ from the task force’s previous recommendations and could be interpreted as saying it’s “unnecessary” for women under age 50 to get mammograms at all. None of that is accurate.

The latest draft recommendations — the public comment period for which ended in late May — are virtually unchanged from the independent task force’s 2009 recommendations on breast cancer screenings. For asymptomatic women who are not at high risk for breast cancer, the recommendations suggest “biennial screening mammography for women ages 50 to 74 years,” and they say for women age 40 to 49, the decision to have a mammogram “should be an individual one.” The task force said it couldn’t evaluate benefits and harms for women 75 and older because of insufficient evidence. That’s the same language used nearly six years ago.

However, if these 2015 recommendations become final, they would change the Affordable Care Act’s requirement for insurers to cover annual mammograms without any copays or deductibles. Specifically, insurance companies no longer would be required to cover free annual mammograms for women age 40 to 49, a requirement that went into effect for non-grandfathered health plans in the fall of 2010.

Some politicians concerned about this change have described the potential impact correctly, but they misplace the blame on the Preventive Services Task Force, which doesn’t issue any kind of insurance mandates or policy decisions. Instead, it was lawmakers who added a provision to the ACA tying the task force’s future recommendations to coverage requirements in the health care law.

As we’ve seen in the past, some claims misrepresent what the task force has said and what it means for women and access to mammography. We don’t know when the task force’s final recommendations on mammography will be released, but — if we were to venture a guess — we would expect to see another round of misleading claims then. We have already fact-checked false assertions about the task force’s mammography recommendations in 2013 and back in 2010.

History, when it comes to fact-checking, definitely repeats itself.

Doctors, Not ‘Bureaucrats’

Let’s start with some background on the U.S. Preventive Services Task Force and what it does. The USPSTF, created in 1984 under Ronald Reagan, is an independent, volunteer panel of primary care physicians and experts in preventive medicine.

The panel examines peer-reviewed evidence and makes recommendations “intended to help primary care clinicians and patients decide together whether a preventive service is right for a patient’s needs,” as the panel’s website says. The recommendations are for patients “who have no signs or symptoms of the specific disease or condition under evaluation” and pertain to “only services offered in the primary care setting or services referred by a primary care clinician.”

Its members are not “bureaucrats,” as Republican Sen. David Vitter called them in a statement opposing the latest recommendations. Vitter, and 61 other lawmakers of both parties, wrote a letter to the Department of Health and Human Services, urging the USPSTF to “not jeopardize access to these screenings.” Vitter said in his May 6 press release: “Given the widespread risk of breast cancer, we shouldn’t let bureaucrats in Washington limit access to prevention and early detection resources. These decisions should be left to women and their doctors.”

In the same press release, Rep. Cathy McMorris Rodgers of Washington said: “I am extremely concerned about the U.S. Preventive Services Task Force’s draft recommendation to limit insurance coverage of mammograms for women between 40-49 years old. When the government is making the calls on what must be covered – not the patient or doctor – patients find their care rationed and their choices limited – this time among women under 50. When 1 in 8 women will develop invasive breast cancer in her lifetime, it is imperative we put the patients in the driver’s seat of their health care choices – not the government.”

The task force does, in fact, recommend that women and their doctors make the appropriate decisions on mammography on an individual basis, and it didn’t make any recommendation to “limit insurance coverage of mammograms.” It does not make any insurance coverage recommendations at all. (And patients and doctors were never making the calls on insurance coverage, as McMorris Rodgers suggests; that was up to insurance companies.)

The task force’s preface to its draft recommendations states: “Clinicians should understand the evidence but individualize decisionmaking to the specific patient or situation. Similarly, the USPSTF notes that policy and coverage decisions involve considerations in addition to the evidence of clinical benefits and harms.”

The panel’s recommendations do have an impact on what federal law now requires insurers to cover at a minimum — but that wasn’t the panel’s doing. Instead, it was lawmakers’ decision.

The task force had no direct ties to what insurers covered until the Affordable Care Act used its recommendations as the basis for determining what preventive services health plans would be required to cover for free — without charging a copay or deductible to consumers.

The law says that group and individual health insurance coverage “shall, at a minimum provide coverage for and shall not impose any cost sharing requirements” for several preventive items, including immunizations recommended by the Centers for Disease Control and Prevention and services with an “A” or “B” rating from the USPSTF.

Some associated with the task force weren’t happy about its work being linked to insurance requirements in the ACA. Dr. Steven H. Woolf, a former task force member, and Dr. Doug Campos-Outcalt, a liaison between the American Academy of Family Physicians and the USPSTF, wrote in 2013 in the Journal of the American Medical Association that the arrangement exposes the board to political pressure and threatens its independence.

“Coverage decisions, like other aspects of public policy, should not always be dictated solely by science,” they wrote, saying that “[t]he role of the USPSTF has never been to make these policy choices but, rather, to give decision makers who consider the evidence an impartial assessment of its quality.”

And, in fact, the USPSTF recommendations on mammography were exposed to political maneuvering immediately, before the law was even enacted.

In 2002, the task force had recommended “screening mammography, with or without clinical breast examination (CBE), every 1-2 years for women aged 40 and older.” But in November 2009, the task force issued new mammography recommendations, saying that it recommended biennial screening starting at age 50. For women younger than 50, it said, the decision to have a mammogram should be an “individual one and take patient context into account, including the patient’s values regarding specific benefits and harms.” The harms were mainly false positive tests.

That recommendation for women under 50 was a “C” recommendation, which means providing the service depends on “individual circumstances,” but for most symptom-free patients “there is likely to be only a small benefit from this service.” That “C” rating would have meant that mammography for women under 50 wouldn’t be part of the no-cost-sharing coverage requirements of the ACA, except that lawmakers, including Vitter and Democratic Sen. Barbara Mikulski, were able to amend the law to say it would require such coverage and would simply ignore the 2009 USPSTF recommendations.

In early December 2009, the Senate passed an amendment to the health care legislation by Mikulski of Maryland that would require full coverage of yearly mammograms, including for women under 50, and the same day, the Senate agreed, without a vote, to an amendment by Vitter that said: “[F]or the purposes of this Act, and for the purposes of any other provision of law, the current recommendations of the United States Preventive Service Task Force regarding breast cancer screening, mammography, and prevention shall be considered the most current other than those issued in or around November 2009.”

That language was in the final legislation that became law in late March 2010, and it meant that the ACA would revert to the 2002 mammography recommendations for purposes of determining what services would be required to be covered without any out-of-pocket costs by women.

The letter from Vitter and other lawmakers says that “a provision was signed into law that was meant to prevent the 2009 USPSTF recommendation from going into effect,” but that twists the facts. The USPSTF’s recommendations don’t go “into effect” at all: They’re evaluations of peer-reviewed scientific evidence intended to serve as a resource for primary care doctors and their patients, who are under no obligation to follow the recommendations. Instead, Vitter’s provision was meant to prevent the ACA from using the 2009 recommendations to determine insurance coverage requirements.

It’s 2009 All Over Again

The language in the law — “the current recommendations” of the USPSTF on mammography “shall be considered the most current other than those issued in or around November 2009” — means that any recommendations issued after 2009 would now be the “current” ones applicable to the ACA.

“It was really about ignoring 2009,” Dr. Richard Wender, the American Cancer Society’s chief cancer control officer, told us in a phone interview. The law didn’t say, “ignore 2015.”

Mikulski, who also wrote a letter to HHS about the draft recommendations, said in a press release that the task force’s latest release “diverges from a previous recommendation that women aged 40 to 74 receive an annual mammogram to screen for breast cancer.” That’s only true if we compare the draft recommendations to 2002.

Perhaps not surprisingly, the 2015 draft recommendations largely mirror what the task force said in 2009. The only difference is that the latest version goes into more detail on the recommendation for women 40 to 49, saying: “Women who place a higher value on the potential benefit than the potential harms may choose to begin biennial screening between the ages of 40 and 49 years.” It continues: “Screening mammography in women ages 40 to 49 years may reduce the risk of dying of breast cancer, but the number of deaths averted is much smaller than in older women and the number of false-positive tests and unnecessary biopsies are larger.” It says that women with a close relative with breast cancer “may benefit more than average-risk women from beginning screening between the ages of 40 and 49 years.”

So the controversy that existed in 2009 is erupting all over again. Back then, cancer groups, including the American Cancer Society and the advocacy group Susan G. Komen for the Cure, reiterated their long-term advice for women over 40 to be screened every year. Even Kathleen Sebelius, who was then the secretary of the Department of Health and Human Services, said women should “keep doing what you have been doing for years.”

Wender says a yearly screening for women over 40 is still the ACS’ recommendation, but it is currently evaluating its guidelines, a process that will be finished later this year. “We have a lot of respect for the members of the task force,” he said, adding “there’s a great deal of agreement” between the ACS and the task force on this issue.

Democratic Rep. Debbie Wasserman Schultz, a breast cancer survivor, wrote in an April 23 op-ed in the Washington Post: “I urge the USPSTF to reverse its recommendation and avoid the needless deaths that will inevitably result when women between 40 and 50 don’t get mammograms, believing that the experts said it would be unnecessary.” The experts — in this case the USPSTF — didn’t say mammograms for women under 50 were “unnecessary” (though that false interpretation was pushed by an ad we debunked in 2010). Instead, as we’ve explained, the USPSTF said mammography for that age group, and for women of “average” risk, should be an individual choice.

The USPSTF could change the language when it makes its final recommendations, but Wender says that he thinks “most likely their final rating will be the same as the draft.” What impact would that have on what insurers cover?

Wasserman Schultz wrote: “Their recommendations could lead to insurance companies dropping coverage of mammograms for women under age 50.” But plenty of insurance plans covered mammograms for women under 50 — albeit with copays — before the ACA put into place legal requirements. Dania Palanker, senior counsel for health and reproductive rights at the National Women’s Law Center, told us that “we do know that issuers generally covered mammograms for women age 40 and over prior to the ACA, including after the 2009 recommendations, although most charged cost sharing as they did with other preventive services prior to the ACA.”

Wender, who notes that the American Cancer Society knows that even small copays are enough to dissuade people from getting screenings, says he thinks few major insurance carriers would reduce their coverage even if they were no longer required to pay for mammograms without cost-sharing by policyholders. His reasoning: Those companies have already accounted for those costs.

But we can’t predict the future. Lawmakers, and the Department of Health and Human Services, also could take some action, as they did in the past to follow older USPSTF recommendations when it comes to insurance coverage mandates. Mikulski, in her letter to HHS, urged the department to take “all appropriate action” and said that if the draft recommendations become final, “I will actively and aggressively pursue all legislative options available to ensure that women aged 40 and older are able to continue receiving free annual mammograms.”

— Lori Robertson