How the mammogram and Pap smear debates ignore the uninsured

by Jeoffry B.Gordon, MD, MPH

The recent recommendation of the US Preventive Services Task Force against routine screening mammograms for healthy, low risk women under the age of fifty has demonstrated our broad consensus about the value of breast cancer screening. The discussions about new guidance from the American Academy of Obstetrics and Gynecology on when to start and how often to do PAP smears illuminate the impact, effectiveness and support for preventive medicine. After practicing family medicine in San Diego for nearly thirty years, I would observe that a critical aspect of the public’s perception and discussion of disease prevention has been totally ignored: the deadly impact of lack of health insurance.

Uninsured women are much more likely to be diagnosed with advanced-stage breast cancer than their insured peers. This is well documented in a 2008 report by the American Cancer Society. In 2005 while 75 per cent of women 18 to 64 with private insurance had had a mammogram in the past 2 years, only 33 per cent of women uninsured greater than twelve months had this test. Just 8 percent of insured women aged 18-64 of all ethnic groups had Stage III or IV breast cancer at diagnosis, compared with 18 percent of uninsured women.

All breast cancer patients with private insurance had an 89 per cent 5 year survival compared with only 77 per cent 5 year survival for those who were uninsured. The same report documents that 87.9 per cent of women with private insurance had had a PAP smear in the past year compared to only 62.7 per cent of women without insurance for more than 12 months. Cervical cancer is slow to progress and it is widely recognized that most women who die from cervical cancer rarely or never had a PAP smear.

Again the common denominator is lack of access to medical care because of uninsurance. Clearly lack of insurance coverage increases the likelihood that a condition like breast cancer or cervical cancer will go undetected and, when found, be less responsive to treatment.

A new Harvard study in the American Journal of Public Health shows being uninsured increases a person’s risk of death by 40 percent. Furthermore, the American Cancer Society report Spending to Survive published in February of this year documented 25 representative cases of cancer patients who were fully insured yet had to limit or give up treatment or even declare bankruptcy because of insurance policy co-pays, deductibles or policy limits. I recently had a patient who refused a mammogram because she feared that if anything was found she would become uninsurable.

The current health reform bills in Congress are very complex. They seem to trying to impact some of these problems, but they leave many insurance company policies unmentioned and untouched such as time consuming and resource expensive prior authorization and payment procedures and increasingly high co-pays and deductibles for care, diagnostic tests and medications. At best they would limit middle class family costs to 20 per cent of income (!) and leave at least 17 million uninsured. In contrast, a single-payer, Medicare-for-all program would be vastly less complex and less expensive, be truly universal and save tens of thousands of lives annually.

Jeoffry B.Gordon is a family physician and a member of Physicians for a National Health Program.

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