Paying For Mammograms: We're Thinking About It All Wrong

Commentary by John R. Graham

Source: Forbes

The third rail of American health policy is women’s health care.  The U.S. Department of Labor states that women make 80 percent of health care decisions for their families, although this appears to be derived from folklore rather than scholarly research. Nevertheless, any politician knows that the way to drive up polling numbers among women is to dial up the rhetoric on health care.

Back in 1996, Hillary Clinton, bitter after the defeat of HillaryCare, campaigned against “drive-by deliveries,” demanding that a federal law should be passed mandating that health insurers pay for mothers to stay in hospital for at least 48 hours after delivery. The campaign succeeded quickly: The Newborns’ and Mothers’ Health Protection Act passed that year, and took effect in 1998. It mandated a 48-hour stay (or 96 hours for Caesarian section). Although, doctors are free to discharge their patients earlier.

More recently, controversy arose when the Affordable Care Act was being debated, because it was being jammed through Congress just as women were struggling with a 2009 decision by the US Preventive Services Task Force to change its guidelines recommending annual mammograms. The new guidelines recommended screening starting at 50 years, not 40 (as previously recommended).

Needless to say, this upset many people. The American Cancer Society maintained its recommendation that preventive screening start at 40, as did the Mayo Clinic. Politicians took note, and made an exception in Obamacare for mammograms, such that the 2009 USPSTF revision was ignored when it came to Obamacare’s “free” preventive care.

The USPSTF looks ready to re-issue its guideline, which means “free” mammograms for women in their 40s will not be mandated by Obamacare. Avalere Health has published a study estimating that this could “eliminate guaranteed coverage” for 17 million women.

I understand that everyone’s personal experience will color their response to these guidelines. Nevertheless, I think we can deal with the issue much more satisfactorily if we look at it in a different way – by recognizing that “free” mammograms are not “free” at all.  Although I am a man, this concerns me directly as the sole breadwinner in my family. If my wife loses any “free” preventive coverage, we’ll pay for it out of my wages if she chooses to undergo the procedure.

My employer-based health plan covers mammograms fully as preventive care. Never having paid for a one cirectly, I went to trusty NerdWallet, which informed me that they are offered for a median price of $250 in San Francisco and $294 in Washington, DC – two of America’s most expensive cities. In Atlanta, the median cost is $130 and in Denver it is $160.

Most mammograms performed are paid by insurers. (A study using data from 2007-2008 reported that only 5.5 percent of women getting mammograms were uninsured.) So, these prices are artificially increased by the administrative load of health insurance. If almost all mammograms were paid directly, the price would drop by a significant percentage.

How much? Let’s look a little deeper at the study citing 2007-2008 data. Overall, the mean (average) price of a mammogram was $266.49, of which the patient payed $32.90 directly. Almost 95 percent of the women were insured (by private insurance, Medicare, or Medicaid) and they paid $31.32 directly out of a total price of $272.09.

So, did the small number of uninsured women pay the total price? No: They paid $60.03 directly, of a total “price” of $170.47. What is the meaning of the so-called “price” of $170.47? Obviously, it has no meaning other than to justify the byzantine billing bureaucracy maintained between government, health insurers, and providers. The actual price of a mammogram in 2007-2008 was about sixty bucks.

So, the question is: Would women rather pay for mammograms directly, and make their own informed decisions about when it is clinically indicated; or pay indirectly through higher insurance premiums, and worry about whether the preventive guidelines are influenced by politicians’ and insurers’ self-interest?

John R. Graham is a Senior Fellow at the National Center for Policy Analysis and Co-Organizer of the Health Technology Forum: DC.