ACA Doesn’t Restrict Mammograms

Q: Does the Affordable Care Act restrict my ability to get a mammogram?

A: No. In fact, the law requires insurers to cover mammography, with no cost-sharing, every one to two years for women starting at age 40. Medicare fully pays for mammograms once every 12 months with no upper age limit.

FULL QUESTION

Is it true that now that ObamaCare or Affordable Care has been enacted, yearly mammograms for women over 70 will not be covered by Medicare or Obamacare. Surely not. Awful rumor going round.

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Does Obamacare limit the number of times women get a mammogram and at what age?

FULL ANSWER

Several readers have asked us questions, such as those listed above, about whether the Affordable Care Act would limit their ability to get a mammogram, or if insurance or Medicare wouldn’t cover mammograms under the law. One reader wrote that a doctor told her cousin she couldn’t get a mammogram under Obamacare once she turned 74. If so, that doctor is misinforming his or her patients.

The Affordable Care Act actually improves coverage of mammograms for Medicare beneficiaries and an unknown number of women on private insurance, depending on what their insurance covered previously. The law requires Medicare to cover a yearly mammography screening at no cost to women starting at age 40. For private insurance plans, the law also requires coverage of mammograms, with no cost-sharing, every one to two years for women starting at age 40.

For seniors, this is a step up in benefits: Before the health care law, mammograms were also covered, but with 20 percent cost-sharing. For private plans, coverage varied, but under the ACA, women get free mammograms as part of required preventive coverage. That’s for non-grandfathered plans starting on or after Sept. 23, 2010. “We know it’s a big change,” said Mona Shah, associate director of federal relations for the American Cancer Society Cancer Action Network. “We know based on research that even a small cost-sharing can be a deterrent to getting screened.”

Traditional Medicare began fully paying for mammograms in 2011, and all Medicare Advantage plans — those offered by private insurers — were required to do so as of 2012. That information is available on the website of the Medicare Rights Center, a nonprofit group that offers counseling and assistance to Medicare beneficiaries.

Also, the law’s requirements for free preventive care — which, beyond mammograms, includes screenings for cholesterol, diabetes, osteoporosis, cancers such as prostate and cervical, and immunizations — are minimum requirements, designed to guarantee certain preventive benefits are part of insurance policies. “Insurers could cover above and beyond what’s in the law,” Shah said.

She told us there wasn’t any kind of upper age limit with Medicare — a fact that a Centers for Medicare and Medicaid Services spokesperson also confirmed with us — and her organization hadn’t heard anything about women being denied coverage. “I think those claims are pretty much inaccurate,” Shah said.

The American Cancer Society recommends women continue yearly mammograms “as long as they are in good health.” For elderly women, mammograms should continue “as long as she does not have serious, chronic health problems such as congestive heart failure, end-stage renal disease, chronic obstructive pulmonary disease, and moderate to severe dementia,” the ACS says.

The Medicare Rights Center’s Mitchell Clark, the senior communications associate, also told us his group hadn’t “heard of any issues where people have been denied coverage of mammogram or had trouble getting a mammogram based on their age, but we do get calls from time to time about unexpected costs.” The group notes that while the preventive services are free, there may be a facility fee at certain hospitals or an office visit fee if the patient has a doctor’s appointment before or after the preventive screening.

We also called the American Geriatrics Society. Carol Goodwin, associate vice president of communications for the group, told us: “We have not been getting any specific reports from our members or the public that screenings have been denied for women over the age of 74.”

So, where does this rumor come from? That magic “74″ age that several readers mentioned leads us to controversial recommendations in 2009 from the U.S. Preventive Services Task Force, recommendations that were specifically rejected by the Affordable Care Act and also widely misinterpreted.

The 2009 Controversy

The U.S. Preventive Services Task Force was created in 1984 during Ronald Reagan’s presidency. It’s an independent, and volunteer, panel of primary care physicians and experts in preventive medicine. The panel makes recommendations on preventive care based on peer-reviewed evidence. Its recommendations “are 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.

Its recommendations apply to 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.”

The task force’s 2002 recommendations on mammography said that it “recommends screening mammography, with or without clinical breast examination (CBE), every 1-2 years for women aged 40 and older.” And that recommendation has been echoed by many cancer organizations, with groups including the American Cancer Society encouraging a yearly screening. The panel said “available trials also have not reported a clear advantage of annual mammography over biennial mammography” for women between ages 40 and 50, and that for women over 50, there’s also “little evidence” that it’s better to get a mammogram annually as opposed to every other year. Risk factors such as family history would strengthen a recommendation for a yearly screening, the task force said.

In November 2009, the task force issued new mammography recommendations, saying that it recommended biennial screening starting at age 50. It said that for women younger than 50, 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.

In the grading system of the Preventive Services Task Force, 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.” As for women 75 and older, the task force said evidence wasn’t available to determine benefits versus harms for that age group. That’s an I statement, which means “[e]vidence is lacking, of poor quality, or conflicting, and the balance of benefits and harms cannot be determined.” The task force described it as a “near total lack of trial data for older women.”

The 2009 recommendations did not say that women under 50 or over 74 shouldn’t get mammograms at all, even though that’s the way the recommendations have been wrongly interpreted by some. The task force issued the new recommendations when the health care law was being debated in Congress, likely intensifying the reaction. We debunked one ad back in 2010, from a conservative group, that falsely claimed the “guidelines” say that “women shouldn’t receive mammograms until age 50″ and that if the health care legislation were passed, such guidelines “could become the law for all kinds of diseases.”

That ad also criticized the task force for being a “government panel” that doesn’t include “cancer experts.” As we said then, that’s a matter of definition. The task force is sponsored by the Agency for Healthcare Research and Quality, which is part of the Department of Health and Human Services, but its members are doctors and professors who volunteer their services. The task force is designed to be made up of primary care doctors and experts in preventive medicine. The 2009 panel included one public health expert and two experts in epidemiology, the study of the spread of disease.

As we said, the task force’s 2009 recommendations were controversial, especially to groups that had long encouraged women to get screened every year once they turned 40. The American Cancer Society and the advocacy group Susan G. Komen for the Cure rejected those recommendations. The Susan G. Komen group said it worried confusion over the recommendations would lead women to not be screened. Health and Human Services Secretary Kathleen Sebelius said women should “keep doing what you have been doing for years.”

Sebelius, Nov. 18, 2009: The U.S. Preventive Task Force is an outside independent panel of doctors and scientists who make recommendations. They do not set federal policy and they don’t determine what services are covered by the federal government. … My message to women is simple. Mammograms have always been an important life-saving tool in the fight against breast cancer and they still are today. Keep doing what you have been doing for years — talk to your doctor about your individual history, ask questions, and make the decision that is right for you.

Dr. Susan Love of the Susan Love Research Foundation supported the guidelines, saying they were “just that, guidelines” and that “mammography is not a good tool for finding breast cancer in younger women and we need to put our efforts to finding something better.”

The chair of the task force, Dr. Virginia A. Moyer, a pediatrician, was quoted by CNN in 2011 saying that the panel’s recommendation wasn’t that women under 40 shouldn’t have a mammogram, though that’s the way it was interpreted. “It’s something that needs to be discussed on an individual basis. For some women, it will be consistent with their values to choose to have a mammogram between 40 and 50. For other women, they will choose not to, and those are both reasonable decisions.”

Affordable Care Act

When the controversy erupted, Congress was debating health care overhaul legislation, which would require insurers to cover, at a minimum, certain preventive services. On Dec. 3, 2009, the Senate passed an amendment by Democratic Sen. Barbara Mikulski of Maryland that would require full coverage of annual mammograms, including for women under 50, and many other women’s preventive services. The same day, the Senate agreed, without a vote, to an amendment by Republican Sen. David Vitter of Louisiana that said the law, and “any other provision of law,” should ignore the 2009 recommendations on mammography by the Preventive Services Task Force.

That language was in the final legislation that was signed into law in late March 2010 by President Obama. Section 2713, which deals with “coverage of preventive health services” says: “[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 section says that group and individual health insurance coverage “shall, at a minimum provide coverage for and shall not impose any cost sharing requirements” for various preventive items, including immunizations recommended by the Centers for Disease Control and Prevention and services with an “A” or “B” rating from the Preventive Services Task Force. Except, as the Vitter amendment said, the law would not consider the 2009 mammography recommendations as current. That means the minimum coverage requirements follow the 2002 recommendations.

The section notes that these are not limitations on what insurers can cover: “Nothing in this subsection shall be construed to prohibit a plan or issuer from providing coverage for services in addition to those recommended by United States Preventive Services Task Force or to deny coverage for services that are not recommended by such Task Force.”

This page on the Preventive Services Task Force’s website lists the panel’s ratings that are relevant to the Affordable Care Act, noting that the law uses the 2002 recommendations on breast cancer screenings.

When the Department of Health and Human Services issued a ruling in July 2010 saying the no-cost annual mammograms starting at age 40 and other preventive services would apply to health plans issued on or after Sept. 23, 2010, the Susan G. Komen organization applauded the announcement. “By requiring health insurers to offer no-cost access to mammography for women age 40 to 49, HHS has relieved concerns women have had since the United States Preventive Services Task Force issued its controversial guidelines last fall,” said Jennifer M. Luray, president of the Komen Advocacy Alliance, in a press release.

So, the Affordable Care Act increases coverage of mammograms for women, depending on what their insurance covered previously. And it specifically rejects those 2009 mammography recommendations, which didn’t limit mammography for women anyway.

The episode highlights the political pressures that may fall on this independent task force. 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 of their concerns in the Journal of the American Medical Association, saying that using the USPSTF in the Affordable Care Act to determine coverage mandates exposes the board to pressure from interest groups and threatens its scientific independence. They concluded: “A law that liberates the USPSTF to focus on the science and creates a more appropriate policy body to determine first-dollar coverage for preventive services would enable Congress to defend scientific independence and create a wiser structure for achieving the good intentions of the ACA.”

Misinformation Lives On

Like a bogus viral email that won’t die, false and misleading information about mammograms and the Affordable Care Act continues to circulate, as evidenced by the questions we’ve received from readers over the past several months. One recent source of such misinformation is a Sept. 25 interview on Fox News’ “Fox & Friends” morning show with Dr. Kris Held, an ophthalmologist and ophthalmic surgeon in Texas, a breast cancer survivor and a founder of American Doctors 4 Truth, a group that opposes the Affordable Care Act. (The group was responsible for the ad depicting President Obama throwing a grandmother off a cliff.) The Fox News segment presents a misleading version of the 2009 task force recommendations as new “Restrictions on Mammograms.”

Held talked to Fox News host Elisabeth Hasselbeck, telling her that “Obamacare has panels and task forces which have changed the very recommendations” for mammography. Hasselbeck asks Held to “talk about the changes, the restrictions now,” as a graphic is shown that says “Health Care Law” and “Restrictions on Mammograms.” That’s followed by a second graphic that lists “Mammogram Restrictions” including “Screenings starting at age 50, not 40″ and “Screenings end at age 74.”

That’s a misrepresentation of the 2009 Preventive Services Task Force recommendations, as we’ve explained. The graphics on screen refer to “restrictions” while Held calls them “recommendations,” but nowhere in the segment do Held and Hasselbeck mention that they’re talking about the 2009 recommendations that aren’t part of the law.

When we reached Held by phone, she said that she wasn’t trying to say that women under 50 can’t get a mammogram under the Affordable Care Act. She knew that the 2009 recommendations had been rejected by the law, saying that was “in added on parts to it” and after a “public outcry.”

Held said her point was to criticize the task force and compare the 2009 recommendations with a recent study published in the journal Cancer that found a significant death rate among younger women who didn’t get regularly mammograms. She said that “experts in the field” come up with “very different recommendations” than the Preventive Services Task Force, which the law refers to in determining free preventive coverage requirements. She said that “government task forces are different” and factor in “allocation of resources.”

“I think those task force recommendations were appalling” she said of the 2009 recommendations. “So they got addressed and [the law] got changed.” But, “what happens in the future?”

That point, however, wasn’t made in the news segment, which leaves the distinct impression that Obamacare is restricting women’s ability to get a mammogram or have one covered by insurance. Held twice stressed to us that it was “really hard in three minutes” to get her points across. We asked in a follow-up email if she thought there should be a clarification or correction to the segment, and she replied: “The clarification to the segment should be for me to emphasize more clearly how horrible the USPSTF is and how powerful their bad recommendations are.”

Held told us over the phone that there was nothing stopping insurance companies from not covering mammograms before the Affordable Care Act, but now “you’re forced to buy something and pay for services you may or may not want.” Indeed, the American Doctors 4 Truth 11-point plan for a health care overhaul says insurance should cover “unanticipated” care, not preventive. “The notion that insurance is pre-payment for routine and preventive healthcare cannot be fiscally sustained,” it says.

In the Fox News interview, Hasselbeck asks about screenings ending at age 74, saying, “You’re 75 years old, even if you’ve had a history? How can this be?”

Held responds: “What does that tell you? They don’t even want to know because I guess they don’t want to spend the money then to go ahead and treat you.”

In our phone interview, Held maintained that mammograms weren’t covered by Medicare for women over age 74, saying her 78-year-old mother “went to have one, and they didn’t cover it this year.” But after we challenged that, Held said, in a subsequent email, that her mother “got through to Medicare” on Oct. 16, and was told annual mammograms are covered, and a letter she says her mother had received denying coverage was wrong. She said she would send us the letter, and we will update this article if we receive it. “In fact, if a doctor says it’s medically necessary a woman could even have one more often” than annually, Held wrote. “I hope it stays that way.”

That makes at least one senior who is no longer misinformed about mammograms and Obamacare.

– Lori Robertson

Sources

Centers for Medicare & Medicaid Services. Your Medicare Coverage — Mammograms. Medicare.gov. accessed 18 Oct 2013.

Medicare Rights Center. “Medicare coverage of mammogram screenings.” Medicareinteractive.org. accessed 18 Oct 2013.

U.S. Department of Health and Human Services. “Preventive Services Covered Under the Affordable Care Act.” HHS.gov. accessed 18 Oct 2013.

American Cancer Society. “American Cancer Society recommendations for early breast cancer detection in women without breast symptoms.” Cancer.org. accessed 18 Oct 2013.

Mona Shah, associate director of federal relations for the American Cancer Society Cancer Action Network. Phone interview with FactCheck.org. 16 Oct 2013.

Mitchell Clark, the senior communications associate, Medicare Rights Center. Email interview with FactCheck.org. 17 Oct 2013.

Carol Goodwin, associate vice president of communications, American Geriatrics Society. Phone interview with FactCheck.org. 16 Oct 2013.

U.S. Preventive Services Task Force. “About the USPSTF.” uspreventiveservicestaskforce.org. accessed 18 Oct 2013.

U.S. Preventive Services Task Force. “Screening for Breast Cancer (2002).” accessed 18 Oct 2013.

U.S. Preventive Services Task Force. “Screening for Breast Cancer, Recommendation Statement” (2009). accessed 18 Oct 2013.

U.S. Preventive Services Task Force. “Grade Definitions After May 2007.” accessed 18 Oct 2013.

Henig, Jess. “Breast Cancer Ballyhoo.” FactCheck.org. 12 Mar 2010.

Susan G. Komen for the Cure. “Susan G. Komen for the Cure® Recommends No Impediments to Breast Cancer Screening.” press release. 16 Nov 2009.

Sebelius, Kathleen. Secretary Sebelius Statement on New Breast Cancer Recommendations. press release. HHS.gov. 18 Nov 2009.

Love, Susan. A Message from Dr. Love about the New Mammography Guidelines. Dr. Susan Love Research Foundation. 18 Nov 2009.

O’Neil Hill, Lisa. “After the mammogram storm, what should women do?” CNN.com. 3 Aug 2011.

Mikulski, Barbara A. “Senate Approves Mikulski Amendment Making Women’s Preventive Care Affordable and Accessible.” press release. mikulski.senate.gov. 3 Dec 2009.

Herszenhorn, David. “Senate Blocks Use of New Mammogram Guidelines.” New York Times. 3 Dec 2009.

Public Law 111–148. Patient Protection and Affordable Care Act. 111th Congress. Enacted 23 Mar 2010.

Susan G. Komen for the Cure. “Newly Announced Rules Expand Access to Mammography and Other Early Detection Services at No Cost to Patients.” press release. 14 Jul 2010.

Woolf, Steven H., MD, MPH and Doug Campos-Outcalt, MD, MPA. “Severing the Link Between Coverage Policy and the US Preventive Services Task Force.” JAMA, Vol 309, No. 18. 8 May 2013.

Fox News. Interview with Dr. Kris Held. “Fox & Friends.” 25 Sep 2013.

American Doctors 4 Trust. americandoctors4truth.org. accessed 18 Oct 2013.

Held, Kris, founder, American Doctors 4 Truth. Phone and email interviews with FactCheck.org. 14-16 Oct 2013.

Medline Plus. “Most Breast Cancer Deaths Occur in Younger, Unscreened Women: Study.” National Institutes of Health. 9 Sep 2013.