I feel compelled to add my voice to all the others talking about mammograms.

I spent years married to a radiologist who did nothing all day but diagnose DCIS and other cancers. He prided himself on his ability to diagnose ductile carcinoma in situ, and he thought he was saving lives. He didn’t know that many of those never progress, and in fact go away. He died before digital imaging became the norm, and he started to practice before doctors appreciated the dangers of overexposure to radiation. Like many radiologists, he died of cancer.

So my thoughts about mammograms are very complex. I’ll try to sum them up.

1) in America, we overdiagnose many diseases and treat things that don’t need to be treated.
2) medical knowledge is constantly changing
3) most medical knowledge is merely opinion
4) suggesting that we now overexpose women to needless radiation and biopsies isn’t rationing — it’s sound science for today
5) breast cancer and prostate cancer have something in common: they subject men and women to assaults on their dignity and sexuality, sometimes for nothing
6) men and women should be able to make their own choices about screening, so I’m glad insurance is still going to cover mammograms for women in their 40s
7) even my husband used to say that mammograms were not as good at detecting cancer as other forms of imaging for high risk women

See how complicated this is? It’s unfortunate that the panel of “experts,” which apparently didn’t have a breast cancer expert on it, released this while we are debating health care reform. It’s easy to see this new guideline as a way to ration care under “Obamacare.” Between this and the Stupak amendment, it is easy to draw the conclusion that we’re bending the cost curve over the backs of women.

But again, it’s complex. We’ve found out the same things about prostate cancer screening, so it’s not just about women. This is what is known as “evidence-based medicine” : let’s spend the money on things that do work, rather than pitch it away on things that don’t. That makes sense, doesn’t it? Why waste scarce health care dollars. Let’s only do things that are proven to work.

I’m a fan of outcomes-based medicine. I long ago learned that most back surgeries don’t work (for long), and that surgeons sell surgery as a panacea the way pharma sells drugs as a panacea. If we were spending our own money, and not the government’s or an insurance company’s, believe me we’d be finding out the most effective (and cost-effective treatments) before we authorize anything. It’s only because medicine is mostly paid for by third parties much removed from ourselves that we demand everything.

I don’t have the answers. I just want to raise the right questions, and keep us talking rationally instead of degenerating into ideological rants about science-based findings.

The health care industry is spending about $1.5 million a day on lobbying efforts in Congress. Most of those dollars are spent fighting against the threat of “rationing.” That doesn’t count the money that’s spent on TV ads in which disgruntled people from Canada tell why they come to the United States for surgery ( supposedly because public plans ration care.) The rant about rationing is designed to make consumers feel that no one will be able to get in to see a doctor under a public plan, and that grandma will be denied her hip replacement because she’s — heaven forbid — over 65. It’s designed to make efforts at real health care reform fail. Fear can be a powerful motivator, and the lobbyists and advertising campaigns are trying desperately to evoke as much fear as they can in the mind of the consumer, hoping that will influence Congress.

What most Americans don’t realize is that our health care is rationed now. If you aren’t employed by someone who provides health insurance your access to health care is limited by your ability to pay for it. That’s rationing. If you are insured, but your plan doesn’t cover the test your doctor thinks you need, or you think you want, your care is also rationed. It you lose your job, your care is rationed, because you probably can’t afford COBRA. Right now, people who have health insurance that’s provided by their employers feel complacent and, understandably, don’t want reform. That perspective shifts in a minute when they get sick, or are unemployed.

Rationing can be done well. We can ration care that has not been proven to prolong life, or to be effective. My late husband, a radiologist, used to see cancer patients all the time. One of the things that made him most upset was when a patient was given chemotherapy or radiation therapy that would make them sick immediately with only a small chance of prolonging life for a few weeks. He thought that this “standard of care” –try everything — was permanent employment for oncologists, and he often counseled his friends to refuse treatment and live well, if not healthy, until they died.

He died twelve years ago this week. He was a Progressive, a man who believed in access to health care as a right. When he became ill, he looked at his own X-rays, realized he was terminal, and did the same thing he told his patients to do: he refused treatment. He happily played with grandchildren and went out to dinner until a week before he died, and then he asked me to make sure he would not receive any more treatment that wasn’t just to relieve pain and suffering. He rationed himself.

Most of the US’s health care dollars are spent in the last six months of a person’s life, and often the patient doesn’t even want the extraordinary measures, or doesn’t know he or she is receiving them. It’s the family that “tries anything” and authorizes the medical staff to use extreme measures. It’s not the elderly person having a hip replacement that we should ration — it’s the elderly person who wants to die peacefully, but whose relatives won’t let go, whose care should be “rationed.”

And who should make that decision? The patient: far in advance of the moment it occurs. If we could get people to take charge of their own health, create “Advance Directives,” and ask their families to abide by them, we’d have plenty of money to take care of the people who can actually benefit from the care they get. Not everybody can be saved.

Single Payer – Not necessarily socialized medicine. Not even necessarily the government. Just means one set of uniform paper work to one entity with common standards. Could be very efficient.Would certainly drive costs down for providers, who wouldn’t have to employ nine clerical workers for one professional, just to bill insurance companies and collect. Could make claims processing faster, too. Would not necessarily change your choice of provider. Remember: the payer is not the provider.

Public Option – A plan run by an entity like Medicare, which could take all the people who couldn’t afford or get into private plans. Not necessarily cheaper, or worse. But a way to guarantee health care for people who can’t afford it. Doesn’t make paperwork more efficient, but gives people with pre-existing conditions or no employer a place to get affordable insurance.

Rationing – What we all think of when we think single payer or public option. But in actuality, what we have now in America, where if you can’t afford or qualify for insurance, you don’t get care. We have more “effective” rationing of health care in America than any other developed country. It’s just not rational rationing. Rational rationing involves letting the sickest go first, or the ones with the best future potential. In America, the old and the rich go first. Also the extremely poor. The middle goes last.

Pre-existing conditions – the way we ration now. Back problems, depression, asthma, epilepsy, diabetes, high blood pressure, arthritis are some of the most common pre-existing conditions. Let’s not even talk about cancer.

By age 50, most Americans have one of them, and many Americans have as many as three. Pre-existing conditions are used by insurance companies to stop people from qualifying for health insurance, or to limit the insurance to exclude pre-existing conditions (a “rider” attached to a policy), or to make the cost of insurance so high that entire families go bare.

Employer-sponsored coverage – this is what we have (had) now, which most uninformed people want to protect. What “low information voters” don’t realize, is that 1) the cost of health insurance is part of what drove GM into bankruptcy, and makes large employers so anxious to lay people off whenever the economy hiccups 2)that’s one thing that makes the cost of American goods more expensive than those produced elsewhere and has forced manufacturing offshore; 3)small employers are trying to duck it like the plague, because the cost of insurance makes hiring too costly for them.

Who likes employer-sponsored coverage? The health insurance industry, because it has found the deepest pockets to shift the costs to. Who doesn’t like it? Any small business. Anyone who works in a small business. Anyone who is laid off. Anyone who works for him/herself.

Now. Armed with this information, imagine yourself laid off, or with a
pre-existing condition and wanting to work for a small company, or
self-employed. What do YOU think you would want?

Sometimes it’s necessary to walk a mile in the other person’s mocassins, folks.

I don’t have a dog in this hunt, because I’m on Medicare, which is single payer. But I know what it’s like to be over 50 in a small business (my own) with employees I cared about and a hip that needed replacing. I never told anyone about it because I didn’t want a pre-existing condition to raise our rates. As a result, I was bone-on-bone in pain when I reached age 65, and collapsed in a heap in the orthopedic surgeon’s office, thanking God for Medicare.