Normally I’d be thrilled to see women’s health issues make the cover of the New York Times two days in a row, but given the circumstances, I’ll pass.
Coming up right behind the U.S. Preventive Services Task Force report recommending an end to baseline mammograms for women under 50 is news that the American College of Obstetricians and Gynecologists recommends women delay their first Pap test until age 21, and then screen every-other-year rather than annually. If a woman is 30 and older and has three consecutive Pap tests that were normal and has no history of seriously abnormal findings, those screens can stretch to three-year intervals.
Pap smears, similar to mammography, are screening tests designed to detect the presence of abnormal cervical cells. Such cells are often precursors to cervical cancer. Cervical cancer is caused by a sexually transmitted and virtually omnipresent virus human papillomavirus, or HPV. Only some people who are exposed to HPV develop cancer, and for those where cancer does develop it can take 10 to 20 years after viral exposure to manifest.
Based on the same justifications as the USPSTF report, this advice is meant to decrease unnecessary testing and potentially harmful treatment, particularly in younger patients. Doctor advocates supporting the new recommendations argue that the change in Pap screening is more compelling that the change in mammography because there is more potential for harm from the overuse of Pap tests and because as a disease cervical cancer grows very slowly, giving practitioners plenty of time to catch the disease between screenings.
It’s clear that there is a risk of harm in action based on early intervention as a result of abnormal Pap results in some cases. Frequently young women develop changes in cervical cells that if left alone, go away. But because all cellular change appears to be precancerous, and because cervical cancer is an especially lethal form of cancer, when faced with an abnormal Pap result doctors often perform surgery to remove the cells. Those procedures can inadvertently damage the cervix and lead to problems later if a woman becomes pregnant, including premature birth and an increased risk of needing a Caesarean delivery.
So that’s the science. But what about the politics? Perhaps it is simply a case of unfortunate timing, but what should be a difficult but informed decision on setting women’s health policy has become so inextricably intertwined with the attack against health care reform that it is nearly impossible to react to these reports with anything other than suspicion. As pointed out in Ann Pietrangelo’s critique of the mammography guidelines, even if the reports fail to influence policy makers in Washington they will undoubtedly have the effect of influencing insurance providers, thus making the availability of potentially life-saving screening devices even scarcer.
But that’s the private sector–that is NOT the government rationing health care. And that is an important distinction to make.
It is the inefficiencies inherent in the current insurance model that will make screening tools less available, not any potential-yet-unformed health care reform. These guidelines, and hundreds of others like them that receive far less political attention, are meant to drive doctor’s differential diagnosis, not dictate individual care. At the end of the day, in an ideal world, these recommendations would be nothing more than another arrow in the quiver of doctors and patients deciding individual care options. That the tests are not affordable, and that it is actuarial analysis more than clear-cut science forcing the health care industry into this kind of standardization says more about the problem of keeping health care in the for-profit market than anything else.
And that this is the context of the debate shows just how far off the rails the Republicans and a lot of Democrats have taken health care reform. Once again the concessions, the politics, all come at the expense of women having simple, affordable access to screening devices when it is appropriate. Doctors may or may not follow the recommendations, but deviation will depend on a lot of measures, and is is the insurance industry, not research task forces, dictating those measures. From setting standards-of-care for tort claims or actuarial support for denying payment for a procedure, make no mistake about it, it is the insurance industry driving this problem.
But Congress certainly isn’t helping. Those who gave full-throated support of Stupak-Pitts and applauded the systematic stripping of women’s equal access to current health insurance products are decrying these reports as evidence of the beginning of government rationing of health care. Really? Is it so difficult to see the disconnect there or does it just not matter because at the end of the day these representatives are debating about procedures that remain for them at best theoretical. Whatever the conclusion, the one thing becoming clearer and clearer is that, in our current political and cultural climate, women’s health remains optional, expensive, and political, regardless of who drives the debate.
photo courtesy of euthman via Flickr
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