The Maryland Public Policy Institute
It’s been a tough autumn for the nation’s new health care law, known as the Patient Protection and Affordable Care Act inside the Beltway and “Obamacare” everywhere else.
First, a new report on employer-provided health insurance found that family premiums increased 9.5 percent in 2011, while the portion of workers covered by employer-provided insurance declined to 58 percent. Then the Obama administration announced that it couldn’t find a way to create a sustainable long-term care insurance program, as required by the new law. And then the latest opinion poll on Obamacare found that it has fallen to a new level of public disfavor, with Democrats increasingly opposed to it.
But the worst news came when a federal health care task force recommended that seemingly healthy men not undergo P.S.A. (prostate-specific antigen) screening for prostate cancer. The announcement may seem unrelated to Obamacare, but its implications are profound.
The task force’s recommendation comes after years of scientific evidence suggesting that P.S.A. screening does not benefit men as a group. The problem is not simply that the test gives false results, though that happens (like other medical tests). The big problem is that P.S.A. screening and follow-up biopsy can’t tell whether a detected cancer is dangerous.
The idea that cancer can be non-dangerous may seem ridiculous. But cancer can be very slow-growing—so slow that the patient will die of other causes long before it becomes a problem. It can also not grow at all, instead existing neutrally in the body like wisdom teeth. And in some cases the body’s own defenses can kill off cancer.
The vast majority of prostate cancer appears to be non-dangerous. Over half of men above age 50 have prostate cancer, as do over 80 percent of men above 70. Yet just 3 percent of men die from the disease.
Another problem is that P.S.A. screening seems to have only modest benefits for men with dangerous cancer. Despite the rise of screening, the frequency of prostate removal surgery and radiation therapy, and the emergence of exotic treatments like hormone therapy, the annual death rate from prostate cancer has declined only a little, from 30 per 100,000 men in 1975 to 25 per 100,000 in 2005.
But isn’t it still worthwhile to undergo screening and receive treatment if the screen and biopsy are positive? The problem is that treatment is risky. About half of men who undergo prostate-removal surgery experience sexual dysfunction; a third have urination problems; and between one and two in a thousand die soon after surgery. Men who undergo radiation treatment also risk impotency and urinary problems (at lower rates than surgery) and 15 percent suffer radiation damage to the rectum, resulting in “moderate or big problems.”
For men with dangerous prostate cancer, the benefits of treatment likely outweigh the risks and side effects. And men experiencing possible symptoms of prostate cancer—urination problems, for instance—should see a doctor (though the cause is often benign). But for healthy men with no symptoms, the task force believes the anxiety and risk of unnecessary treatment outweigh the benefits of P.S.A. screening. (The task force did not consider financial costs.)
What’s this to do with Obamacare? One of the law’s more important provisions is the strengthening of a federal body known as the Independent Payment Advisory Board. IPAB is to “recommend policies to Congress to help Medicare provide better care at lower costs,” with the hope that private insurers will also follow the recommendations. Eliminating coverage of P.S.A. screening would be a prime candidate for IPAB. But history and politics suggest IPAB will have bad results.
In 2009, the same federal task force announced that it did not recommend breast cancer mammography screening for seemingly healthy women under age 50. Its reasons were similar—though less severe—to P.S.A. screening: the benefits to women as a group seem not to outweigh the harms of false alarms and unnecessary treatment. (The task force does recommend screening for women over 50, and women with possible symptoms should see their doctor.)
How did politicians react to that announcement? Congress considered terminating the task force and the Obama administration mandated that government programs continue to provide screening for women in their 40s. Beginning next year, Obamacare will require insurers to cover screening for women in their 40s, with no deductible. That means government is increasing health care costs with no overall benefit to Americans’ health.
Expect a similar response to the P.S.A. recommendation, except that government policy will increase costs and harm Americans’ health. In fact, legislation already mandates that Medicare ignore the task force and continue covering P.S.A. screening.
Of course, no government body can say whether an individual should undergo—and pay for—P.S.A. or mammography screening. Individuals have many different preferences, values and circumstances. Because of that, some people may value the uncertain information provided by screening while others may not. In a perfect world, under limited government, people would bear both the costs and benefits of screening and decide whether or not to have one.
In a less perfect world with a more interventionist government, such decisions are socialized. Government sets policies that generally benefit society, rather than increasing individuals’ freedom to pursue their own benefit. IPAB is part of that world.
But it’s a far less perfect world where government receives an expert recommendation on how to benefit society, but then adopts a policy opposite of that recommendation. That’s what’s happened with mammography screening for women under 50. That’s what’s happening with P.S.A. screening.
And that’s very bad news for Obamacare.
 For more on prostate cancer symptoms, see: Mayo Clinic staff, “Prostate Cancer: Symptoms,” MayoClinic.com, http://www.mayoclinic.com/health/prostate-cancer/DS00043/DSECTION=symptoms, accessed October 14, 2011.
 Nancy-Ann DeParle. “The Facts about the Independent Payment Advisory Board.” White House Blog. April 20, 2011. http://www.whitehouse.gov/blog/2011/04/20/facts-about-independent-payment-advisory-board.
 U.S. Department of Health and Human Services. “Preventive Services Covered under the Affordable Care Act.” HealthCare.gov. July 2010. http://www.healthcare.gov/news/factsheets/2010/07/preventive-services-list.html#CoveredPreventiveServicesforWomenIncludingPregnantWomen.