After all-night markups, two key House committees approved GOP budget legislation that would cut hundreds of billions of dollars from federal health programs over the next decade, mostly from the Medicaid program for people with low incomes or disabilities. The legislation is far from a done deal, though, with at least one Republican senator voicing opposition to Medicaid cuts.

Meanwhile, Health and Human Services Secretary Robert F. Kennedy Jr. testified before Congress for the first time since taking office. In sometimes surprisingly combative exchanges with lawmakers in the House and Senate, Kennedy denied cutting programs despite evidence to the contrary and said at one point that he doesn’t think Americans “should be taking medical advice from me.”

This week’s panelists are Julie Rovner of 麻豆女优 Health News, Julie Appleby of 麻豆女优 Health News, Joanne Kenen of the Johns Hopkins University Bloomberg School of Public Health and Politico Magazine, and Alice Miranda Ollstein of Politico.

Panelists

Among the takeaways from this week’s episode:

• House Republicans this week released 鈥� then quickly ushered through committee 鈥� major legislation that would make deep cuts to federal spending while funding President Donald Trump’s domestic priorities, including renewing tax cuts and boosting border security. A preliminary estimate by the Congressional Budget Office found the bill would cut at least $715 billion from federal health spending over 10 years 鈥� with most of that money coming from the Medicaid program.
• Overall, the House GOP’s proposal would make it harder to enroll, and stay enrolled, in Medicaid and Affordable Care Act coverage. Among other changes, the bill would impose a requirement that nondisabled adults (with some exceptions) work, volunteer, or study at least 80 hours per month to be eligible for coverage. But Democrats and patient advocates point to evidence that, rather than encouraging employment, such a mandate results in more people losing or dropping coverage under burdensome paperwork requirements.
• Republicans also declined to extend the enhanced tax credits introduced during the covid-19 pandemic that help many people afford ACA marketplace coverage. Those tax credits expire at the end of the year, and premiums are expected to balloon, which could prompt many people not to renew their coverage.
• And Kennedy’s appearances on Capitol Hill this week provided Congress the first opportunity to question the health secretary since he assumed his post. He was grilled by Democrats about vaccines, congressionally appropriated funds, agency firings, and much more.

Plus, for “extra credit,” the panelists suggest health policy stories they read this week that they think you should read, too:听

Julie Rovner: The New York Times’ “,” by Rob Copeland.听听

Alice Miranda Ollstein: ProPublica’s “” by Margaret Coker, The Current.

Julie Appleby: Scientific American’s “,” by Andrea Thompson.听听

Joanne Kenen: The Atlantic’s “,” by Nicholas Florko.

Also mentioned in this week’s podcast:

• Politico’s “,” by Alice Miranda Ollstein.
• The New York Times’ “,” by Sen. Josh Hawley (R-Mo.).
• NPR’s “,” by Pien Huang.

[Editor’s note: This transcript was generated using both transcription software and a human’s light touch. It has been edited for style and clarity.]听

Julie Rovner: Hello and welcome back to “What the Health?” I’m Julie Rovner, chief Washington correspondent for 麻豆女优 Health News, and I’m joined by some of the best and smartest health reporters in Washington. We’re taping this week on Thursday, May 15, at 9:30 a.m. As always, and particularly this week, news happens fast and things might have changed by the time you hear this. So, here we go.听

Today we are joined via videoconference by Alice Miranda Ollstein of Politico.听

Alice Miranda Ollstein: Hello.听

Rovner: Joanne Kenen of the Johns Hopkins Bloomberg School of Public Health and Politico.听

Joanne Kenen: Hi, everybody.听

Rovner: And my 麻豆女优 Health News colleague Julie Appleby.听

Julie Appleby: Hi.听

Rovner: No interview this week because so much news, so we will get straight to it. So, quiet week, huh? Just kidding. The House Ways and Means and Energy and Commerce committees completed all-nighter markups on their portions of President [Donald] Trump’s “one big, beautiful” reconciliation bill. And in fact, Ways and Means is officially calling it the “One, Big, Beautiful Bill” in its summary of the measure.听

We will start with Energy and Commerce, which after a 26-hour marathon, one hour short of the record it set in 2017, voted out its part of the bill Wednesday afternoon, including an estimated $715 billion in reductions to health programs, mostly Medicaid, over the next 10 years. Now, the final committee bill does not include the threatened cuts to the 90% match for the Affordable Care Act expansion population, nor does it include the per capita cap for that population.听

Nonetheless, it would represent the biggest cut to Medicaid in the program’s 60-year history. Guys, tell us some of the things that it would do instead to get to that $715 billion amount.听

Kenen: The 715 includes some ACA cuts as well. It’s not 100% Medicaid, but it’s largely Medicaid. The biggest one is the one that we knew was almost inevitable given the current Congress, which is work requirements. It is something the Republicans have wanted a long time. In the prior administration, a few states did pass them. Arkansas got going with them. The courts stopped it.听

The Medicaid statute is pretty clear that it’s about health, not about health for working people. The courts today are different. If I had to guess, I would guess there will be a legal battle and that the courts are likely to uphold work requirements.听

Rovner: We’ll talk more about work requirements in a minute. But what else is in the bill?听

Kenen: There’s lots of extra layers of verification. Supposedly, it’s about fraud. We can get to the Kennedy testimony later, but there were some assertions that did not add up for me. The biggest thing is work requirements, and there’s other things that will make it harder to maintain coverage, that it’s not that tou’re getting kicked off, per se. And there are also some copays. There are some copays for the upper rank. There’s been a lot of information this week. And if I get any details wrong, because we’ve all had to absorb a lot in 48 hours, someone correct me. But my recollection was a $35 copay for certain treatments for the people who are on the higher end of the income.听

Rovner: Right, meaning over 100% of poverty鈥斕�

Kenen: Right.听

Rovner: 鈥攂ut still under the level required to qualify for Medicaid.听

Appleby: Right. It would require states actually to impose these cost sharings of up to $35 per service. Although they’re excluding some things like primary care, emergency stuff, that kind of thing, for people in that 100% of poverty to 138% of poverty, and there’s also an upper limit of 5% of the family’s income. But that’s a lot for people in that category.听

Rovner: And we know, there is an enormous body of research that says when you put copays on services, people get fewer of them. And it’s not like people who are just scraping by have a lot of extra money to spend. So we know that one of the ways that they’ll save money is that people won’t get services, presumably needed services.听

Kenen: Although the primary care exemption is important, because primary care, which also usually includes pediatricians, are considered primary care, can deal with a lot of diseases that you don’t always need to see a specialist. I’m not saying it’s a good idea. I’m just saying in terms of an incentive to get basic care, keeping primary care free is an important distinction.听

Rovner: Well, I do want to talk a little bit about that work requirement, which Massachusetts Democratic Rep. Jake Auchincloss called not a work requirement but a paperwork requirement. Once more, for those who haven’t heard us explain this 100 times, it’s not just people who don’t work who lose coverage because of this. I see you nodding, Alice. Please explain this again.听

Ollstein: Yes. So Democrats really hammered over the course of this 26-hour hearing that the only states that have made a foray in this direction so far, Arkansas and Georgia, have seen that these work requirements do not boost employment. They kick people off who should have been eligible because they can’t navigate, like you said, the paperwork. And so it was really striking, over this hearing, where 鈥� I watched from 8 a.m. Wednesday to 2 p.m. Wednesday 鈥� and during that whole time, every single amendment vote was party-line. Nobody crossed in either direction. So this was really a political exercise in Democrats because they were not able to convince Republicans to change or soften the bill at all. They really focused on branding it, branding it as punishing the poor and threatening their health care.听

And so they were pointing to what happened in Arkansas, what happened in Georgia, where the work requirements really were successful in only that they cut people from the rolls and saved the states money, not successful in helping people find work or helping people get coverage. They also made an effort to brand the copays issue. I heard Democrats calling it a “sick tax.” We’ll see if that phrase sticks around throughout this process.听

Rovner: So kind of in an interesting twist, the work requirements in the bill don’t become mandatory until the year 2029. That suggests to me that those who voted for this don’t really want it to take effect, but they do want to be able to count the savings to pay for other things in the bill. And then, cherry on top of the sundae, if Democrats want to repeal the work requirements later, they would have to find a way to pay for them, because the savings would get built into the budget baseline. Or is that just me being cynical because I’ve only had like five hours of sleep this week?听

Kenen: Well, there are two important dates between now and 2029. One is the 2026 off-year elections, the House elections and some Senate, and then 2028 is the presidential. So there’s several things that have changed politically about Medicaid in recent years, which we can talk to and which I’ve written about quite extensively. One of them is that a lot of people who are Trump’s base are now on Medicaid and particularly that expansion population, and nobody likes having their health care taken away from them, particularly if it’s free or very, very heavily subsidized in the lower ranks of the exchanges.听

So if you’re going to kick your own voters off of their health care, you’re probably more likely to want to do it after they voted for you again. It is not uniquely cynical. We have seen both parties do similar things over the years, either for budgetary game-playing or for political things. It’s quite notable that this goes into effect in 2029.听

Ollstein: It’s just interesting that this is getting criticized from both sides. So Democrats are upset that Republicans want to reap the nominal savings but not have to look like the bad guy. And conservative Republicans are upset that this doesn’t kick in sooner, because they want stricter work requirements even sooner to cut the program even more. So it’s pleasing few.听

Rovner: Well, as Joanne alluded to, it’s not just Medicaid. This bill is also a bit of a stealth assault on the Affordable Care Act, too. Right, Julie? We haven’t talked about it a lot, but this administration seems to be working very hard to make the ACA a lot less effective. And the combination of reductions in Medicaid and changes to the ACA will mean lots more people will be uninsured if this bill becomes law in its current form. Yes?听

Appleby: There are a lot of moving parts to this. So yeah, let’s back up just briefly and look at March, when the Trump administration did propose their first major rule affecting the Affordable Care Act, and it’s called the Patient Protection and Affordable Care Act; Marketplace Integrity 鈥� it’s a long-name rule. Anyway, it does a bunch of things. For one, it shortens the open enrollment period by about a month. So open enrollment would end on Dec. 15. And notably, this would apply to all states that run their own state-based marketplaces, as well as the federal marketplace. So there’s 16 plus D.C. that do that. So they would all also be tied to this. So that’s one of the things that the rule would do if it’s finalized in its form.听

It would also end a special enrollment period that allows low-income people to essentially enroll anytime during the year. And people who are automatically reenrolled in a zero-premium plan would instead be charged a $5 premium for reenrollment in that same plan until they confirm their eligibility. Now, the Trump administration says that a lot of these rules are in part to try to combat what they say is fraud and waste, and they point to situations where people are being enrolled without their permission or switched to different plans, generally these zero-premium plans, by unscrupulous brokers who are trying to get commissions.听

We’ve written a lot about that over the past year. So they’re saying that, Oh, we need to do this so that people know they’ve been enrolled. The special enrollment period for low-income people they thought was part of that. That’s disputed by a number of places. And some of the states have pushed back on this, too, and said, Hey, we don’t have this problem with fraud, so why would this now apply to us? Why would the special enrollment period, the shortened enrollment period, etc., etc.?听

So those are things in the proposed rule. And the proposed rule acknowledges that it would reduce enrollment by about up to 2 million people in 2026, with coverage losses concentrated in a bunch of states like Alabama, Florida, Georgia, etc. So that’s the proposed rule. And then if you look at the House bill, like, for example, Energy and Commerce, these would codify some of those proposals from that ACA rule. So it would make it harder for a future president to change the rule and that kind of thing.听

So those things that are codified would be 鈥� there’d be more hoops to jump through to verify income, for one thing. That special enrollment period based on income would be barred, and the shorter enrollment period would be in it. And if this goes through, these changes are set to go into effect next year. So a lot of insurers and states would have to scramble to try to get this put in place by then. So that’s just a short thing about what some of the ACA effects would be.听

Rovner: So, it feels like there’s kind of a theme here that’s going to make it harder for people to get on and stay on both the ACA and Medicaid. Is that sort of a fair way to describe this?听

Appleby: Yeah, that’s fair. In the House bills, there are also a lot of things that would bar automatic reenrollment, which a lot of people rely on. People just don’t go back in and sign up for their coverage. They’re automatically reenrolled. The bills differ a little bit. The harshest one would require everybody to sort of verify their income before they can reenroll. There would be a lot more of that. So it would essentially bar reenrollment. And we haven’t even talked about the enhanced tax credits, because that’s also sort of fitting here.听

Rovner: Which was my, yes, my next question. So there’s been a lot of fighting this week about how many people would lose coverage as a result of this bill, and a lot of it is sort of philosophical fighting. We don’t have final CBO [Congressional Budget Office] numbers yet. We may not have them for another week, I am told. But what we do know is one of the things this bill could do but doesn’t do is re-up those additional subsidies that were installed during the Biden administration, during covid, that basically effectively doubled the number of people who enrolled under the marketplaces, right?听

Appleby: It certainly added a lot. Most people who get a subsidy are benefiting from the enhanced subsidies. And remember, these sort of expanded at the lower end and it cut off that cliff at 400% of the poverty level that used to exist where you wouldn’t get a subsidy if you made more than that. So it smoothed all that out. So a lot of people are getting these extra subsidies.听

And a lot of the data I’ve seen have said 鈥� I’m looking at an Oliver Wyman report earlier 鈥� something like, if these enhanced subsidies are allowed to expire at the end of this year, which they’re poised to do unless Congress acts, that, on average, premiums would go up by about 90%. That will be enough to cause a lot of people not to reenroll. So that’s where we’ve seen some of these estimates of I think it’s around 5 million people may not reenroll as a result of that over time.听

That’s a pretty big number. But like you said, there’s a lot of numbers in the mix, but the enhanced premium subsidies do cost taxpayers. It’s not inexpensive. So if they’re looking for savings, which they are, Congress may decide not to extend them. But at the same time, many people and in a lot of states that are dominated by the GOP and others, people are getting these subsidies, and it would suddenly be a huge hit to many people to have a 90% increase in their premiums, for example.听

Rovner: Yeah, as Joanne said. Which you’re about to say again, right? These are Republican voters now, right?听

Kenen: I think that’s more mixed, the upper income within the ACA. We’ve expected that to go away, because there’s a difference between Congress having to yank something away versus something in the law that expires and they have to proactively renew it. We have always anticipated that enhanced subsidies would decline this year. But I just sort of want to point out, during the first Trump administration, without all this coverage, the uninsurance rate rose in the country.听

And that even before ’29, there are all sorts of things, with shortened enrollment periods, how much outreach they do, there’s lots of things even before 2029 that we can expect a fairly significant erosion of health coverage. Not to what it was in pre-ACA levels 鈥� it’s not going to be that extreme, and not all the benefits that those of us with employer-sponsored insurance also get, some things through the ACA.听

So this is not repeal 鈥� it’s damage. And it’s more damage than they did in the first Trump administration. All of us would be extremely surprised if there was not a significant drop in the number of insured Americans one, two years from now.听

Rovner: One of the ways conservatives hope to secure the votes for this bill in the House is a provision that would bar Planned Parenthood from the Medicaid program. This would certainly be popular in the House. But when it was in the Affordable Care Act repeal bill in 2017, the Senate parliamentarian ruled that it couldn’t be included in budget reconciliation, because it is not primarily budgetary. Alice, are House leaders just hoping no one will remember that?听

Ollstein: If at first you don’t succeed, try, try again. Yes, I think so. And especially because we just got a new CBO estimate of what the budgetary impact of cutting these funds would be. And it’s, like they have found before, it does not save money. It actually costs the government money because people lose access to contraception and don’t have other sources that they can afford to obtain contraception. And it’s a lot more expensive to have a baby on Medicaid than to access contraception. So I think that also contributes to the parliamentarian problem.听

Rovner: Yes. You can put stuff in reconciliation that costs money, but that was sort of not the intent here. Joanne, you wanted to say something.听

Kenen: And we should point out that this is still at the committee level, right? Is it going to get through the House in this exact form? We can’t be sure yet. Is something going to get through the House at the end of the day? Yes. Yes. But is all of this going to get in? Is this the final draft? Probably not. You have moderates who are still, don’t like some of the things in here, and you have conservatives who think it doesn’t go far enough.听

As we said at the beginning, as far as it does go, it does not go anywhere near as far as the initial, of some of the things that were being discussed, which really would have ended Medicaid as an entitlement. These are big changes. They’re not existential in the same way that a per capita cap or a block grant or blowing up the ACA expansion by changing the rates. There are things they could have done that were far more radical that they don’t have the votes for. And鈥斕�

Rovner: But they still can only lose, what, three or four votes and get something through the House.听

Kenen: Right. Right. Because Medicaid is actually quite popular, and people in both parties are covered by it. We still don’t know the pathway, what gets through the House at the end of the day. Something does, right? We all think that they will, somehow or other. Not necessarily by Memorial Day, right? But something at some point will get through the House, and we don’t know exactly what it looks like.听

Rovner: For the record, I’m still shrugging. I think something gets鈥斕�

Kenen: And it is a bigger question mark, you know?听

Rovner: Which is my next question. What are the prospects for this bill in the Senate? Do we really believe that the very conservative Missouri Republican Josh Hawley would vote against this? He had a piece in The New York Times this week saying, “.”听

Kenen: He’s been really consistent. Have we seen politicians do huge flip-flops in our years of covering Congress and politics? Yes. He’s really out there on this. It’s sort of hard to see how he just says, Whoops, I didn’t really mean it. But right now in terms of who’s out there in public, we don’t have a critical mass of people who’ve said they can’t vote for this. But we do know there are provisions in this very extensive bill that some people don’t like. It will go through changes in the Senate.听

I don’t have a grasp and I don’t think any of us have a grasp on exactly what’s going to change. I think work requirements, depending on what bells and whistles are attached, could get through the Senate. There might be changes like making it a state option or redefining certain things with it. I think there probably are 51 votes for a work requirement of some type in the Senate.听

That doesn’t mean the way this has been written survives. And there’s just 鈥� these are big cuts. And there’s also, remember, we’re only talking about the health stuff. There’s a lot. There’s energy. There’s all sorts of 鈥� this is a big bill. This is a big, historic bill. There’s lots and lots of hurdles. We all remember that the ACA repeal, it took several tries. It was really harder than expected. It finally got through the House, and it did die in the Senate. So this is not the last word. We don’t have to shut the podcast.听

Rovner: Yes, long way to go. All right, moving on. Health and Human Services Secretary Robert F. Kennedy Jr. testified before not one but two committees on Wednesday: the House labor, HHS Appropriations subcommittee in the morning and the Senate Health, Education, Labor, and Pensions Committee in the afternoon. And shall we say it didn’t all go swimmingly. Right off the bat, this was the greeting he got from House Appropriations Committee ranking member Rosa DeLauro of Connecticut. DeLauro basically saying, Everything you’re doing is illegal.听

Rep. Rosa DeLauro: Mr. Secretary, this administration is recklessly and unlawfully freezing and stealing congressionally appropriated funds from a wide swath of agencies, programs, and services across the government that serve the American people. And recall that this is a violation of the Constitution.听

The power of the purse resides with the Congress. It’s Article 1, Section 9, Clause 7. Yourself and President Trump and Elon Musk are attacking health programs to pay for tax cuts for billionaires. And by promoting quackery, we are endangering the health of the American people with pseudoscience, fearmongering, and misinformation.听

Rovner: If you want to hear more, we did a live recap of the hearings yesterday afternoon. You can find that on . But I want to know what you all took away from the hearings. Joanne, you watched most of them, right?听

Kenen: I watched a lot of it. I did not watch every minute of both hearings, but I watched enough. And I thought that very first exchange with DeLauro was really striking because she kept saying, over and over and over again she kept saying: Congress appropriated this money. You don’t have the right to not spend it. And he kept saying, If you appropriate the money, I will spend it. And she said, We have appropriated the money, and you’re not spending it. And he said, If you appropriate the money 鈥�听

And she explained. What a continuing wrestle. It was like this endless 鈥� well, it wasn’t endless, but it was repeated when she kept saying, We appropriated it, and he kept saying, Huh? And she actually said the first time sort of under her breath, but the mic picked it up, and then she said it again. She said, “Unbelievable.” She’s not known for understatement, but she said, “Unbelievable.” And then she said it again. “Unbelievable.” So that was sort of 鈥� the rest of the day was sort of there.听

Rovner: Yeah. I personally found it refreshing that someone finally called out HHS, saying: You know, there was an appropriations bill that got signed by the president, and you are withholding this money. And this is our province. We get to decide how the money is spent. You don’t get to decide how the money is spent. The other big headline that came out of this hearing was when Kennedy said that, after being raked over the coals again about his vaccine comments, he said, Well, you shouldn’t be taking medical advice from me. And I’m like, isn’t that the job of the HHS secretary?听

Ollstein: It was very clear that, like in the markups of the bill, Democrats, unless Republicans are willing to cross the aisle and join them, are just left sort of railing against what’s happening and not really having any power to impact it. We did see some Republicans expressing some concern about the cuts that have happened. But unless that turns into real oversight action, real legislative action, I just imagine we’re set up for this to happen again where Congress appropriates and the cuts happen anyway.听

Rovner: I was surprised at how much Sen. Cassidy, Sen. Bill Cassidy, the chairman of the HELP Committee, didn’t say. He basically said when he voted for Kennedy’s nomination that he was torn. He believes in vaccines. He’s a practicing doctor. He, Cassidy. And he made Kennedy promise that he wasn’t going to change any of these vaccine rules, which he’s already done. And he’s installed anti-vax people at many levels of HHS. And yet Cassidy was incredibly conciliatory in his opening statement.听

And it was left to Chris Murphy of all people, the firebrand Democrat from Connecticut, to basically be Cassidy’s anger manager. And sort of, he said, “If I were the chairman 鈥� my head would be exploding,” which I believe is a line that I’ve been saying for the last several months. What’s happening with Cassidy? Do we know? He can’t be happy with what’s happening here.听

Ollstein: This was well previewed by everything Cassidy has sort of put out publicly since the confirmation hearing. If you track his press releases, they’ve been sort of selectively praising HHS for doing certain things and being silent on the things that we imagine he might not like on the vaccine front. And so that dynamic carried forward right into this hearing, which was the first opportunity for Congress to really grill Kennedy since he’s taken office.听

And so many people have pointed out that Cassidy is up for reelection. He is facing a primary challenge from the right. He wants to align himself with the Trump administration and with the sort of “MAGA [Make America great Again]” movement. And he has pushed back on accusations that his treatment of Kennedy is influenced by that, but people can draw their own conclusions.听

Kenen: I also wanted to point out that Kennedy insisted that he hadn’t fired any scientists, and he made that assertion a few times, which I think the Democrats, their jaws collectively dropped in unison. The cuts to NIH [the National Institutes of Health] have been extreme, in the billions. And in addition to the NIH scientists, there are also the ripple effect of training the next generation of scientists, because of the cuts to universities.听

And also Kennedy, I sort of noticed at one point he was saying something about some universities don’t need this money, but then he mentioned specifically but Maine, where Susan Collins is the chair of the Appropriations Committee of the Senate, and Alabama, where Katie Britt has been, Sen. Katie Britt, has been sort of vocal about this, which is also, people don’t think of or may not realize that University of Alabama is a huge scientific center.听

It is a powerhouse, but it is a state-funded university without such a big environment. Kennedy said: You know what? We’re going to make these cuts. But maybe not Maine and Alabama. It was like 鈥� talk about politics. But I think that they were really floored when he said over and over again that no scientists have been let go.听

Rovner: You were right. There was also a lot of sort of ad hoc, If you have a particular problem, why don’t you鈥斕�

Kenen: Call my office.听

Rovner: 鈥�call my office. Yeah. And we can take care of it. Which seemed just sort of mind-blowing to me. It’s like, this is how we’re making policy now. And somebody, I meant to go back and look at who, somebody in the morning at the House hearing, one of the Democrats, said, Is there a special phone number for Democrats to call your office to see if we can get some of these cuts restored? That literally seems to be how HHS is being run right now.听

Ollstein: And I think it’s reflected across the government. When Elon Musk was more involved directly with the DOGE [Department of Government Efficiency] stuff, he was reportedly telling Republican senators the same. Oh, if you have an issue, you know, just text me, just call me. And folks who study government pointed out that this smacks of the kind of personalism that has defined some authoritarian governments in the past where things happen more through favors than through normal government processes that are more transparent.听

Kenen: And a phone call from your senator is not how you should be able to get back into a clinical trial. There was also a lot of exchanges about what’s happening to clinical trials and harm to patients, which he was 鈥� there was some gaps there. And you’re watching him saying, Oh yeah, I can get her in. Just, you call me tomorrow. Call my office, to Sen. [Patty] Murray. And the state of him asserting that not much has changed and anything we got wrong we’ll fix versus the fact that huge numbers of things have changed that have affected both patients and future patients.听

One of the Democrats said: What’s wrong with researching cancer and Alzheimer’s, particularly if you’re trying to deal with chronic diseases? These are chronic conditions, and we’re gutting research into them. So there was a lot of disconnects. There was some, also鈥斕�

Rovner: It’s not just cuts. They are pushing the “Make America Healthy Again” agenda. Just this week the FDA [Food and Drug Administration] is for kids. These are generally drops, tablets, and lozenges prescribed to kids who live in places that don’t have fluoridated water.听

This move contradicts recommendations from both the CDC [Centers for Disease Control and Prevention] and the U.S. Preventive Health Services Task Force. And RFK was taken to task at the House hearing by Congressman Mike Simpson of Idaho, who’s one of a handful of dentists in the chamber. I have to say I didn’t have eliminating fluoride on my 2025 public health bingo card.听

Ollstein: Yes. And I think that this is raising concerns for a few reasons. One, the public health impact. This goes against decades of research and evidence and the medical community’s consensus. But this also is moving sort of beyond the personal-choice, medical freedom kind of framing that has been used to argue about fluoridating public water. This is taking away a parent’s choice, potentially. If they want these supplements for their kids, they’re not going to be available any longer. And this is exactly what people fear could extend into the vaccine space. It’s not just that it’s going to not have mandates for schools or rules around that, that it won’t even be an option for the people who want it.听

Rovner: All right, well, moving on to abortion, the one piece of potential news out of the Kennedy hearings came in response to a question from the aforementioned Sen. Josh Hawley from Missouri about a new study claiming that the abortion pill mifepristone has way more complications than numerous studies over the past 40 years it’s been in use have found. Alice, tell us about this particular study, which RFK Jr. suggested might prompt the FDA to change the status of the abortion pill.听

Ollstein: So, one, it’s not a study. Even its supporters admit in private that it’s not a study. that a lot of these groups pushing this held recently to talk about how they hoped to use this information to influence government policy. And they noted that because this is something that a conservative think tank just put out themselves, they did not submit it to a medical journal. It did not go through peer review.听

So they said directly that it is not a study in the traditional sense. Still, you have senators and now the secretary of health and human services referring to it as a study and calling for policy changes based on it. So I want people to keep that in mind as this is discussed going forward. These drugs have been available for 25 years now. There have been lots of more rigorous, peer-reviewed studies that have found them to be overwhelmingly safe and effective.听

Some of this new data actually aligns with some of the findings from those previous, more rigorous studies, but their own unique definitions of certain things, calling some things adverse events when the FDA does not consider that to be so, and so medical experts told me, including some from 麻豆女优, that this has so many red flags that they think it could never have been published in a credible medical journal.听

Rovner: And just to clarify, while we’re talking about different time periods: It’s been available in the U.S. for 25 years.听

Ollstein: Yes.听

Rovner: It’s been available internationally since the 1980s.听

Ollstein: Right. Right.听

Rovner: So, it has been well studied for quite a long time. Well, in other abortion news this week, the Texas Legislature is moving forward with a new piece of anti-abortion legislation that can’t be challenged in court, this one aimed at the abortion pill. Alice, this is like Chapter 2 in Texas trying to figure out how they can ban abortion-related things without anybody challenging the law, right?听

Ollstein: There’s a lot of different moving parts right now. There’s that. There’s the new case that’s also pending in Texas, brought by three GOP states seeking to impose national restrictions on abortion pills. There’s this new review that the FDA is allegedly going to undertake around dispensing rules. And so this has been an overwhelming focus of the anti-abortion movement since even before Dobbs, but especially now.听

They know that the ability of people to get these pills prescribed online, sent by mail, is the primary way that people are getting around state bans, other than travel, which is not always possible for folks. And so there are just efforts going on in state legislatures, in Congress, in the FDA, in state courts and federal courts, all to impose restrictions.听

And so it’s a very throw-spaghetti-at-the-wall-and-see-what-sticks approach. But that has proven very effective for them over the decades. Arguably that’s how we got to where we are now, where abortion is banned in much of the country. So it’s something to take seriously and watch carefully.听

Rovner: And this is Texas trying again with this. Individuals can sue other individuals who they think have used the abortion pill. It does not require the involvement of the state to prosecute, which has not, I don’t think, spread beyond Texas at this point, but it would be Texas’ second bite at this apple.听

Kenen: But the proposed language in that bill is extraordinary. We at the state legislature of Texas is passing a bill and no court has the right to review whether it is constitutional, etc. It seems pretty extreme, right?听

Rovner: Well, this was how Texas did their first ban.听

Kenen: Right.听

Rovner: Remember that the Supreme Court allowed it to stand because they weren’t quite sure what to do with it.听

Kenen: But that was also because they did unique legal things in terms of, they sort of created a legal structure. This, the language is in the bill 鈥� and no court can double-check us.听

Rovner: Yeah.听

Kenen: So, and then what else can they use that for, right? And apparently there are even some Republicans who are a little concerned about that language. And I’m not up on the exact makeup of constitutional views of the entire Texas Legislature.听

Rovner: Yes. We should point out, it hasn’t passed the full legislature yet.听

Kenen: No. It’s proposed.听

Rovner: Just the Texas Senate. It’s passed the Senate. We’re awaiting to see if it will pass the Texas House. All right, well, finally in this incredibly newsy week, just before he left for his overseas trip, President Trump unveiled what he touted as an enormous announcement that turned out to be an executive order basically wishing down drug prices by tying them to other countries’ price-controlled prices. Except this isn’t really going to happen anytime soon. Right, Julie?听

Appleby: Well, it is interesting. It’s this “most favored nations” idea that we would tie drug prices in the United States to what’s paid by other countries where they have much stronger drug negotiation issues. And it’s not clear how it works. So yeah, it’s not clear what the path forward is with that.听

Ollstein: The problem with saying drug prices are coming down is if they do not come down, people might be mad at you for saying they’re coming down.听

Rovner: I would say he did wish down the price of eggs. He said that egg prices were coming down when they weren’t, except now they are, because he had nothing to do with them going up or coming down. It had to do with the bird flu. And so now he can say, See, I got egg prices down.听

Kenen: But they’re still higher than they were when he鈥斕�

Rovner: They are still higher than they were.听

Kenen: But they have come down.听

Rovner: But I will say, I was going to say, this is super-clever marketing. This is the one thing that President Trump is really, really good at. He hyped this announcement ahead of time. He actually got headlines insisting that this will really do something. I have had people tell me that they’ve had sort of their grown kids and stuff saying: Oh look, drug prices. He’s going to reduce drug prices. When in fact this is one of those executive orders that just doesn’t really do anything.听

Kenen: We don’t know what’s going to happen to drug prices over the next four years. There’s a law on the books from the Biden administration. In his first administration, I think it might’ve even been a day or two before inauguration, he went on a tear against the drug companies. Remember, he called them killers or something like that. And he also came up with a list of something like 40-odd steps that he could take. And I think half of them had a question mark after them. So he’s been mad at drug prices for a while now. He did not achieve that in the first administration. That’s bipartisan. There’s no Americans who want to pay higher prices for drugs, unless maybe they work for a drug company. People want more鈥斕�

Rovner: Right. It’s an 80/20 issue 鈥� 80% of people want drug prices down.听

Kenen: Right.听

Rovner: That’s probably more than an 80/20 issue.听

Kenen: There could be some room for bipartisanship on drugs. There’s not a lot of room for bipartisanship, but that’s particularly if he’s not trying to repeal what [President Joe] Biden did, if that stays or gets built on. We don’t know what’s going to happen. But no, you can’t just sign an executive order. It’s not a magic wand.听

Rovner: And I don’t think we’re going to be importing other countries’ price controls anytime soon. I’m going to go on a limb on that one. All right, that is this week’s news. Now it is time for our extra-credit segment. That’s where we each recognize a story we read this week we think you should read, too. Don’t worry if you miss it. We’ll put the links in our show notes on your phone or other mobile device. Alice, I want you to go first this week because you have a story that’s directly relevant to something that we talked about in the Medicaid discussion.听

Ollstein: Yeah. So I have this great story from ProPublica [“”] about Medicaid work requirements and about how the small-business owner that Georgia decided to make the face of its program, and they filmed a video of him praising it, even he multiple times lost his coverage, even though he tried to do everything right. He logged his work hours. He signed up for alerts. And just because of bureaucratic things and falling through the cracks, two times he lost his coverage and he had to plead for someone to intervene to get him his benefits back. And he has really soured on all of this, even though he was the face of selling it that the governor used. So I think this is a great example of what could happen as this is debated as a national policy.听

Rovner: And I will say, I learned about this ProPublica story from the markup, where a number of members brought it up. He’s now the poster child for what happens when you have work requirements, even if people are working. Joanne.听

Kenen: There’s a great piece in The Atlantic by Nick Florko called “.” And although it is not in the headline, it’s particularly romaine, which has periodically been in the news as being a source of harmful bacteria. And if you think you can just buy bagged lettuce and wash it yourself and it’ll be safe 鈥� no, that doesn’t work, either.听

Basically it goes through like the equivalent of a salad woodchopper and there are all this different lettuce. All this lettuce goes through it. And once one blade gets contaminated, it all gets contaminated. So also, if you are a part of a marriage or one of you likes romaine and the other one would rather have red leaf, this is pretty good ammunition, right? But we should be going back to buying heads of lettuce, washing them yourself.听

And they’re not as safe and sanitary as it sounds, particularly as some issues are going on right now. And of course, we have less public notification and less monitoring and there’s less, less, less of food safety kinds of things coming down the pike at FDA. So it’s even more timely.听

Rovner: It’s a pretty vivid story. Julie.听

Appleby: Thanks. Mine is also, the story I’ve picked is also along the same lines of cuts and what the perhaps unintended consequences were, but the consequences nonetheless. And it’s from the Scientific American. It’s by Andrea Thompson. The headline is “.”听

And it just talks about the National Weather Service with a lot of interesting facts that I didn’t know for sure, that how the improvements have been made in forecasting, why this is important, and how it’s understaffed, and how these cuts are going to just make things worse. And it talks about it costs the average American, it says, about $4 a year for the National Weather Service. “It’s a cup of coffee,” said one person that’s being quoted.听

And it said the National Weather Service provides an overall benefit of $100 billion to the economy. Aside from the fact that you might want a tornado warning ahead of time, that kind of thing, this is also just really important to quantify the overall value at a time when we are seeing a lot of hurricanes and tornadoes and other climate issues going on. So that would be my pick.听

Kenen: But the Sharpie can just make it move.听

Rovner: Yeah, that’s true. All right, my extra credit this week is what Joanne has dubbed “Theranos for Pets,” though the actual headline in The New York Times is “.” And it’s kind of a scary history-repeats-itself story. Even as Elizabeth Holmes herself remains in jail, having been convicted of fraud over her novel blood-testing company that was really cool but also didn’t work, her partner and the father of her two children, Billy Evans, is raising money for a new blood-testing company.听

He’s called it Haemanthus 鈥� I hope I’ve said that right 鈥� which is a flower also called the blood lily. And unlike his incarcerated partner, Evans plans to start out by testing the blood of pets, then move to humans. As they say, what could possibly go wrong?听

All right, that is this week’s show. As always, if you enjoy the podcast, you can subscribe wherever you get your podcasts. We’d appreciate it if you left us a review. That helps other people find us, too. Thanks as always to our editor, Emmarie Huetteman, and our producer, Francis Yang. Also, as always, you can email us your comments or questions. We’re at whatthehealth@kff.org. Or you can still find me on X, , or on Bluesky, . Where are you guys hanging these days? Julie Appleby.听

Appleby: I’m still on X, .听

Rovner: Joanne.听

Kenen: I’m only a little . I’m more on and , @joannekenen.听

Rovner: Alice.听

Ollstein: Mostly on Bluesky, , and still on X, .听

Rovner: We will be back in your feed next week. Until then, be healthy.听

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Algunos médicos e investigadores que están interesados en un enfoque más individualizado para encontrar tumores problemáticos se muestran escépticos y plantean preguntas sobre los datos y el razonamiento detrás del cambio radical del Grupo de Trabajo de Servicios Preventivos de Estados Unidos con respecto a sus .

“La evidencia para que todas comiencen a los 40 no es convincente”, dijo Jeffrey Tice, profesor de medicina en la Universidad de California-San Francisco.

Tice es parte del equipo de investigación del , que tiene como objetivo, en palabras de Laura Esserman, cirujana de cáncer de seno y líder del equipo, “hacer pruebas de manera más inteligente, no probar más”. Esserman lanzó el estudio en curso en 2016 con el objetivo de adaptar las pruebas de detección al riesgo de una mujer, y poner fin al debate sobre cuándo iniciar las mamografías.

Los defensores de un enfoque personalizado enfatizan los costos de la detección universal a los 40, no en dólares, sino en resultados falsos positivos, biopsias innecesarias, sobretratamiento y ansiedad.

Las pautas provienen del , parte del Departamento de Salud y Servicios Humanos (HHS) federal, un panel independiente de 16 expertos médicos voluntarios que se encargan de ayudar a guiar a los médicos, aseguradoras de salud y legisladores.

En 2009, y de nuevo en 2016, el grupo presentó el , que elevó la edad para comenzar la mamografía de rutina de 40 a 50 años e instó a las mujeres de 50 a 74 a hacérselas cada dos años.

Las mujeres de 40 a 49 años que “le otorgan un mayor valor al beneficio potencial que a los daños potenciales” también deberían someterse al procedimiento de detección, dijo el grupo de trabajo.

Ahora, el grupo ha publicado un borrador de una actualización de sus directrices, recomendando la a partir de los 40 años.

“Esta nueva recomendación ayudará a salvar vidas y evitará que más mujeres mueran debido al cáncer de mama”, dijo Carol Mangione, profesora de medicina y salud pública en UCLA, quien presidió el panel.

Pero la evidencia no es clara. Karla Kerlikowske, profesora de la UCSF que ha estado investigando la mamografía desde la década de 1990, dijo que no vio una diferencia en los datos que justificara el cambio. Dijo que la única forma en que podía explicar las nuevas pautas era un cambio en el panel.

“Son diferentes miembros del grupo de trabajo”, dijo. “Interpretaron los beneficios y los daños de manera diferente”.

Sin embargo, Mangione citó dos puntos de datos como impulsores cruciales de las nuevas recomendaciones: el aumento de la incidencia de cáncer de mama en mujeres más jóvenes, y modelos que muestran la cantidad de vidas que podrían salvar las pruebas de detección, especialmente entre las mujeres negras.

No hay evidencia directa de que evaluar a mujeres de 40 años salve vidas, dijo. La cantidad de mujeres que murieron de cáncer de mama desde 1992 hasta 2020, debido en parte a una detección más temprana y a mejores tratamientos.

Pero los modelos predictivos que construyó el grupo de trabajo, basados en varias suposiciones en lugar de datos reales, encontraron que expandir la mamografía a mujeres de 40 años podría evitar 1.3 muertes adicionales por cada 1,000 en esa cohorte, dijo Mangione. Lo más crítico, agregó, es que un nuevo modelo que incluye solo mujeres negras mostró que se podría salvar 1.8 por 1,000.

Un aumento anual del 2% en la cantidad de personas de 40 a 49 años diagnosticadas con cáncer de mama en el país entre 2016 y 2019 alertó al grupo de trabajo sobre una tendencia preocupante, dijo.

Mangione lo llamó un “salto realmente considerable”. Pero Kerlikowske lo llamó “bastante pequeño” y Tice lo llamó “muy modesto”: percepciones contradictorias que subrayan cuánta subjetividad está involucrada en la ciencia de las pautas de salud preventiva.

A los miembros del grupo de trabajo los designa la Agencia para la Investigación y la Calidad de la Atención Médica del HHS, y cumplen mandatos de cuatro años. El nuevo borrador de las pautas está abierto para . Después de incorporar los comentarios, el grupo de trabajo planea publicar su recomendación final en JAMA, la revista de la Asociación Médica Estadounidense.

Cerca de 300,000 mujeres serán diagnosticadas con cáncer de mama en el país este año, y morirán más de 43,000 por este mal, según proyecciones del . Muchos consideran que expandir la detección para incluir a mujeres más jóvenes es una forma obvia de detectar el cáncer antes y salvar vidas.

Pero los críticos de las nuevas pautas argumentan que hay verdaderas concesiones.

“驴Por qué no empezar al nacer?”, ironizó Steven Woloshin, profesor del Instituto de Políticas de Salud y Práctica Clínica de Dartmouth. “驴Por qué no todos los días?”.

“Si no hubiera inconvenientes, eso podría ser razonable”, dijo. “El problema son los falsos positivos, que dan mucho miedo. El otro problema es el sobrediagnóstico”. Algunos tumores de mama son inofensivos y el tratamiento puede ser peor que la enfermedad, enfatizó.

Tice estuvo de acuerdo en que el sobretratamiento es un problema subestimado.

“Estos cánceres nunca causarían síntomas”, dijo, refiriéndose a ciertos tipos de tumores. “Algunos simplemente retroceden, se encogen y desaparecen, son de crecimiento tan lento que una mujer muere de otra cosa antes de que causen problemas”.

Las pruebas de detección tienden a encontrar cánceres de crecimiento lento que tienen menos probabilidades de causar síntomas, dijo. Por el contrario, las mujeres a veces descubren cánceres letales de crecimiento rápido poco después de haberse realizado mamografías que salieron normales.

“Nuestro fuerte sentimiento es que una sola talla no sirve para todos y que debe personalizarse”, dijo Tice.

WISDOM, que significa “Mujeres informadas para evaluar según las medidas de riesgo”, evalúa el riesgo de las participantes a los 40 mediante la revisión de los antecedentes familiares y la secuenciación de nueve genes. La idea es comenzar con mamografías periódicas de inmediato para las mujeres de alto riesgo mientras que esperar para las de menos.

Las mujeres negras no hispanas tienen más probabilidades de hacerse mamografías de detección que las mujeres blancas no hispanas. Sin embargo, tienen un 40% más de probabilidades de morir de cáncer de seno y de que les diagnostiquen cánceres mortales a edades más tempranas.

El grupo de trabajo espera que las mujeres negras se beneficien más de la detección temprana, dijo Mangione.

No está claro por qué las mujeres negras tienen más probabilidades de sufrir cánceres de mama más letales, pero las investigaciones apuntan a disparidades en el tratamiento.

“Las mujeres negras no obtienen un seguimiento de las mamografías tan rápido ni un tratamiento adecuado tan rápido”, dijo Tice. “Eso es lo que realmente impulsa las discrepancias en la mortalidad”.

También continúa el debate sobre la detección en mujeres de 75 a 79 años. El grupo de trabajo optó por no pedir pruebas de detección de rutina en el grupo de mayor edad porque un estudio observacional no mostró ningún beneficio, dijo Mangione. Pero el panel emitió un llamado urgente para investigar si las mujeres de 75 años o más deberían hacerse una mamografía de rutina.

Los modelos sugieren que evaluar a las mujeres mayores podría evitar 2,5 muertes por cada 1,000 mujeres en ese grupo de edad, más de las que se salvarían al expandir la evaluación a las mujeres más jóvenes, apuntó Kerlikowske.

“Siempre decimos que las mujeres mayores de 75 años deberían decidir junto con sus médicos si se hacen mamografías, según sus preferencias, valores, historial familiar y de salud”, dijo Mangione.

Tice, Kerlikowske y Woloshin argumentan que lo mismo es cierto para las mujeres de 40 años.

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Some doctors and researchers who are invested in a more individualized approach to finding troublesome tumors are skeptical, raising questions about the data and the reasoning behind the U.S. Preventive Services Task Force’s about-face from its .

“The evidence isn’t compelling to start everyone at 40,” said Jeffrey Tice, a professor of medicine at the University of California-San Francisco.

Tice is part of the research team, which aims, in the words of breast cancer surgeon and team leader Laura Esserman, “to test smarter, not test more.” She launched the ongoing study in 2016 with the goal of tailoring screening to a woman’s risk and putting an end to the debate over when to get mammograms.

Advocates of a personalized approach stress the costs of universal screening at 40 鈥� not in dollars, but rather in false-positive results, unnecessary biopsies, overtreatment, and anxiety.

The guidelines come from the federal Department of Health and Human Services’ , an independent panel of 16 volunteer medical experts who are charged with helping guide doctors, health insurers, and policymakers. In 2009 and again in 2016, the group put forward the , which raised the age to start routine mammography from 40 to 50 and urged women from 50 to 74 to get mammograms every two years. Women from 40 to 49 who “place a higher value on the potential benefit than the potential harms” might also seek screening, the task force said.

Now the task force has issued a draft of an update to its guidelines, for all women beginning at age 40.

“This new recommendation will help save lives and prevent more women from dying due to breast cancer,” said Carol Mangione, a professor of medicine and public health at UCLA, who chaired the panel.

But the evidence isn’t clear-cut. Karla Kerlikowske, a professor at UCSF who has been researching mammography since the 1990s, said she didn’t see a difference in the data that would warrant the change. The only way she could explain the new guidelines, she said, was a change in the panel.

“It’s different task force members,” she said. “They interpreted the benefits and harms differently.”

Mangione, however, cited two data points as crucial drivers of the new recommendations: rising breast cancer incidence in younger women and models showing the number of lives screening might save, especially among Black women.

There is no direct evidence that screening women in their 40s will save lives, she said. The number of women who died of breast cancer from 1992 to 2020, due in part to earlier detection and better treatment.

But the predictive models the task force built, based on various assumptions rather than actual data, found that expanding mammography to women in their 40s might avert an additional 1.3 deaths per 1,000 in that cohort, Mangione said. Most critically, she said, a new model including only Black women showed 1.8 per 1,000 could be saved.

A 2% annual increase in the number of 40- to 49-year-olds diagnosed with breast cancer in the U.S. from 2016 through 2019 alerted the task force to a concerning trend, she said.

Mangione called that a “really sizable jump.” But Kerlikowske called it “pretty small,” and Tice called it “very modest” 鈥� conflicting perceptions that underscore just how much art is involved in the science of preventive health guidelines.

Task force members are appointed by HHS’ Agency for Healthcare Research and Quality and serve four-year terms. The new draft guidelines are until June 5. After incorporating feedback, the task force plans to publish its final recommendation in JAMA, the Journal of the American Medical Association.

Nearly 300,000 women will be diagnosed with breast cancer in the U.S. this year, and it will kill more than 43,000, according to . Expanding screening to include younger women is seen by many as an obvious way to detect cancer earlier and save lives.

But critics of the new guidelines argue there are real trade-offs.

“Why not start at birth?” Steven Woloshin, a professor at the Dartmouth Institute for Health Policy and Clinical Practice, asked rhetorically. “Why not every day?”

“If there were no downsides, that might be reasonable,” he said. “The problem is false positives, which are very scary. The other problem is overdiagnosis.” Some breast tumors are harmless, and the treatment can be worse than the disease, he said.

Tice agreed that overtreatment is an underappreciated problem.

“These cancers would never cause symptoms,” he said, referring to certain kinds of tumors. “Some just regress, shrink, and go away, are just so slow-growing that a woman dies of something else before it causes problems.”

Screening tends to find slow-growing cancers that are less likely to cause symptoms, he said. Conversely, women sometimes discover fast-growing lethal cancers soon after they’ve had clean mammograms.

“Our strong feeling is that one size does not fit all, and that it needs to be personalized,” Tice said.

WISDOM, which stands for “Women Informed to Screen Depending On Measures of risk,” assesses participants’ risk at 40 by reviewing family history and sequencing nine genes. The idea is to start regular mammography immediately for high-risk women while waiting for those at lower risk.

Black women are more likely to get screening mammograms than white women. Yet they are 40% more likely to die of breast cancer and are more likely to be diagnosed with deadly cancers at younger ages.

The task force expects Black women to benefit most from earlier screening, Mangione said.

It’s unclear why Black women are more likely to get the most lethal breast cancers, but research points to disparities in cancer management.

“Black women don’t get follow-up from mammograms as rapidly or appropriate treatment as quickly,” Tice said. “That’s what really drives the discrepancies in mortality.”

Debate also continues on screening for women 75 to 79 years old. The task force chose not to call for routine screening in the older age group because one observational study showed no benefit, Mangione said. But the panel issued an urgent call for research about whether women 75 and older should receive routine mammography.

Modeling suggests screening older women could avert 2.5 deaths per 1,000 women in that age group, more than those saved by expanding screening to younger women, Kerlikowske noted.

“We always say women over 75 should decide together with their clinicians whether to have mammograms based on their preferences, their values, their health history, and their family history,” Mangione said.

Tice, Kerlikowske, and Woloshin argue the same holds true for women in their 40s.

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La decisión del Tribunal de Distrito de Estados Unidos para el Distrito Norte de Texas podría abrir la puerta para que las aseguradoras o los empleadores restablezcan los copagos para algunos de esos servicios preventivos, aunque muchos pueden mostrarse reacios o no podrían hacerlo, al menos de inmediato.

El fallo del se basa en otro previo, de septiembre, en el que también dijo que el requisito de ACA de que los empleadores cubran el tratamiento PrEP (profilaxis previa a la exposición) para prevenir el VIH viola la Ley de Restauración de la Libertad Religiosa (Religious Freedom Restoration Act).

Su fallo es la última de muchas batallas legales por ACA. “Casos anteriores amenazaron la existencia misma de la ley y las protecciones fundamentales. Esta decisión no hace eso”, dijo Larry Levitt, vicepresidente ejecutivo de políticas de salud de 麻豆女优. Pero “anula una parte de la ley, aunque muy popular, que utiliza mucha gente”.

Es casi seguro que este fallo será apelado, posiblemente por ambas partes: los grupos conservadores que presentaron el caso y esperaban que la decisión fuera más amplia, y la administración Biden, que apoya ACA.

“Hay mucho en juego”, porque la decisión final podría afectar a millones de estadounidenses, dijo , director asociado de política de salud e iniciativa legal en el Instituto O’Neill de la Universidad de Georgetown.

“Los estadounidenses deben tener la tranquilidad de que no habrá una interrupción inmediata en la cobertura de atención”, dijo , presidente y director ejecutivo de AHIP, el principal grupo de cabildeo de la industria de seguros de salud.

Ahora, el Departamento de Justicia debe decidir si busca una orden de emergencia que suspenda el fallo durante el proceso de apelación.

La decisión podría afectar los exámenes de detección sin copago y servicios preventivos similares que la mayoría de los estadounidenses con seguro tienen como parte de sus planes de salud. Pero al principio, los consumidores pueden sentir poco impacto.

“La palabra prevención aparece un par de cientos de veces en ACA”, dijo , profesor de derecho emérito de la Facultad de Derecho de la Universidad Washington and Lee, quien sigue de cerca a ACA. “Parte de la idea de ACA fue que pensamos en tratar de prevenir la enfermedad, o al menos identificarla antes, cuando es más curable”.

Hacer que esta atención sea gratuita para los afiliados fue una forma de fomentar la detección de enfermedades.

Pero el fallo de O’Connor dijo que una de las formas en que se seleccionan esos servicios sin costo, tarea que realiza el Grupo de Trabajo de Servicios Preventivos de EE.UU., un grupo asesor no gubernamental, es inconstitucional.

En su opinión de septiembre, O’Connor escribió que los miembros del grupo de trabajo, que es convocado por una agencia federal de salud, son en realidad “funcionarios de los Estados Unidos” y, por lo tanto, deben ser designados por el presidente y confirmados por el Senado.

El juez agregó que su decisión no se aplica específicamente a los anticonceptivos o vacunas sin copago, que son seleccionados por otras agencias, aunque los grupos conservadores que presentaron el caso también habían buscado su inclusión.

Las mamografías se encuentran entre esos servicios preventivos que pueden estar en una categoría especial porque también son recomendadas por una de esas otras agencias, por lo que los expertos de 麻豆女优 dicen que probablemente seguirán cubiertas sin costo compartido para el paciente, incluso con esta decisión.

O’Connor emitió en el caso en septiembre. En ese momento, la decisión se aplicaba únicamente a los empleadores que presentaron el caso.

El fallo del jueves amplía eso a todos los empleadores y aseguradoras en todo el país.

Por ahora, es probable que los consumidores, especialmente aquellos que compran su propia cobertura a través del mercado de seguros establecido por ACA, continúen recibiendo atención preventiva sin costo en muchos planes, dijeron expertos.

Eso se debe a que la mayoría de estos planes se ejecutan en el año calendario y los afiliados esencialmente han firmado contratos “que cubrirán esos servicios hasta fin de año”, explicó Jost.

Aún así, dependiendo del resultado de las apelaciones, con el tiempo cada aseguradora probablemente sopesará los pros y los contras de restablecer los copagos para el paciente.

Comenzarán a tomar “decisiones comerciales para continuar cubriendo sin costo o imponer costos compartidos”, dijo Twinamatsiko.

En los planes basados en el trabajo, a través de los cuales la mayoría de los estadounidenses asegurados obtienen su cobertura, el impacto inicial también puede no sentirse.

El 80% de los directores de recursos humanos dijeron que no restaurarían los costos compartidos para la atención preventiva, según una encuesta no científica reciente de 25 directores de recursos humanos en empresas con un total de alrededor de 600,000 trabajadores.

Hacerlo podría molestar a los empleados, señaló , director de investigación de beneficios de salud en el Employee Benefit Research Institute, que realizó la encuesta. Y cubrir completamente la atención preventiva de los afiliados, sin requerir copagos, es relativamente económico.

En , descubrió que incluso uno de los tratamientos de atención preventiva más costosos, la PrEP, de casi $14,000 al año, para prevenir el VIH, agrega solo un 0.4% al gasto anual del empleador en atención médica. Incluso si un empleador agregara un copago del 20% para el trabajador, reduciría el gasto general en menos de una décima parte del 1%, según el estudio.

Aparte de unos pocos empleadores que podrían querer restringir la cobertura sin costo por motivos religiosos para tratamientos como PrEP, dijo que dudaba que muchas compañías fueran a restablecer los copagos. Gelfand es presidente del , que representa a grandes empleadores autoasegurados.

Los servicios respaldados por el Grupo de Trabajo de Servicios Preventivos de EE.UU. fueron seleccionados porque funcionan y “pueden prevenir condiciones más agudas más adelante”, que son mucho más costosas, dijo Gelfand.

Si bien la mayoría de las recomendaciones del grupo de trabajo no son controversiales, algunas han provocado la protesta de algunos empleadores, incluidas las partes en la demanda, quienes argumentan que no deberían verse obligados a pagar por servicios o tratamientos con los que no están de acuerdo, como medicamentos para la prevención del VIH. .

El fallo de O’Connor confirmó la afirmación del demandante Braidwood Management, una corporación cristiana con fines de lucro propiedad de , que se opone a proporcionar la PrEP gratuita a sus 70 empleados, diciendo que, al hacerlo, entra en conflicto con sus creencias religiosas.

El juez estuvo de acuerdo y dijo que obligar a Braidwood a brindar tal atención gratuita en su plan autoasegurado viola la Ley de Restauración de la Libertad Religiosa.

El fallo que elimina la cobertura preventiva sin costos compartidos para la PrEP por motivos religiosos muestra un “claro sesgo”, dijo Carl Schmid, director ejecutivo del .

Algunos estados han aprobado leyes que seguirán exigiendo la cobertura de los servicios preventivos exigidos por ACA incluso si se eliminan las protecciones federales.

tienen leyes que exigen que las aseguradoras que venden planes individuales cubran los servicios preventivos que requiere ACA, según un análisis realizado por investigadores del Centro de Reformas de Seguros Médicos de Georgetown.

Al igual que ACA, esas leyes estatales exigen la cobertura sin costo para los consumidores.

En algunos de los estados, los trabajadores en planes de seguro grupales regulados por el estado, llamados planes “totalmente asegurados”, también reciben esas protecciones, encontró el análisis.

Esas leyes estatales cubiertos en todo el país cuyos empleadores pagan sus reclamos de atención médica directamente, en lugar de comprar un seguro para ese fin.

En general, los servicios preventivos pueden conducir a mejores resultados, dijo Lisa Lacasse, presidenta de la Red de Acción contra el Cáncer de la Sociedad Americana del Cáncer.

Agregó que millones de personas se someten a pruebas de detección de cáncer de mama, colorrectal, de pulmón o de cuello uterino cada año, y que hay evidencia que muestra que cualquier tipo de copago o deducible disuade a las personas de realizarse las pruebas.

Lacasse dijo que espera que las aseguradoras continúen sin cobrar copagos porque un cambio tan drástico a mitad de año sería destructivo, y que los afiliados deberían seguir recibiendo atención preventiva.

“Si tiene una evaluación, debe seguir adelante con eso”, dijo.

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The decision from the U.S. District Court for the Northern District of Texas could open the door for insurers or employers to reinstate copayments for some of those preventive services, although many may be reluctant or unable to do so, at least immediately.

The ruling by builds on a September judgment in which he also said the ACA requirement that employers cover preexposure prophylaxis treatment to prevent HIV violates the Religious Freedom Restoration Act.

His ruling is the latest shot in the legal battle over the ACA. “Previous cases threatened the very existence of the law and fundamental protections. This decision does not do that,” said Larry Levitt, 麻豆女优 executive vice president for health policy. But “it strikes down a portion of the law, albeit a very popular one, that is used by a lot of people.”

It is almost certain to be appealed, possibly by both sides: the conservative groups that brought the case and had hoped the decision would be broader, and the Biden administration, which supports the ACA.

“The stakes are really high,” because the ultimate decision could affect millions of Americans, said , associate director of the health policy and the law initiative at the O’Neill Institute at Georgetown University.

“Americans should have peace of mind there will be no immediate disruption in care coverage,” said , president and CEO of AHIP, the health insurance industry’s leading lobbying group.

Now, the Department of Justice must decide whether to seek an emergency order putting the ruling on hold during the appeal process.

The decision could affect the no-copay screenings and similar preventive services that most insured Americans have as part of their health plans. But consumers may see little impact initially.

“The word prevention appears a couple hundred times in the ACA,” said , law professor emeritus at Washington and Lee University School of Law, who closely follows the ACA. “Part of the idea of the ACA was we thought to try to prevent disease or at least identify it earlier when it’s more curable.”

Making such care free to enrollees was a way to encourage screening for disease.

But O’Connor’s ruling said one of the ways those no-cost services are selected 鈥� by the U.S. Preventive Services Task Force, a nongovernmental advisory group 鈥� is unconstitutional. In his September opinion, O’Connor wrote that members of the task force, which is convened by a federal health agency, are actually “officers of the United States” and should therefore be appointed by the president and confirmed by the Senate.

The judge said his decision specifically does not apply to no-copay contraceptives or vaccines, which are selected by other agencies, although the conservative groups that brought the case had sought their inclusion as well.

Mammograms are among those preventive services that may be in a special category because they, too, are recommended by one of those other agencies, so experts at 麻豆女优 say they will probably continue to be covered without patient cost sharing, even with this ruling.

O’Connor issued a in the case in September. At the time, the decision applied only to the employers that brought the case.

Thursday’s ruling expands that to all employers and insurers nationwide.

For now, consumers, especially those who buy their own coverage through the ACA marketplace, are likely to continue to get no-cost preventive care in many plans, experts said.

That’s because most such plans run on the calendar year and enrollees have听essentially signed contracts “which will cover those services through the end of the year,” said Jost.

Still, depending on the outcome of the appeals, over time each insurer will likely weigh the pros and cons of reinstituting such patient cost sharing.

They will start to make “business decisions to either continue to cover without cost or to impose cost sharing,” said Twinamatsiko at Georgetown.

In job-based plans, through which most insured Americans get their coverage, initial impact may also be muted.

Eighty percent of human resources directors said they would not restore cost sharing for preventive care, according to a recent nonscientific survey of 25 human resources directors at companies with a collective total of about 600,000 workers.

Doing so could upset employees, noted , director of health benefits research at the Employee Benefit Research Institute, which ran the survey. And fully covering enrollees’ preventive care, without requiring copayments, is relatively inexpensive. In a , he found that even one of the more costly preventive care treatments 鈥� the nearly $14,000-a-year PrEP, to prevent HIV 鈥� adds only 0.4% to annual employer spending on health care. Even if an employer were to add a 20% copayment for the worker, it would reduce overall spending by less than one-tenth of 1%, according to the study.

Outside of a few employers that might want to restrict no-cost coverage on religious grounds for treatments like PrEP, said, he doubted many companies would reinstitute copayments.听Gelfand is president of the , which represents large, self-insured employers.

Services endorsed by the U.S. Preventive Services Task Force were selected because they work and “can prevent more acute conditions later,”听which are far more costly, said Gelfand.

While most of the task force’s recommendations are noncontroversial, a few have elicited an outcry from some employers, including the parties to the lawsuit, who argue they should not be forced to pay for services or treatments they disagree with, such as HIV-prevention drugs.

O’Connor’s ruling upheld the contention by plaintiff Braidwood Management, a Christian for-profit corporation owned by , which objects to providing free PrEP to its 70 employees, saying it runs afoul of its religious beliefs to do so.

The judge agreed, saying that forcing Braidwood to provide such free care in its self-insured plan violates the Religious Freedom Restoration Act.

The ruling eliminating preventive coverage without cost sharing for PrEP on religious grounds shows “clear bias,” said Carl Schmid, executive director of the .

Some states have passed laws that will continue to require coverage of ACA-mandated preventive services even if the federal protections are eliminated.

have laws requiring insurers that sell individual plans to cover the preventive services that the ACA requires, according to an analysis by researchers at Georgetown’s Center on Health Insurance Reforms.

Like the ACA, those state laws mandate the coverage at no cost to consumers.

In some of the states, workers in group insurance plans regulated by the state 鈥� called “fully insured” plans 鈥� also receive those protections, the analysis found.

Those state laws do not apply to the whose employers pay their health care claims directly rather than buy insurance for that purpose.

Overall, preventive services can lead to better outcomes, said Lisa Lacasse, president of the .

Millions of people get screened for breast, colorectal, lung, or cervical cancer each year, she said, adding there is evidence showing any kind of copayment or deductible deters people from getting such testing.

Lacasse said she hopes insurers will continue not to charge copays because such a sharp change midyear would be disruptive, and that enrollees should keep going in for preventive care.

“If you have a screening, you should move forward with that,” she said.

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Una prueba sencilla como ésta, que se puede hacer en casa, ayudaría a los Estados Unidos a acercarse a la erradicación del cáncer de cuello uterino o cáncer cervical.

El año que viene, el Instituto Nacional del Cáncer (NCI) lanzará un estudio en diferentes localidades que involucrará a unas 5,000 mujeres para evaluar si la autoprueba casera puede equivaler a la que realiza el médico en un consultorio.

serán diagnosticadas con un cáncer que es prevenible, y más de 4,000 morirán. Las mujeres que no tienen seguro o que no pueden acceder a servicios médicos regulares tienen más probabilidades de no hacerse pruebas de detección que salvan vidas, dijo Vikrant Sahasrabuddhe, de la División de Prevención del Cáncer del NCI.

Sin salir de sus casas, las mujeres podrían recolectar células vaginales y cervicales para analizarlas en la detección del virus del papiloma humano (VPH), que causa virtualmente todos los cánceres cervicales, de la misma manera que las muestras de heces en casa pueden usarse para detectar el cáncer de colon, añadió.

“Sigue existiendo un número constante de mujeres que padece cáncer cervical cada año”, explicó Sahasrabuddhe, que supervisa los estudios sobre los . “Y ese número no va a bajar”.

Las autoridades federales esperan que la investigación acelere un test aprobado por la Administración de Alimentos y Medicamentos (FDA) que podría formar parte de las directrices de evaluación si se demuestra que tomar la muestra en casa es eficaz, señaló Sahasrabuddhe.

En lugar de esperar a que las empresas que realizan las pruebas de VPH para los médicos hagan estudios de automuestreo, los funcionarios federales se unirán a empresas, instituciones académicas y otros en una asociación público-privada, explicó. Los funcionarios del NCI, que esperan gastar unos $6 millones en fondos federales, supervisarán los datos y el análisis del estudio.

“Queremos acelerar ese proceso”, indicó Sahasrabuddhe.

El automuestreo del VPH, existente en países como Australia y los Países Bajos, es uno de los enfoques de los investigadores del cáncer cervical en los Estados Unidos. Otra estrategia clave consiste en vacunar a las adolescentes contra el VPH, que se transmite a través de la actividad sexual. En 2018, años, al igual que casi el 49% de los niños, según los datos federales más recientes.

Los países que han tenido más éxito en la reducción del cáncer cervical 鈥攗n análisis predice que 鈥� han hecho hincapié en la vacunación contra el VPH en adolescentes.

Las autoridades siguen aconsejando a las mujeres vacunadas que se sometan regularmente a pruebas de detección, ya que la vacuna no protege contra todas las cepas que causan el cáncer de cuello uterino.

Sin embargo, a veces es un desafío.

Para algunas, el acceso o el costo puede ser un problema. La mayoría de los planes médicos cubren los exámenes y , pero las mujeres sin seguro que no los conocen tienen que pagar por la consulta y la prueba.

Además, las mujeres no siempre salir del trabajo o encontrar una guardería, o pueden haber tenido “emociones o experiencias negativas en el pasado con los exámenes pélvicos”, señaló Rachel Winer, profesora de epidemiología de la Escuela de Salud Pública de la Universidad de Washington que estudia el automuestreo del VPH.

Invertir la tendencia

Unas 4 de cada 5 mujeres se someten regularmente a pruebas de detección de cáncer cervical, pero los índices alcanzaron su punto máximo alrededor del año 2000 y desde entonces, según datos federales.

Otro análisis de registros médicos de 27,418 mujeres de Minnesota, de entre 30 y 65 años, encontró que en 2016, según publicó el año pasado el Journal of Women’s Health.

“Lamentablemente, creo que nuestros datos probablemente reflejan mejor lo que está sucediendo con los índices de evaluación en nuestro país”, expresó la doctora Kathy MacLaughlin, autora del estudio e investigadora de la Clínica Mayo en Rochester, Minnesota.

Un obstáculo para la prueba podría ser la complejidad de las directrices, dijo MacLaughlin. En lugar de un examen anual fácil de recordar, las evaluaciones ocurren en intervalos de más de un año.听 ayuda a determinar cuándo se recomienda la prueba de VPH o la citología vaginal (el Papanicolau), que recoge células del cuello uterino para buscar cambios precancerosos.

“El reto es cómo recordar que debemos hacer algo cada tres o cada cinco años”, comentó MacLaughlin.

Logística en casa

Si bien el NCI aún no ha decidido el tipo de automuestreo que utilizará, la técnica generalmente requiere que la mujer inserte un pequeño hisopo en su vagina y lo rote varias veces para recolectar las células.

Luego desliza el hisopo en un contenedor de muestras que tiene una solución conservante y devuelve el kit para el análisis del VPH.

Según un informe publicado en 2018 en la revista médica BMJ, la precisión de la identificación del VPH era similar cuando las muestras eran recogidas por las mujeres en casa que cuando lo hacía un médico.

También se estudia una , que podría resultar más fácil de realizar para las mujeres, dijo Jennifer Smith, profesora de epidemiología de la Escuela Gillings de Salud Pública Global de la Universidad de Carolina del Norte.

Antes que las compañías puedan aplicar para pruebas caseras aprobadas por la FDA, el automuestreo de las mujeres debe ser comparable en la detección del VPH, aunque no sea tan preciso, como cuando lo hace un médico, señaló Sahasrabuddhe.

Los funcionarios del NCI aún están ultimando los detalles del estudio. Pero el plan es invitar a participar a cuatro compañías que ya fabrican pruebas de VPH para médicos, dijo Sahasrabuddhe.

Las empresas pagarán el costo de las pruebas y las futuras tarifas relacionadas con la solicitud de licencias a través de la FDA. Sahasrabuddhe espera que los resultados del estudio estén disponibles para 2024, si no antes.

Si una mujer da positivo en las pruebas de VPH podría necesitar una biopsia, para buscar células anormales o cáncer cervical, indicó Sahasrabuddhe.

Si se desarrolla un test casero aprobado por la FDA, es crucial que las mujeres sin seguro y otras que no tienen acceso fácil a la atención médica puedan conseguirlo, enfatizó Smith.

“Porque no se envían kits al azar a los hogares”, dijo Smith, “y nadie se asegura que tengan a alguien con quien hablar sobre los resultados y que puedan tener un seguimiento”.

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Proponents believe a simple test like this, which can be done at home, may help the U.S. move closer to eradicating cervical cancer. The National Cancer Institute plans to launch a multisite study next year involving roughly 5,000 women to assess whether self-sampling at home is comparable to screening in the office by a clinician.

will be diagnosed with the highly preventable cancer, and more than 4,000 will die. Women who are uninsured or can’t get regular medical care are more likely to miss out on lifesaving screening, said Vikrant Sahasrabuddhe, a program director in the NCI’s Division of Cancer Prevention. If women could collect the vaginal and cervical cells to be tested for human papillomavirus (HPV) 鈥� the virus that causes virtually all cervical cancers 鈥� they could get screened from home, just as home-based stool samples can be used to detect colon cancer, he said.

“What we have seen is this persistent group of women who continue to get cervical cancer every year,” said Sahasrabuddhe, who oversees studies involving . “And that number is really not going down.”

Federal officials hope the research will fast-track a test approved by the Food and Drug Administration that could be part of screening guidelines if self-sampling is proved effective, Sahasrabuddhe said. Rather than wait for self-sampling studies to be done by the individual companies that make the HPV tests for clinicians, federal officials will team up with the companies, academic institutions and others in a public-private partnership, he explained. NCI officials, who expect to spend about $6 million in federal funds, will oversee the study’s data and analysis.

“If every company goes and does their own trial, they may take years to achieve it,” Sahasrabuddhe said. “We want to accelerate that process.”

HPV self-sampling, already promoted in countries such as Australia and the Netherlands, is one of several approaches that U.S. cervical cancer researchers are pursuing. Another key strategy involves vaccinating adolescents against HPV, which is transmitted through sexual activity. As of 2018, by age 17, as had almost 49% of boys, according to the most recent federal data. The countries that have had better success in reducing cervical cancer 鈥� one analysis 鈥� have emphasized HPV vaccination for adolescents.

Federal officials still advise vaccinated women to get regularly screened, as the vaccine doesn’t guard against all the strains that cause cervical cancer. But persuading some women to come into the office for the physical exam is sometimes a tough sell.

For some, access or cost may be an issue. Most insurance plans cover screening and there are also , but uninsured women who are unaware of them may have to pay for an office visit and test. Besides, women can’t always break away from work or find child care, or they may have had “negative emotions or experiences in the past with pelvic exams,” said Rachel Winer, a professor of epidemiology at the University of Washington School of Public Health who studies HPV self-sampling.

Reversing The Trend

Roughly 4 out of 5 women get regularly screened for cervical cancer, but the rates peaked around 2000 and have been on a , according to federal data. That figure, which is based on patient self-reporting, may be optimistic. Another analysis, which looked at the medical records of 27,418 Minnesota women ages 30 to 65, found that nearly as of 2016, according to the findings, published last year in the Journal of Women’s Health.

“Sadly, I think our data is probably more reflective of what’s happening with screening rates in our country,” said Dr. Kathy MacLaughlin, a study author and researcher at Mayo Clinic in Rochester, Minnesota.

One hurdle to getting screened may be the complexity of the guidelines, MacLaughlin said. Rather than an easy-to-remember annual exam, screenings occur at intervals of longer than a year. helps determine when the HPV test or a Pap smear, which collects cells from the cervix to look for precancerous changes, is recommended by the U.S. Preventive Services Task Force.

“It’s just that challenge of, how do any of us remember to do something every three years or every five years?” MacLaughlin said. “That’s hard.”

At-Home Logistics

While the NCI hasn’t yet settled on the precise self-sampling approach it will use, the technique generally requires the woman to insert a tiny brush into her vagina and rotate it several times to collect the cells. Then she slides the brush into a specimen container that has a preservative solution and returns the kit for HPV analysis.

According to a review of studies published in 2018 in the medical journal BMJ, the accuracy of identifying HPV was similar when the samples were collected by women at home as when collected by clinicians. , which may prove easier for women to perform, also is being studied, said Jennifer Smith, a professor of epidemiology at the University of North Carolina’s Gillings School of Global Public Health.

Before companies can pursue applications for an FDA-approved home test, self-sampling by women has to be shown comparable to detect HPV, though perhaps it may not be quite as accurate as when a clinician is involved, Sahasrabuddhe said. NCI officials are still finalizing study details. But the plan is to invite four companies that already manufacture HPV tests for clinicians to participate, Sahasrabuddhe said. The companies will pick up the tab for the cost of the tests as well as future fees related to pursuing license applications through the FDA, he said. Sahasrabuddhe expects the study results to be available by 2024, if not sooner.

Any woman who tests positive for HPV will be referred for procedures, including possibly a biopsy, to look for abnormal cells or cervical cancer, Sahasrabuddhe said.

If an FDA-approved home test is developed, it’s crucial that uninsured women and others who don’t have easy access to medical care be able to get those procedures, Smith said.

“You just don’t send random kits out to people’s homes,” Smith said, “and not ensure that they have someone to talk to about the results and are going to be able to be integrated into a follow-up system.”

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A leading group of medical experts on Tuesday declined to endorse cognitive screening for older adults, fueling a debate that has simmered for years.

The U.S. Preventive Services Task Force said it could neither recommend nor oppose cognitive screening, citing insufficient scientific evidence of the practice’s benefits and harms and calling for further studies.

The task force’s work informs policies set by Medicare and private insurers. Its , an accompanying scientific statement and two editorials were published Tuesday in the Journal of the American Medical Association.

The task force’s new position comes as concern mounts over a rising tide of older adults with Alzheimer’s disease and other dementias and treatments remain elusive. Nearly 6 million Americans have Alzheimer’s disease; that population is expected to swell to nearly 14 million by 2050.

Because seniors are at higher risk of cognitive impairment, proponents say screening 鈥� testing people without any symptoms 鈥� is an important strategy to identify people with unrecognized difficulties and potentially lead to better care.

“This can start a discussion with your doctor: 鈥榊ou know, you’re having problems with your cognition, let’s follow this up,’” said Stephen Rao of Cleveland Clinic’s Lou Ruvo Center for Brain Health.

Opponents say the benefits of screening are unproven and the potential for harm is worrisome. “Getting a positive result can make someone wary about their cognition and memory for the rest of their life,” said Benjamin Bensadon, an associate professor of geriatric medicine at the University of Florida College of Medicine.

The task force’s stance is controversial, given how poorly the health care system serves seniors with memory and thinking problems. Physicians routinely in older patients, these conditions at least 50% of the time, according to several studies.

When the surveyed 1,954 seniors in December 2018, 82% said they thought it was important to have their thinking or memory checked. But only 16% said physicians regularly checked their cognition.

What’s more, Medicare policies appear to affirm the value of screening. Since 2011, Medicare has required that physicians assess a patient’s cognition during an annual wellness visit. But only took advantage of this voluntary benefit in 2016, the most recent year for which data is available.

Dr. Ronald Petersen, co-author of an editorial accompanying the recommendations, cautioned that they shouldn’t discourage physicians from evaluating older patients’ memory and thinking.

“There is increased awareness, both on the part of patients and physicians, of the importance of cognitive impairment,” said Petersen, director of the Mayo Clinic’s Alzheimer’s Disease Research Center. “It would be a mistake if physicians didn’t pay more attention to cognition and consider screening on a case-by-case basis.”

Similarly, seniors shouldn’t avoid addressing worrisome symptoms.

“If someone has concerns or a family member has concerns about their memory or cognitive abilities, they should certainly discuss that with their clinician,” said Dr. Douglas Owens, chair of the task force and a professor at Stanford University School of Medicine.

In more than a dozen interviews, experts teased out complexities surrounding this topic. Here’s what they told me:

Screening basics. Cognitive screening involves administering short tests (usually five minutes or less) to people without any symptoms of cognitive decline. It’s an effort to bring to light problems with thinking and memory that otherwise might escape attention.

Depending on the test, people may be asked to recall words, draw a clock face, name the date, spell a word backward, relate a recent news event or sort items into different categories, among other tasks. Common tests include the , the , the and the .

The task force’s evaluation focuses on “universal screening”: whether all adults age 65 and older without symptoms should be given tests to assess their cognition. It found a lack of high-quality scientific evidence that this practice would improve older adults’ quality of life, ensure that they get better care or positively affect other outcomes such as caregivers’ efficacy and well-being.

A disappointing study. High hopes had rested on by researchers at Indiana University, published in December. In that trial, 1,723 older adults were screened for cognitive impairment, while 1,693 were not.

A year later, seniors in the screening group were not more depressed or anxious 鈥� important evidence of the lack of harm from the assessment. But the study failed to find evidence that people screened had a better health-related quality of life or lower rates of hospitalizations or emergency department visits.

Two-thirds of seniors who tested positive for cognitive impairment in her study declined to undergo further evaluation. That’s consistent with findings from other studies, and it testifies to “how many people are terrified of dementia,” said Dr. Timothy Holden, an assistant professor at Washington University School of Medicine in St. Louis.

“What seems clear is that screening in and of itself doesn’t yield benefits unless it’s accompanied by appropriate diagnostic follow-up and care,” said Nicole Fowler, associate director of the Center for Aging Research at Indiana University’s Regenstrief Institute.

Selective screening. “Selective screening” for cognitive impairment is an alternative to universal screening and has gained support.

In published last fall, the American Academy of Neurology recommended that all patients 65 and older seen by neurologists get yearly cognitive health assessments. Also, the American Diabetes Association 听recommends that all adults with diabetes age 65 and older be screened for cognitive impairment at an initial visit and annually thereafter “as appropriate.” And the American College of Surgeons now recommends screening older adults for cognitive impairment before surgery.

Why test select groups? Many patients with diabetes or neurological conditions have overlapping cognitive symptoms and “it’s important to know if a patient is having trouble remembering what the doctor said,” said Dr. Norman Foster, chair of the workgroup that developed the neurology statement and a professor of neurology at the University of Utah.

Physicians may need to alter treatment regimens for older adults with cognitive impairment or work more closely with family members. “If someone needs to manage their own care, it’s important to know if they can do that reliably,” Foster said.

With surgery, older patients who have preexisting cognitive impairments are at higher risk of developing delirium, an acute, sudden-onset brain disorder. Identifying these patients can alert medical staff to this risk, which can be prevented or mitigated with appropriate medical attention.

Also, people who learn they have early-stage cognitive impairment can be connected with community resources and take steps to plan for their future, medically and financially. The hope is that, one day, medical treatments will be able to halt or slow the progression of dementia. But treatments currently available don’t fulfill that promise.

Steps after screening. Screening shouldn’t be confused with diagnosis: All these short tests can do is signal potential problems.

If results indicate reason for concern, a physician should ask knowledgeable family members or friends what’s going on with an older patient. “Are they depressed? Having problems taking care of themselves? Asking the same question repeatedly?” said Dr. David Reuben, chief of geriatrics at UCLA’s David Geffen School of Medicine and director of UCLA’s Alzheimer’s and Dementia Care program.

A comprehensive history and physical examination should then be undertaken to rule out potential reversible causes of cognitive difficulties, implicated in about 10% of cases. These include sleep apnea, depression, hearing or vision loss, vitamin B12 or folic acid deficiencies, alcohol abuse and side effects from anticholinergic drugs or other medications, among other conditions.

Once other causes are ruled out, neuropsychological tests can help establish a diagnosis.

“If I detect mild cognitive impairment, the first thing I’ll do is tell a patient I don’t have any drugs for that but I can help you compensate for deficits,” Reuben said. The good news, he said: A substantial number of patients with MCI 鈥� about 50% 鈥� don’t develop dementia within five years of being diagnosed.

The bottom line. “If you’re concerned about your memory or thinking, ask your physician for an assessment,” said Dr. David Knopman, a neurologist at the Mayo Clinic. If that test indicates reason for concern, make sure you get appropriate follow-up.

That’s easier said than done if you want to see a dementia specialist, noted Dr. Soo Borson, a professor emerita of psychiatry at the University of Washington. “Everyone I know who’s doing clinical dementia care says they have wait lists of four to six months,” she said.

With shortages of geriatric psychiatrists, geriatricians, neuropsychologists and neurologists, there aren’t enough specialists to handle demands that would arise if universal screening for cognitive impairment were implemented, Borson warned.

If you’re a family member of an older adult who’s resisting getting tested, “reach out privately to your primary care physician and express your concerns,” said Holden of Washington University. “And let your doctor know if the person isn’t seeing these changes or is resistant to talk about it.”

This happens frequently because people with cognitive impairments are often unaware of their problems. “But there are ways that we, as physicians, can work around that,” Holden said. “If a physician handles the situation with sensitivity and takes things one step at a time, you can build trust and that can make things much easier.”

We’re eager to hear from readers about questions you’d like answered, problems you’ve been having with your care and advice you need in dealing with the health care system. Visit to submit your requests or tips.

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Una recepcionista le preguntó si quería una actualización gratuita a una “mamografía 3D” o tomosíntesis.

“Dijo que hay un nuevo enfoque, que es mucho mejor y que encuentra todo el cáncer”, dijo McCaskill-Stevens, quien rechazó la oferta.

Poco después, un técnico volvió a preguntar: 驴Seguro la paciente no quería una 3D?

Intentar venderles a los consumidores exámenes de detección de cáncer de seno de alta tecnología es solo una de las formas en que la industria de la mamografía 3D promueve agresivamente su producto.

Una investigación de Kaiser Health News (KHN) encontró que fabricantes, hospitales, médicos y algunos defensores de pacientes han puesto su poder de marketing, y millones de dólares, al servicio de empujar las mamografías 3D. Este esfuerzo titánico ha dejado a muchas mujeres con la sensación de haber sido presionadas a someterse a pruebas de detección que no han demostrado ser más efectivas que las , según el .

“Se puede hacer mucho dinero”, dijo el doctor Steven Woloshin, director del Center for Medicine and Media en The Dartmouth Institute for Health Policy and Clinical Practice, quien publicó un estudio en enero que muestra que la industria de la atención de salud gasta $30 mil millones al año en marketing.

La investigación de KHN muestra que el dinero de la industria ha delineado políticas, a la opinión pública y a la atención al paciente en torno a las pruebas 3D de la siguiente manera:

• Pagando a médicos influyentes. En los últimos seis años, los fabricantes de equipos 3D, incluidos Hologic, GE Healthcare, Siemens Medical Solutions USA y Fujifilm Medical Systems USA, han pagado a médicos y hospitales universitarios más de $240 millones, incluidos más de $9.2 millones relacionados con mamografías 3D, según un análisis de KHN de la . Poco más de la mitad de ese dinero estaba relacionado con la investigación; otros pagos cubrieron tarifas por discursos, consultorías, viajes, comidas o bebidas. La base de datos muestra que artículos de revistas influyentes, los citados cientos de veces por otros investigadores, fueron escritos por médicos con vínculos financieros con la industria 3D.
• Marketing directo con los consumidores. Los fabricantes han instado a las mujeres a exigir , utilizando voceras famosas como la cantante , sobreviviente de cáncer de seno. Gastaron $14 millones para comercializar los exámenes 3D en los últimos cuatro años, sin incluir el gasto en redes sociales, según Kantar Media, que monitorea la industria de la publicidad
• Cabildeo con legisladores estatales. Las aseguradoras privadas en 16 estados ahora tienen la obligación legal de cubrir las pruebas de detección 3D, junto con los programas de Medicaid en 36 estados y Washington, DC. Funcionarios en Hologic, el fabricante líder, le dijeron a KHN que aproximadamente el 95% de las mujeres con seguro tienen cobertura para la tomosíntesis.
• Financiando a expertos y defensores. Hologic ha otorgado a la American Society of Breast Surgeons, una asociación médica que recientemente recomendó las mamografías 3D como su método de detección preferido, según el sitio web del grupo. Hologic se negó a revelar cantidades. La compañía también ha financiado a grupos defensores de pacientes, como Black Women Health Imperative, que cabildea por el acceso a las mamografías 3D.

El entusiasmo por las mamografías 3D ha provocado una carrera armamentista de tecnología médica, con hospitales y prácticas de radiología compitiendo por ofrecer el equipo más nuevo. Los pacientes también han contraído la fiebre. Cuando los no pueden pagar las máquinas 3D, las suelen ayudar a . Más del ofrecen evaluaciones en 3D, .

Los contribuyentes pagan por muchas evaluaciones en 3D, que agrega cerca de $50 al costo de una mamografía típica. Medicare, que comenzó a pagar por los exámenes 3D en 2015, gastó $230 millones adicionales en exámenes de detección de cáncer de seno dentro de los primeros tres años de cobertura. Para 2017, casi la mitad de las mamografías pagadas por el programa federal eran 3D, según un análisis de KHN de datos federales.

Peter Valenti, de Hologic, dijo que el marketing de la compañía es educativo. Su compañía es una “organización con fines de lucro, pero nuestra premisa es tratar de mejorar la atención médica para las mujeres en todo el mundo”, dijo Valenti, quien es presidente de la Breast and Skeletal Health Solution Division de Hologic.

El debate sobre las mamografías 3D ilustra la tensión en la comunidad médica sobre cuánto deberían investigar las empresas antes de comercializar nuevos productos. En un comunicado, funcionarios de Hologic dijeron que sería “irresponsable y poco ético” retener la tecnología que detecta más cánceres de seno, dado que los ensayos clínicos definitivos pueden llevar muchos años.

En promedio, las evaluaciones en 3D pueden aumentar , encontrando alrededor de un tumor de seno adicional por cada 1,000 mujeres estadounidenses evaluadas, según en el Journal of the National Cancer Institute. La mayoría de los estudios también muestran que las pruebas de detección en 3D generan menos “falsas alarmas”, por las que se suele llamar a las mujeres para que vuelvan a realizar procedimientos que no necesitan, dijo la doctora , vicepresidenta de Hologic.

Sin embargo, la tecnología más nueva no es necesariamente mejor, y puede causar daño, dijo el doctor Otis Brawley, profesor de la Universidad Johns Hopkins. “No es ético impulsar un producto antes de saber que ayuda a las personas”, dijo.

Una imagen borrosa

Como investigadora principal en el Instituto Nacional del Cáncer, McCaskill-Stevens no necesitaba un folleto brillante para aprender sobre las mamografías 3D. Ayudó a diseñar financiado con fondos federales de $100 millones, del que participarán 165,000 mujeres, que medirá si las pruebas 3D las ayudan o las dañan. El estudio, que ahora está reclutando pacientes, hará el seguimiento de las mujeres durante cinco años.

“驴Podemos decir que 3D es mejor?”, preguntó McCaskill-Stevens. .

La , y el también dicen que todavía no hay evidencia suficiente para aconsejar a las mujeres sobre mamografías 3D.

Cuando la Administración de Alimentos y Drogas (FDA) , producido por Hologic, la agencia requirió que la tecnología fuera para , no para mejorar la supervivencia.

“Las compañías hacen la investigación mínima necesaria para obtener la aprobación de la FDA, y eso generalmente significa que no hay evidencia significativa sobre cómo ayuda a los pacientes”, dijo Diana Zuckerman, presidenta del National Center for Health Research.

Valenti dijo que Hologic presentó pruebas sólidas a la FDA. “Los datos de que la 3D era una mamografía superior fueron abrumadores”, dijo Valenti.

Describir un examen 3D de los senos puede evocar imágenes de hologramas o de realidad virtual. De hecho, la tomosíntesis está más cerca de una mini tomografía computada (TC).

Aunque todas las mamografías usan rayos X, los exámenes 2D convencionales proporcionan dos vistas de cada seno, una de arriba hacia abajo y otra de lado. Las proyecciones en 3D toman fotografías desde múltiples ángulos, produciendo docenas o cientos de , y lleva solo unos segundos más.

Sin embargo, algunos estudios sugieren que las mamografías 3D son menos precisas que las 2D.

Un estudio de 2016 en encontró que las mujeres examinadas con mamografías 3D tenían más falsas alarmas. Un ensayo aleatorio de 29,000 mujeres publicado, en junio, en The Lancet mostró que 3D no detectó más tumores de seno que las mamografías 2D.

Y, como todas las mamografías, la versión 3D conlleva riesgos. Los sistemas 3D más antiguos exponen a las mujeres a dos veces más radiación que una mamografía 2D, aunque esos niveles aún se consideran seguros, dijo Diana Miglioretti, profesora de bioestadística en la Escuela de Medicina de la Universidad de California en Davis.

Valenti dijo que los sistemas 3D más nuevos proporcionan aproximadamente la misma dosis de radiación que los 2D.

El diagnóstico de más cánceres no necesariamente ayuda a las mujeres, observó Brawley. Eso se debe a que no todos los tumores de seno son potencialmente mortales; algunos crecen tan lentamente que las mujeres vivirían el mismo tiempo si los ignoraran, o incluso si nunca supieran que están allí. Encontrar estos tumores a menudo lleva a las mujeres a someterse a tratamientos que no necesitan.

Un estudio de 2017 estimó que una de cada 3 mujeres con cáncer de seno detectado por una mamografía recibe tratamiento innecesario. Es posible que las mamografías 3D empeoren ese problema, al encontrar aún más tumores de mama pequeños y de crecimiento lento que las 2D, dijo el doctor Alex Krist, vicepresidente del , un panel de expertos que emite consejos de salud. Al impulsar a las mujeres hacia las mamografías 3D antes que toda la evidencia esté disponible, “podríamos estar dañándolas”, dijo Krist.

Algunos expertos temen que las pacientes, que tienden a , actúen por miedo cuando eligen el tratamiento.

“Si alguna vez hubo un público susceptible a la publicidad directa al consumidor, son las mujeres que temen al cáncer de seno”, dijo Zuckerman.

Algunos defensores de las mamografías 3D dejan entrever que las mujeres que optan por las 2D corren un riesgo.

La , jefa de imágenes mamarias de la Escuela de Medicina de Yale, defendió un para que las pruebas de detección 3D fueran mandatorias. “Cuando miro una mamografía 2D ahora, no sé cómo las leemos con algún grado de confianza”, dijo Philpotts en una carta de apoyo. “Parecen extremadamente inadecuadas”.

La carta de Philpotts no mencionaba que ella trabajó como consultora para Hologic, que le pagó $13,500 de 2013 a 2018, principalmente para investigación, según Open Payments. En una entrevista, Philpotts dijo que su trabajo para Hologic no ha influido en su consejo médico. “[La tomosíntesis es] mucho mejor para los pacientes”, dijo. “Me apasiona mucho”.

La doctora Linda Greer, radióloga comunitaria en Phoenix, dijo que estaba “conmocionada” por la cantidad de tumores detectados con 3D comparado con 2D. En una entrevista de 2013, le dijo a , “Nos asustamos por lo que nos perdimos durante tantos años” con las mamografías 2D. ha aceptado más de $305,000 de los fabricantes de máquinas de mamografía, incluidos $222,000 relacionados con productos 3D, según la base de datos de Open Payments.

Greer señaló que mantiene su independencia intelectual al escribir , incluso si Hologic paga su viaje. “No creo que me puedan comprar”, dijo.

Construyendo una marca

La primera pregunta que muchas mujeres tienen sobre las mamografías 3D es: 驴son menos dolorosas?

En anuncios, Hologic afirma que su dispositivo 3D fue menos doloroso para el 93% de las mujeres. Pero esa afirmación proviene de un pequeño estudio financiado por la compañía que no ha sido revisado formalmente por expertos externos, señaló Zuckerman. Dados los limitados datos proporcionados en el estudio, es posible que los hallazgos sean resultado del azar, dijo Zuckerman, quien calificó los anuncios de “muy engañosos”.

Valenti dijo que la revisión de los colegas es importante en los estudios sobre detección de cáncer o falsas alarmas. Pero cuando se trata de “satisfacción general del paciente o preferencia del paciente, esos son datos que obtenemos de otras maneras”, agregó. “Muchos [médicos] tienen el sistema [3D] ahora y puedes tener sus comentarios”.

Si bien las evaluaciones pueden no generar muchos ingresos, pueden atraer a pacientes que necesitan otros procedimientos hospitalarios más rentables.

“Cada vez que diagnosticas más tumores, puedes tratar más tumores”, dijo Amitabh Chandra, directora de investigación de políticas de salud en la Escuela de Gobierno John F. Kennedy de la Universidad de Harvard.

Cambiando la ley

Durante años, las mujeres que querían un examen en 3D tenían que pagar de $50 a $100 adicionales de su bolsillo.

Valenti dijo que Hologic quería que más mujeres tuvieran acceso a la tecnología. Por eso, , con un sitio web, tweets y publicidad de celebridades, para a cubrir las 3D.

Los , que se beneficiarán de un grupo más grande de clientes que pagan, también son firmes defensores de que los seguros las cubran.

En 2017, de Nueva York le pidió a una que presentara un proyecto de ley que exigiera la cobertura de las pruebas de detección 3D.

En un comunicado, un funcionario del Memorial Sloan Kettering dijo que el hospital apoyó el proyecto de ley para mejorar la atención del paciente. “Nuestros pacientes merecían la detección más óptima disponible”, dijo la , jefa del servicio de imágenes mamarias del hospital.

Los partidarios de las mamografías 3D también se reunieron en torno a un mandato de las aseguradoras en Texas en 2017. Los incluyeron HCA Healthcare, una cadena con fines de lucro que administra 185 hospitales y el Black Women Health Imperative. Ese grupo también testificó ante un panel de la FDA en 2010 para abogar por la aprobación del dispositivo de Hologic.

Linda Goler Blount, presidenta y directora ejecutiva del grupo, dijo que la organización abogaba por la detección temprana mucho antes que comenzara su asociación con Hologic en 2016.

“Si tienes , es mucho menos probable que tengas una mamografía 3D que si tiene ingresos altos”, dijo Blount.

Blount señaló que su grupo sigue siendo “independiente y libre para decir lo que pensamos”.

Pagando a doctores

El doctor Stephen Rose ha sido un defensor especialmente activo de las pruebas 3D. Rose, radiólogo, testificó en nombre del proyecto de ley de seguro de Texas dos veces. La práctica donde trabaja Rose, , publicó comunicados de prensa a favor de la legislación. En 2010, testificó a favor de las evaluaciones en 3D ante .

En los últimos seis años, ha recibido de compañías que fabrican máquinas de mamografía, incluidos más de $50,000 relacionados específicamente con productos 3D, según la base de datos de Open Payments. El 12% de los pagos de Rose relacionados con 3D estuvieron vinculados a la investigación.

Rose dijo que el dinero de la industria no lo ha influenciado. “Puedo decirte que tuvo cero impacto”, dijo Rose.

En 2014, fue coautor de que describía los beneficios de las mamografías 3D.

En conjunto, Rose y 12 de sus coautores aceptaron más de $1 millón de los cuatro fabricantes líderes de equipos 3D en los últimos seis años, incluidos $589,000 relacionados con productos 3D, según un análisis de KHN de los datos de Open Payments. Además, Hologic contribuyó con $855,000 a la investigación en la que muchos de estos autores tuvieron roles centrales.

Valenti dijo que Hologic no espera nada a cambio de los pagos: “Dejamos que el producto y el médico hablen por sí mismos”.

Una red de relaciones

La enumera a Hologic como un socio corporativo. , la sociedad como su método de detección preferido.

“No hay conexión entre las subvenciones educativas de la sociedad y el desarrollo de declaraciones”, dijo su vocera Sharon Grutman.

Fran Visco, presidente de la National Breast Cancer Coalition, ha abogado por las mujeres durante décadas. Pero dijo que no puede encontrar una solución para reducir la influencia de la industria en la medicina.

“Es increíblemente preocupante”, dijo Visco, ella misma sobreviviente de cáncer de seno. “Todo el mundo tiene una participación diferente en todo esto, y todo parece estar vinculado a la ganancia financiera”.

La editora de datos de KHN, Elizabeth Lucas, colaboró con este informe.

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A receptionist asked if she wanted a free upgrade to a “3D mammogram,” or tomosynthesis.

“She said there’s a new approach and it’s much better, and it finds all cancer,” said McCaskill-Stevens, who declined the offer.

A short time later, a technician asked again: Was the patient sure she didn’t want 3D?

Upselling customers on high-tech breast cancer screenings is just one way the 3D mammography industry aggressively promotes its product.

A KHN investigation found that manufacturers, hospitals, doctors and some patient advocates have put their marketing muscle 鈥� and millions of dollars 鈥� behind 3D mammograms. The juggernaut has left many women feeling pressured to undergo screenings, which, according to the , haven’t been shown to be more effective than .

“There’s a lot of money to be made,” said Dr. Steven Woloshin, director of the Center for Medicine and Media at The Dartmouth Institute for Health Policy and Clinical Practice, who published a study in January showing that the health care industry spends $30 billion a year on marketing.

KHN’s investigation shows that industry money has shaped policy, public opinion and patient care around 3D by:

• Paying influential doctors. In the past six years, 3D equipment manufacturers 鈥� including Hologic, GE Healthcare, Siemens Medical Solutions USA and Fujifilm Medical Systems USA 鈥� have paid doctors and teaching hospitals more than $240 million, including more than $9.2 million related to 3D mammograms, according to a KHN analysis of the Just over half of that money was related to research; other payments covered speaking fees, consulting, travel, meals or drinks. The database shows that influential journal articles 鈥� those cited hundreds of times by other researchers 鈥� were written by doctors with financial ties to the 3D industry.
• Marketing directly to consumers. Manufacturers have urged women to demand “the ,” using celebrity spokeswomen such as breast cancer . Manufacturers spent $14 million to market 3D screening over the past four years, not including spending on social media, according to Kantar Media, which tracks the advertising industry.
• Lobbying state lawmakers. Private insurers in 16 states are now legally required to cover 3D screenings, along with Medicaid programs in 36 states and Washington, D.C. Officials at Hologic, the leading manufacturer, told KHN that about 95% of insured women have coverage for tomosynthesis.
• Funding experts and advocates. Hologic has given to the American Society of Breast Surgeons, a medical association that recently 3D mammograms as its preferred screening method, according to the group’s website. Hologic declined to reveal amounts. Hologic also has funded such as the Black Women’s Health Imperative, which lobbies for access to 3D mammograms.

Enthusiasm for 3D has sparked a medical technology arms race, with hospitals and radiology practices competing to offer the newest equipment. Patients have caught the fever, too. When can’t afford 3D machines, often pitch in to More than offer 3D screenings, first .

Taxpayers write the check for many 3D screenings, which add about $50 to the cost of a typical mammogram. Medicare, which began paying for 3D exams in 2015, spent an additional $230 million on breast cancer screenings within the first three years of coverage. By 2017, nearly half the mammograms paid for by the federal program were 3D, according to a KHN analysis of federal data.

Hologic’s Peter Valenti said the company’s marketing is educational. His company is a “for-profit organization, but our premise is to try to improve the health care for women globally,” said Valenti, president of Hologic’s breast and skeletal health solutions division.

The debate over 3D mammograms illustrates the tension in the medical community over how much research companies should do before commercializing new products. In a statement, officials at Hologic said it would be “irresponsible and unethical” to withhold technology that detects more breast cancers, given that definitive clinical trials can take many years.

On average, 3D screenings may , finding about one extra breast tumor for every 1,000 U.S. women screened, according to a in the Journal of the National Cancer Institute. Most studies also show that 3D screenings cause fewer “false alarms,” in which women are called back for procedures they don’t need, said a Hologic vice president.

Yet newer tech isn’t necessarily better 鈥� and it can cause harm, said Dr. Otis Brawley, a professor at Johns Hopkins University. “It’s unethical to push a product before you know it helps people,” he said.

A Fuzzy Picture

As a senior researcher at the National Cancer Institute, McCaskill-Stevens didn’t need a glossy brochure to learn about 3D mammograms. She helped design a $100 million federally funded of 165,000 women, which will measure whether women are helped or hurt by 3D testing. The study, now recruiting patients, will follow the women for five years.

“Can we say that 3D is better?” asked McCaskill-Stevens.

The , and the also say there isn’t yet enough evidence to advise women on 3D mammograms.

When the Food and Drug Administration , made by Hologic, the agency required the technology to be at 鈥� not at improving survival.

“The companies do the minimal research needed to get FDA approval, and that usually means no meaningful evidence of how it helps patients,” said Diana Zuckerman, president of the National Center for Health Research.

Valenti said Hologic presented strong evidence to the FDA. “The data was overwhelming that 3D was a superior mammogram,” Valenti said.

Describing a breast exam as 3D may conjure up images of holograms or virtual reality. In fact, tomosynthesis is closer to a mini-CT scan.

Although all mammograms use X-rays, conventional 2D screenings provide two views of each breast, one from top to bottom and one from the side. 3D screenings take pictures from multiple angles, producing dozens or hundreds of , and take only a few seconds longer.

Yet some studies suggest that 3D mammograms are less accurate than 2D.

A 2016 study in found that women screened with 3D mammograms had more false alarms. A randomized trial of published in The Lancet in June showed that 3D detected no more breast tumors than 2D mammograms did.

And, like all mammograms, the 3D version carries risks. Older 3D systems expose women to as a 2D mammogram, although those levels are still considered safe, said Diana Miglioretti, a biostatistics professor at the University of California-Davis School of Medicine.

Valenti said the newest 3D systems provide about the same radiation dose as 2D.

Diagnosing more cancers doesn’t necessarily help women, Brawley said. That’s because not all breast tumors are life-threatening; some grow so slowly that women would live just as long if they ignored them 鈥� or never even knew they were there. Finding these tumors often leads women to undergo treatments they don’t need.

A 2017 study estimated 1 in 3 women with breast cancer detected by a mammogram are treated unnecessarily. It’s possible 3D mammograms make that problem worse, by finding even more small, slow-growing breast tumors than 2D, said Dr. Alex Krist, vice chairman of the preventive services task force, an expert panel that issues health advice. By steering women toward 3D mammograms before all the evidence is in, “we could potentially hurt women,” Krist said.

Some experts worry that patients, who their risk of dying from breast cancer, are acting out of fear when they choose treatment.

“If there was ever an audience susceptible to direct-to-consumer advertising, it’s women afraid of breast cancer,” Zuckerman said.

Some proponents of 3D mammograms imply that women who opt for 2D are taking a risk.

, chief of breast imaging at Yale School of Medicine, championed a to mandate insurance coverage for 3D screenings. “When I look at a 2D mammogram now, I don’t know how we read them with any degree of confidence,” Philpotts said in a “They seem grossly inadequate.”

Philpotts’ letter did not mention she has worked as a consultant for Hologic, which paid her $13,500 from 2013 to 2018, mostly for research, according to Open Payments. In an interview, Philpotts said her work for Hologic has not influenced her medical advice. “[Tomosynthesis is] just so much better for patients,” she said. “I feel very passionately about it.”

, a community radiologist in Phoenix, has said she was “shocked” by how many more tumors were detected with 3D than 2D. In a 2013 interview, she told , “We got scared about what we were missing for so many years” with 2D mammograms. has accepted more than $305,000 from makers of mammography machines, including $222,000 related to 3D products, according to the Open Payments database.

Greer noted she maintains her intellectual independence by writing her own , even if Hologic pays for her travel. “I don’t think I could be bought,” she said.

Building A Brand

The first question many women have about 3D mammograms is: Are they less painful?

In ads, Hologic claims its 3D device was less painful for . But that claim comes from a small, that hasn’t been formally reviewed by outside experts, Zuckerman noted. Given the limited data provided in the study, it’s possible the findings were the result of chance, said Zuckerman, who called the ads “very misleading.”

Valenti said peer review is important in studies about cancer detection or false alarms. But when it relates to “general patient satisfaction or patient preference, those are data that we get in other ways,” he said. “Plenty of [doctors] have the [3D] system now and you can get feedback from them. “

While screenings may not generate a lot of income, they can attract patients who need other, more profitable hospital procedures.

“Anytime you diagnose more tumors, you can treat more tumors,” said Amitabh Chandra, director of health policy research at Harvard University’s John F. Kennedy School of Government

Changing The Law

For years, women who wanted a 3D screening had to pay an extra $50 to $100 out-of-pocket.

Valenti said Hologic wanted more women to have access to the technology. So Hologic launched a 鈥� with a website, paid and billboards 鈥� to 听to cover 3D.

鈥� who stand to benefit from an expanded pool of paying customers 鈥� are also fierce advocates for insurance coverage.

In 2017, a doctor at New York’s asked a to introduce a bill mandating insurance coverage for 3D screenings.

In a statement, an official at Memorial Sloan Kettering said the hospital supported the bill to improve patient care. “Our patients deserved the most optimal screening available,” said , chief of the hospital’s breast imaging service.

Supporters of 3D mammograms also rallied around an insurance mandate in Texas in 2017. included HCA Healthcare, a for-profit chain that manages 185 hospitals, and the . That group also testified before an FDA panel in 2010 to advocate approving Hologic’s device.

Linda Goler Blount, the group’s president and CEO, said the organization was advocating for early detection long before its partnership with Hologic began in 2016.

“If you’re you’re much less likely to get 3D mammography than if you’re upper-income,” Blount said.

Blount noted that her group remains “independent and free to speak our mind.”

Paying Doctors

Dr. Stephen Rose has been an especially active advocate for 3D screenings.

Rose, a radiologist, testified on behalf of the Texas insurance bill twice. The practice where Rose works, put out press releases in favor of the legislation. In 2010, Rose testified in favor of 3D screenings at an .

In the past six years, he has received from companies that manufacture mammogram machines, including more than $50,000 related to specific 3D products, according to the Open Payments database. Twelve percent of Rose’s 3D-related payments were related to research.

Rose said industry money hasn’t influenced him. “I can tell you it had zero impact,” Rose said.

In 2014, Rose co-wrote an that described the benefits of 3D mammograms.

Collectively, Rose and 12 of his co-authors accepted more than $1 million from the four leading manufacturers of 3D equipment over the past six years, including $589,000 related to 3D products, according to a KHN analysis of Open Payments data. In addition, Hologic contributed $855,000 to research in which many of these authors took leading roles.

Valenti said Hologic doesn’t expect anything in return for the payments: “We let the product and the doctor speak for themselves.”

A Web Of Relationships

The , lists Hologic as a corporate partner. , the society as its preferred screening method.

“There is no connection between the society’s educational grants and statement development,” said Sharon Grutman, a society spokeswoman.

Fran Visco, president of the National Breast Cancer Coalition, has advocated for women for decades. But she said she’s at a loss for a solution to curtail industry influence in medicine.

“It’s incredibly troubling,” said Visco, a breast cancer survivor. “Everyone has a different stake in all this, and it all seems to be tied to financial gain.”

KHN data editor Elizabeth Lucas contributed to this report.

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