When President Obama turned 50 last year, he made an “informed patient request” for a PSA (prostate specific antigen) test. This is the blood test routinely used to screen men over 50 for possible prostate cancer. The President received his PSA test. But under ObamaCare, you may not be able to.
Now that ObamaCare has been upheld by the Supreme Court, all of its major provisions will be in force, not just the controversial “individual mandate.” This includes government medical practice guidelines that will affect millions of Americans.
ObamaCare empowers the government U.S. Preventive Services Task Force (USPSTF) to determine which preventive health services are medically appropriate. This is the same agency that aroused enormous controversy in 2009 when it proposed restricting screening mammograms to women over age 50 (and only every 2 years), despite the proven benefits of annual mammograms beginning at age 40. (Under pressure, Secretary of Health Sebelius later backpedalled from those guidelines, declaring them non-binding.)
This year, the USPSTF aroused similar controversy by giving a “D” grade (“not recommended”) to routine PSA prostate cancer screening.
Prostate cancer is the most common cancer affecting American men and the second leading cause of cancer deaths. Thousands of American men have benefited from early detection and treatment of prostate cancer made possible by PSA testing.
However, there are legitimate scientific debates regarding PSA screening. PSA testing, like all screening tests, is not 100% accurate. Some patients who initially test positive will undergo further biopsy or surgery that show it was a false alarm. Others who test positive will have slow-growing cancers that do not require treatment — i.e., they will die from unrelated conditions before their prostate cancers pose a threat. Some patients who test positive will suffer unavoidable complications from subsequent “downstream” biopsies or surgeries that in retrospect weren’t necessary. PSA testing can thus cause some patients more harm than good.
For these reasons, the American Cancer Society does not issue a hard-and-fast rule about PSA screening. Instead, they recommend that men over 50 make an “informed decision” following a discussion with their doctor on the “uncertainties, risks, and potential benefits of prostate cancer screening.”
Medicine cannot be reduced to cookbook procedures. A 50-year old African-American man whose father and brother both died of prostate cancer might legitimately prefer PSA screening, whereas a 50-year old Caucasian man without risk factors might legitimately choose to skip it. Patients should decide based on their overall health, family history, and the benefits of detecting a treatable cancer vs. the risks of unnecessary downstream procedures. The physician’s job is to honestly advise the patient of his best medical interests. This is the heart of the doctor-patient relationship.
However, the USPSTF guidelines will undermine this doctor-patient relationship because of their enhanced role under ObamaCare.
ObamaCare links insurance coverage of preventive medical services to their USPSTF rating. Medicare must cover all “A” or “B” services, such as cholesterol testing or colonoscopies. For now, Medicare still covers PSA screening despite the USPSTF “D” rating. But under ObamaCare, Medicare payment decisions will become increasingly controlled by the new Independent Payment Advisory Board, explicitly created to reduce Medicare spending. Given Medicare’s skyrocketing costs, it’s only a matter of time before the government stops paying for services that its own scientific panel has given a “D” rating.
Similarly, private health insurance companies must cover for “free” all USPSTF “A” or “B” rated services, while abiding by government price controls. To reduce costs, many private insurers will likely drop coverage for “C” and “D” rated services. Hence under ObamaCare, the USPSTF guidelines will likely become the de facto standards for both government and private health insurance coverage.
But suppose a patient wishes to pay for PSA testing with his own money, rather than through insurance? Even then, ObamaCare will make that more difficult.
ObamaCare includes various financial carrots and sticks to pressure doctors into joining large “Accountable Care Organizations” (ACOs). These ACOs will use mandatory electronic medical records to track how closely physicians adhere to government practice guidelines. Doctors who obey government practice guidelines will be rewarded. Those who order more tests or procedures than the government deems necessary will be penalized.
ACO physicians may thus be reluctant to recommend PSA screening even when the patient is willing to pay for it himself. Patients who test positive will require further downstream procedures such as prostate ultrasounds, MRI scans, or biopsies, which may count against the doctor’s ACO practice statistics. USPSTF guidelines could slowly erode many doctors’ willingness to offer their best honest advice to their patients. If your doctor recommends against a PSA test, can you be sure he’s offering his best medical opinion, without being biased by the bonus he’ll receive for reducing the number of procedures performed by the ACO?
Urologists — who regularly treat patients with prostate cancer — are overwhelmingly opposed to the USPSTF guidelines. Dr. Ian Thompson, a urologist at the University of Texas, notes that the USPSTF guidelines will prevent his patients from making properly informed decisions about their own health. Instead, they amount to a bureaucrat telling patients, “Follow my priorities instead of your own.”
When President Obama had his routine physical last year, he enjoyed the freedom to consult with his doctors, weigh the pros and cons of PSA testing, and decide for himself what was in his best medical interest. But under ObamaCare, the President will not allow you that same freedom. Instead, the federal government will decide for you.
Is that fair? Is President Obama’s prostate gland more important than yours?
Paul Hsieh is a radiologist and co-founder of Freedom and Individual Rights in Medicine. This article originally appeared in Forbes.
