S.7785-A.8387- Breast Cancer Screening 2nd Degree Relative Mandate

This legislation S.7785/A.8387, would require health plans to cover mammograms for individuals with a second degree relative with a prior history of breast cancer. New York’s health plans support early detection and early treatment of breast cancer — and all cancers. While this bill is well intended, the New York Health Plan Association (HPA) opposes the legislation for several reasons.

Health plans support appropriate use of diagnostic screenings used to detect breast cancer, and plans cover a variety of imaging methods. The key reason that HPA opposes this bill is that it is unnecessary. Current New York law already requires coverage of a baseline mammogram for covered persons age 35 through 39 and an annual mammogram for persons age 40 and older, as well as coverage for mammograms at any age for a covered person that has a prior history of breast cancer or a first degree relative with a prior history of breast cancer when a physician recommends the mammogram.

When someone should get any breast cancer screening is a matter that should be thoroughly discussed between a patient and their physician, and should consider family history. Health plans support and promote the use of evidence-based, best practices as it relates to cancer screenings, and develop coverage criteria of which modalities are “medically necessary” based on these best practices. According to the Centers for Disease Control and Prevention (CDC), people who have a second-degree female relative with breast cancer are not considered to be at increased risk for developing breast cancer. The risk for those with one or two first-degree or two second-degree female relatives with breast cancer is considered to be “somewhat” higher than the general population, but the CDC goes on to note, “most women from these types of families will not develop breast or ovarian cancer.”[1]

Moreover, when discussing breast cancer screenings, it is important to be mindful of the potential harm associated with screening. The United States Preventive Services Task Force (USPSTF), an independent, volunteer panel of national experts in disease prevention and evidence-based medicine, is widely recognized for its efforts to develop evidence-based recommendations about clinical preventive services. In its recommendations for breast cancer screening, the USPSTF notes, “Potential harms of screening mammography include false-positive results, which may lead to psychological harms, additional testing, and invasive follow-up procedures; overdiagnosis and overtreatment of lesions that would not have led to health problems in the absence of detection by screening; and radiation exposure.”[2]

HPA also opposes the bill because it creates a new mandated benefit. In general, HPA opposes mandates because they increase the cost of coverage for consumers and employers, ultimately undermining affordability and leading to some people becoming uninsured. Mandated benefit bills pertain only to fully-insured policies, which are purchased either by individuals who purchase coverage on their own or receive it through a small or medium-sized business.

Large companies typically “self-insure,” providing employee health benefits by directly paying health care claims to providers. They are governed by the federal Employee Retirement Income Security Act (ERISA) and are not subject to state mandated benefits. This exemption from state mandated benefits is a key reason that large employers typically self-insure. Today, roughly 50 percent of the commercial market in New York is covered under a self-insured plan. As more employers self-insure, state laws mandating specific types of benefits and services, or expanding existing mandates as this bill would, affect an increasingly smaller portion of the privately insured marketplace and fall largely on small and medium-sized employers.

Health plans must be able to set coverage criteria based on evidence and unique circumstance of the patient. In addition, mandating coverage benefits that will increase the cost of health insurance for individuals and employers conflicts with New York’s efforts to ensure every resident has access to high quality, affordable health care.

For these reasons, HPA opposes S.7785/A.8387.

[1] https://www.cdc.gov/genomics/disease/breast_ovarian_cancer/risk_categories.htm

[2] https://www.uspreventiveservicestaskforce.org/uspstf/recommendation/breast-cancer-screening#fullrecommendationstart