Monday morning found me at the St. Joseph Regional Breast Care Center in Bangor, feeling grateful. Not for my 7:30 routine mammogram appointment that had required me to leap out of bed before daybreak like a ninja, startling Douglas and the cats. Certainly not for the flimsy, pale blue, side-tying wrap that I was wearing in the chilly exam room. And most definitely not for what I knew was about to happen: the deflating ignominy of the exam itself, followed by the uncertain days ahead when I would try to steer my thoughts elsewhere while awaiting the radiologist’s findings. Which — knock on wood — have never shown any sign of a lump or lesion.
At 61, and at average risk of becoming one of the one in eight women in America who will develop breast cancer over the course of her lifetime, I am very grateful to have health insurance that pays for my annual mammogram. Breast cancer is the second most lethal form of cancer in women, second only to lung cancer. Mammography is widely accepted as the key to early detection and effective treatment. Recommendations vary, but generally advise most women 50 and older to be screened every year or two. My doctor and I agree that annual screenings make sense for me.
Not everyone has health coverage, despite the progress of the Affordable Care Act. People without coverage, many of whom are poor, typically pay out of their own pockets for medical care, or else go without. Preventive care, like cancer screenings, are seldom a priority in a population that struggles to pay for rent and food.
Nationwide, according to a recent article I read online, the out-of-pocket cost for a screening mammogram can range from $23 at a 25-bed hospital in Hardinsburg, Kentucky to nearly $2,000 at a fertility clinic in Washington, D.C. In Maine, according to a fascinating data tool developed by the Maine Health Data Organization, the least expensive screening mammogram costs $131 at PenBay Medical Center in Rockland and the priciest is $474 at Inland Hospital in Waterville. The state average is $158.
This may not be an apples-to-apples comparison; health care prices in this country are infamous for being hard to pin down. Most providers — doctors, nurses, technicians — have no idea what anything costs, including even the most common procedures and medications. That’s because they assume patients have health care coverage of some sort, like Medicare, Medicaid, or the private insurance I purchase at a group rate as an employee of the Bangor Daily News. Having that coverage means we pay only a fraction of what gets billed to our insurance, so most of us don’t concern ourselves with these prices any more than our providers do.
Medicare, Medicaid and private insurers have a lot of financial clout, and they use it to negotiate what they’ll pay to hospitals and medical providers. So, paradoxically, the billed cost of medical procedures is higher for individuals who have no health insurance. That includes the approximately 24,000 Maine adults who can’t enroll in Medicaid because ours is one of the 19 states that has refused to expand the program under the provisions of the Affordable Care Act. This means that a low-income woman in her 60s who has no insurance will pay more for her mammogram than my insurer, Cigna, pays for mine. Which is crazy.
There are public and private programs that help some low-income women obtain screening mammograms, including the National Breast and Cervical Cancer Early Detection Program, administered here by the Maine Center for Disease Control and Prevention, and the Susan B. Komen Foundation. But many women do not know about these programs and others do not qualify. And, as is the case with most health disparities, those most affected are also likely to experience other challenges, which could be as basic as not having access to a telephone or transportation, or as overarching as lacking the confidence or social skills to advocate for their own needs.
The combination of these factors — being uninsured, being low-income, not knowing how to self-advocate and not being able to easily access price information — mean that many women my age simply won’t get a mammogram when they absolutely should. Compared to the deep injustice of that reality, my flimsy cotton johnnie and the technician’s chilly hands are nothing but a minor inconvenience.