High Breast Cancer Screening Costs Leave Women Vulnerable

Molly Smith, a 46-year-old mother of two from Myrtle Beach, South Carolina, faced a common but distressing scenario when she went for her first mammogram in 2021. With a family history of breast cancer, including her grandmother, mother, sister, and another relative, she had ample reason to be cautious. To her relief, further testing revealed that the abnormal tissue detected in the mammogram was not cancerous. However, the aftermath of her ordeal came at a financial cost, as she incurred more than $1,000 in medical bills that her insurance did not cover.

Like Smith, millions of American women find themselves at high risk for breast cancer, yet their insurance policies often fall short in covering the necessary follow-up screenings required to detect the disease. For many women, breast cancer can remain hidden in mammograms, prompting doctors to recommend additional screenings such as ultrasounds, MRIs, and tomosynthesis (3D mammograms).

Challenges Faced by Women with Dense Breast Tissue

Dr. Madhavi Raghu, a radiation oncologist in western Connecticut, emphasizes the limitations of mammograms in detecting breast cancer, particularly for women with dense breast tissue—a prevalent condition affecting roughly half of women over the age of 40. The Food and Drug Administration has acknowledged this issue and mandated that mammogram providers inform women with dense breast tissue about the potential need for further evaluations and screenings to rule out cancer. However, for the majority of women, these additional screenings come with a hefty price tag, often requiring out-of-pocket expenses.

While private health insurance plans typically cover one mammogram per year, they rarely reimburse the full cost of additional screenings. Furthermore, in 2024, doctors in Connecticut, New York, North Carolina, and Texas reported that Medicare stopped reimbursing for breast cancer ultrasound screenings that it had previously reimbursed in 2023. This lack of coverage places women with Medicare and those with private insurance in a precarious position, as they grapple with the crucial question of whether to pursue further screenings and at what financial cost.

Policy and Reimbursement Challenges

A representative from the Centers for Medicare and Medicaid Services stated that ultrasound or MRI scans are only covered by Medicare when conducted as a diagnostic test. If the scans are performed as a screening test, Medicare cannot cover them by law. This classification creates a dilemma for women seeking additional screenings, as the diagnostic vs. screening distinction is often blurred in practice. Physicians argue that this interpretation fails to consider the nuanced nature of breast ultrasounds and their role in early cancer detection. As a result, the recent denials of coverage by Medicare have implications not only for women but also for private insurers who often align their reimbursement decisions with those of Medicare.

The rising costs of unreimbursed screenings pose a significant burden for women, particularly those who are enrolled in high-deductible insurance plans. A study published in the journal Radiology revealed that faced with the prospect of out-of-pocket expenses for necessary screenings, a substantial proportion of women—approximately 21%—indicated that they would decline additional screenings if they had to bear the costs themselves. This trend is particularly concerning in light of the most recent statistics from the American Cancer Society, which found a notable increase in breast cancer diagnoses among younger women (those under 50) between 2012 and 2021. The financial barriers to accessing early detection services can impede timely cancer detection, undermining the efficacy of treatment.

Legislative Initiatives and Financial Strain

Recognizing the pressing need for equitable access to breast cancer screenings, some states have taken legislative action. Last year, Iowa enacted a law mandating that private health insurers cover the full cost of additional breast cancer screenings such as ultrasounds and MRIs. Similarly, Massachusetts passed a law requiring insurers to cover these screenings without imposing additional costs on patients. Efforts to introduce similar vaccination bills have emerged in states including Connecticut, Florida, Indiana, Hawaii, South Carolina, and Virginia, as advocated by the American College of Radiology. The American Cancer Society further articulates its intent to support analogous legislation in Nebraska, Pennsylvania, Rhode Island, and Wisconsin. The momentum towards legislative reforms signifies a recognition of the financial concerns faced by women necessitating breast cancer screenings and a commitment to addressing these disparities.

However, challenges remain in enacting such legislation. Some states, such as South Dakota and Montana, have encountered obstacles in advancing similar legislative measures. In Montana, a recent effort to pass such legislation fell short, leaving advocates like Shelley Emslie, a schoolteacher and breast cancer survivor, disheartened. Emslie, who requires regular MRIs to monitor potential cancer recurrence, faces annual costs of approximately $3,500 for these additional screenings, which are not covered by her employer's high-deductible insurance plan. Emslie emphasizes the ethical dilemma posed by the financial barriers, asserting that there are undoubtedly other women who are forgoing necessary screenings due to their costs.