23-03, Study of Proposed Mandatory Health Insurance Coverage for Early Access Breast Cancer Screening

Posted on Feb 6, 2023 in Summary

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HOUSE CONCURRENT RESOLUTION NO. 33, SENATE DRAFT 1 (2022 Regular Session) (HCR 33, SD 1), requests the Auditor to assess the social and financial effects of mandating health insurance coverage for “early access breast cancer screening,” as proposed in Senate Bill No. 827, Senate Draft 2 (2021 Regular Session) (SB 827, SD 2). Based on our analysis of the bill and our interviews and surveys with insurers and health care providers, the major difference between current mandated insurance coverage and that proposed by the bill is the addition of a baseline mammogram for average-risk women ages 35 to 39. We therefore focused our assessment on the proposed mandatory coverage for a baseline mammogram for average-risk women ages 35 to 39.

We conducted this assessment in accordance with Sections 23-51 and 23-52, Hawai‘i Revised Statutes (HRS).

Hawai‘i law currently requires health insurance plans to provide coverage for annual mammograms for women 40 years of age and older and for women of any age with a history of breast cancer or whose mother or sister has had a history of breast cancer. The state’s two largest insurers, Hawai‘i Medical Service Association and Kaiser Permanente, represent that aside from the baseline mammogram for average-risk women ages 35 to 39, the proposed revisions in SB 827, SD 2, are already covered under their current health policies.*

We found that, while a number of states have enacted laws that mandate insurance coverage for baseline mammograms for women ages 35 to 39, none of the major medical organizations we reviewed currently recommend mammography screening for average-risk women ages 35 to 39. The U.S. Preventative Services Task Force guidelines, referred to in both SB 827, SD 2, and HCR 33, SD 1, recommend mammograms for average-risk women starting at age 50. The American College of Obstetricians and Gynecologists, the American Cancer Society, and the National Comprehensive Cancer Network recommend offering mammography screenings starting at age 40.

With regard to our analysis of the social impacts set forth in Section 23-52, HRS, we were unable to determine the level of demand for a baseline mammogram for average-risk women ages 35 to 39. We
note that the affected population is a relatively limited one. According to figures provided by the six insurers that responded to our survey, there was a combined enrollment of 375,023 females ages 35 and over in 2021. This included 44,584, or about twelve percent, who were ages 35 to 39, the age group targeted by the proposed mandate. And we found little information on the impact of providing coverage for a baseline mammogram for average-risk women ages 35 to 39 on morbidity, mortality, and quality of care. The published studies and other articles, generally, focus on women ages 40 and older.

In reviewing the financial impacts of the proposed coverage, in general, the health insurance companies project only very small increases in total healthcare costs and insurance premiums. For the purposes of the Patient Protection and Affordable Care Act, the required coverage would be a new mandate and the State will be responsible for defrayment of the costs of these added benefits to individuals enrolled in the State’s qualified health plans. Given the fact that in 2021 there were only 22,903 Hawai‘i residents
enrolled in private individual market plans through the State’s health insurance marketplace, the number of average-risk women ages 35 to 39 is likely only a relatively small fraction of the total enrollment.

* In addition to the baseline mammogram, SB 827, SD 2, specifies coverage for an annual mammogram for women ages 30 to 50 deemed by a physician or clinician to be at an above-average risk for breast cancer, provided that a formal risk factor screening assessment is first made. We conclude that this falls under currently mandated coverage. The bill also specifies coverage for any additional imaging or supplemental imagery deemed medically necessary by an applicable American College of Radiology guideline; however, any supplemental imaging deemed medically necessary is already required by law to be covered.

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