People lucky enough to live in Maine get beautiful beaches -- they also get a higher chance of dying from colon cancer. The same goes for Indiana residents over Ohioans: Hoosiers are more at risk than their neighbors. Ecologically, Arkansas and Mississippi are similar, but not so for colon cancer. Arkansas residents are better off.
How surprising! Epidemiologists list family history as the greatest risk factor for colon cancer: If a relative has had it, you are more at risk than somebody with, medically-speaking, a healthier family tree. A second risk factor is inflammatory bowel disease. A third is the prevalence of colon polyps, which can develop into cancers. Lifestyles play a role: obesity, meat-laden diets and smoking up the risks. So do being male, and being over age 50. Race and ethnicity seem to matter too.
But epidemiologists have no ready biological explanation for the impact of a patient's home-state. The explanation lies within the bizarre workings of America's own Alice-in-Insurerland.
The key to beating colon cancer is preventing it. The initial symptoms -- stomach aches, sometimes anemia -- creep up slowly. By the time the patient goes to the doctor, explaining "Something doesn't feel right," it isn't right.
While medical wizardry offers treatments for colon cancer, the efficacy of those treatments hasn't improved much over the past thirty years. Many people, once diagnosed, will undergo painful treatments that may prolong their lives, but rarely lead to total remission. For men, it is the second leading cause of cancer deaths, after lung cancer; for women, it ranks third, after lung and breast cancers.
Fortunately, medical wizardry offers a detection device: a colonoscopy. The patient spends one day emptying his colon, and a short stint under anesthesia while a physician peers into the colon. If polyps are growing, the physician can see -- and remove -- them. Typically, a patient should return for a colonoscopy every 10 years. The process is uncomfortable; some patients liken it to a root canal. But it works.
This outpatient procedure costs from $600 to $1200. There are other tests for colon cancer -- less invasive, less expensive, but less effective. Clinicians consider colonoscopy the most thorough test. Also, since physicians remove the pre-cancerous polyps, the procedure is truly preventive.
Some insurers will pay; others won't.
One determinant of insurers' decisions is state legislation.
Fifteen states "mandate" that private insurers cover the costs of routine colonoscopies. Another 8 states require some level of coverage. (Catherine Arnst, BusinessWeek.com, March 2007). Twenty-seven states leave decisions solely to insurers and clients: Arizona, Colorado, Florida, Hawaii, Idaho, Iowa, Kansas, Kentucky, Maine, Massachusetts, Michigan, Minnesota, Mississippi, Montana, Nebraska, New Hampshire, New Mexico, New York, North Dakota, Ohio, Pennsylvania, South Carolina, South Dakota, Utah, Vermont, Washington, Wisconsin. In those states, many insurers won't pick up the tab for routine testing. Why should they? The procedure is expensive, but not exorbitant: upper-income enrollees may well pick up the tab themselves. Lower-income enrollees are not going to battle for this benefit.
Mandates don't make for rational public policy. Often legislators who would never ever pass a law that raised taxes will cavalierly pass laws that raise premium costs. Indeed, the zeal-to-mandate has created an insurance pastiche. Depending upon an enrollee's home-state, an insurer may, or may not, cover in vitro fertilization (15 states), bone measurement tests (13), prostate cancer screening (20). Predictably, the pastiche has spurred large employers to self-insure, if only to standardize employment benefits.
Yet in states that have mandated coverage of colonoscopies, more people get the screening test. No surprise there.
This mandate would save lives. The failure of 23 states to pass such a mandate is the surprise.
Joan Retsinas is a sociologist who writes about health care in Providence, R.I. Email firstname.lastname@example.org.
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