Chapter 11 – Preventing Preventive Medicine

This is Chapter 11 of my book-in-progress, “Open Wide And Say Moo! – The Good Citizen’s Guide to Right Thoughts And Right Actions Under Obamacare.” Comments are fervently sought; you can leave them here.

You can read my rationale for undertaking this project, and thus opening myself up to the possibility of public failure, humiliation, derision, disapprobation, and unwanted scrutiny, here.

And here is the up-to-date archive for all the chapters that have been posted so far.
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Update – September 1, 2012

Open Wide and Say Moo! is now revised and published!

 

You can find it on Kindle here.

 

Now available in the audiobook version!

 

 

 

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Chapter 11 – Preventing Preventive Medicine

Back in 2009, when the Obamacare legislation was being debated, we in the herd were given frequent assurances by our Progressive leaders that turned out to be misleading. We were told that we could keep our own health insurance if we liked it. We were told that Obamacare would reduce costs and increase the quality of our healthcare. We were told that anyone who opposed Obamacare most certainly wished to see the cemeteries filled with the sad remains of uninsured children and neglected old people.

But when we were told that Obamacare was all about prevention, that was probably the biggest whopper of all.

Speaker Pelosi, in particular, liked to remind us that if Obamacare signified anything, it signified “prevention, prevention, and prevention.” Indeed, it was by providing the funds and the systems for disease prevention that Obamacare would achieve the twin goals of creating a healthier citizenry, and creating the cost reductions necessary to rescue us from the healthcare system’s fiscal black hole.

And when spokespersons for the Progressive leadership, such as Citizen Pelosi, were marched out before the microphones to say so, they  implied they were talking about providing services such as mammograms and other screening tests that would detect serious illnesses at a time when they were still treatable, and providing medications that would reduce our risk of developing this disease or that. In other words, we were led to believe they were talking about preventive medical services. Indeed, it seems likely that these high profile spokespersons were actually talking about this very thing.

If so, then even the spokespersons were kept innocent of the truth. For the unnamed framers of Obamacare understood “preventive medicine” in a very different way, and they designed the new law to advance their own, very circumscribed, concept of preventive medicine – and to stifle what the rest of us would consider preventive medical services.

The authors of Obamacare actually never intended to increase spending on the kind of preventive medical services everyone thought they were talking about. Rather, they intended to reduce spending on such preventive medical services as much as possible, and wrote into the legislation the mechanism for doing so.

They did this because they fully understood a fundamental truth about preventive medical services, a truth that they were obligated to act upon, but which they could not speak out loud. Namely, that preventive medical services – virtually every preventive medical service you can name – invariably will cost the healthcare system far more money than they can ever save.

This being the case, then under any publicly-funded healthcare system that is serious about keeping costs down, preventive medical services will have to be, well, de-emphasized.

I must hasten to add that there are, of course, preventive measures that turn out to be cost-effective. And to demonstrate that this is the case, and as a public service, I will now conduct these preventive measures, in their entirety: Don’t smoke. Eat a sensible diet. Keep your weight down. Get plenty of exercise.

There you are. And the only reason these measures are cost-effective is that it costs the system very little to utter them.

And to the extent that Obamacare will be serious about disease prevention, finding ways to entice, cajole, embarrass, or force American citizens into what our leaders consider to be healthier lifestyle choices will constitute the bulk of it. This is why we are seeing a great acceleration in the efforts by the Central Authority to regulate what we eat, and why obese Americans have joined the short list of identifiable groups (along with conservative blacks and conservative women) whom it is entirely acceptable, and even laudable, to demonize publicly. This is what our Progressive leaders really (and secretly) mean by “prevention.” We will be addressing this variety of preventive medicine in a later chapter.

Here, my intent is to demonstrate how our hew healthcare system has established the mechanisms for preventing the very kinds of preventive medical services most of us thought Ms. Pelosi was talking about a few years ago.

Why Preventive Medical Services Are Too Expensive

While it may initially seem counter-intuitive to think that preventive medical services will invariably cost the healthcare system far more money than they can ever save, a few moments of thought will demonstrate the truth of it:

a) The preventive measure itself costs money.
b) The preventive measure may not be very effective.
c) Many “preventive healthcare services” consist of some kind of screening test for “early detection,” and these screening tests almost always produce more false positive results than true positive results – leading to the need for more definitive, more expensive, and often invasive confirmatory tests.
d) “Early detection” of any medical condition often detects “occult” disease, that may or may not have become manifest if it had remained undetected.
e) Treating the diagnosed – and often occult – medical condition is often very expensive, produces expensive complications, and/or is ineffective.
f) Early treatment of many medical conditions will not lead to a cure, but rather, may convert what would likely have been a relatively short and fatal disease to a much more chronic, much more expensive disease.
g) Spending money to successfully prevent a particular medical condition simply gives the beneficiary the time to develop some other medical condition – possibly a much more expensive one – in the future.
h) If the patient whose life is saved by the screening test and subsequent therapy is an Old Fart (like your author), that patient will persist, for several more years, to soak younger, worthier Americans for Social Security and Medicare payments.

Q.E.D. The healthcare system will spend far more money by offering these preventive services than if it did not offer them.

This result should not be very surprising. It is the natural result any time healthcare services are to be paid for with pooled funds. Consider what would happen if smoke detectors were regarded as a preventive medical service. Smoke detectors clearly save lives here and there – we have all heard anecdotes about a family being aroused to safety by a smoke detector. But we cannot show any real data proving that the overall survival of people who have smoke detectors is significantly higher than of people who don’t. So if it were society’s job to buy smoke detectors for every individual, then society would – rightly – determine that the cost is not worth the insubstantial benefit.

The only reason most people have smoke detectors is that it is NOT society’s job to pay for them. The individual does. And the individual does not care that smoke detectors cost $1.2 million per life saved. They only care that the life saved, potentially, is theirs, and that owning the smoke detector that might just save their life does not cost them $1.2 million, it only costs them $19.99.

Therefore, I am not arguing here that preventive services are useless or undesirable. Often they are quite useful and very desirable. Rather, I am simply pointing out that, even when a preventive medical service works exactly as designed, all you get is a healthier patient; in the long run, at least, you have not actually saved any money. In fact, if you must provide that preventive service to everyone, you will necessarily lose money. The people who will be running Obamacare understand this, and further, understand they will have to find a graceful way to stifle preventive medical services.

This fact ought to prove embarrassing to our leaders, who have spent the last few years assuring us otherwise. Indeed, we cannot overemphasize the extent to which they have doggedly insisted that not only are preventive healthcare services cost-effective, but also it is precisely because of such preventive services (delivered in the remarkably efficient manner which will be achieved by our new healthcare system) that we will enjoy tremendous cost savings over the next decades.

However, the fact that preventive services are simply too expensive to provide is not news to our leaders. They understood it all along. And accordingly, in the Obamacare legislation they took pains to provide themselves with the tools they will need to accomplish this feat. Their chief tool will be the United States Preventive Services Task Force.

The New Role of the USPSTF

Under Obamacare, the job of determining which preventive services are to be available to Americans and which are not has been assigned to the United States Preventive Services Task Force (USPSTF), a panel of experts appointed by the administration.

The USPSTF has been around for a very long time, and traditionally its job has been to periodically review available data pertaining to various preventive medical services, and to issue recommendations regarding those services – who ought to receive them and when. Its recommendations have been generally respected by American physicians, but were never intended to be binding, and have never been treated as if they were. In fact, most medical specialists in America have been more likely to pay attention to recommendations on preventive services issued by their own professional organizations (such as the American College of Cardiology).

This all changes under Obamacare. The USPSTF is to become the one and only arbiter of preventive medical services. The new law gives the USPSTF final say in which preventive services are to be covered by private insurers (Section 2713), by Medicare (Section 4105), and by Medicaid (Section 4106). If the USPSTF awards a preventive service a grade of A or B, it must be covered. If it awards a preventive service any other grade, it cannot be covered. The recommendations of the USPSTF (including the ones they have issued in the past, prior to Obamacare), are now to be binding – for everyone.

And as we have seen (Chapter 7), if a service is deemed by this expert panel not to be a covered service, it very likely will not be available at all, even if you are willing to pay for it yourself.*

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*While Chapter 7 makes the case that Progressive healthcare systems will always tend to restrict individual prerogatives, this is especially true with preventive medical services like screening tests. For, if a self-paid screening test turns out to be positive and a new diagnosis is made, it will lead to expensive confirmatory tests and/or treatments that the healthcare system itself will have to pay for.
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The USPSTF And Mammography

It is likely that the first time most Americans will recall ever hearing about the USPSTF was when this panel, in the fall of 2009 as the fight over Obamacare was reaching a crescendo, chose that moment to release its controversial new “recommendations” on breast cancer screening.

Many American women were stunned at these new recommendations, most particularly because the USPSTF determined that most women under 50 no longer need screening mammograms. Women were shocked because they had been urged for over a decade by various cancer societies, by the government, and by their doctors to get regular mammograms beginning at age 40. They had been told this screening was important because the early detection of breast cancer was the best way not to die from breast cancer.

The outcry by women was so great that, apparently, our Progressive leaders feared the controversy would cause people to actually begin reading the proposed Obamacare legislation. If people had done so, they would quickly learn that Obamacare was converting the heretofore mild-mannered and unobtrusive USPSTF into an all-powerful final arbiter of which preventive services would be available to Americans and which would not. Furthermore, they would learn that all of the prior recommendations ever made by the USPSTF would become retroactively binding once the new law took effect.

Damage control was required. Accordingly, Secretary Sebelius quickly issued a statement telling Americans that the mammography recommendations of the USPSTF were merely that – non-binding recommendations – and that women should continue getting their screening mammograms as they and their doctors thought best. Then, in order to remove her hasty statement from the category of “lie,” the Secretary quickly caused specific language to be inserted into the pending Obamacare legislation exempting the new mammography recommendations from the law, thus making them non-binding.

That special new language can be found in Section 2713, which addresses private health plans. Similar language, however, does not appear in the Medicare or Medicaid sections (4105 and 4106), so it appears that patients covered by these programs will indeed be subject to the USPSTF ruling on mammography.

The mammogram controversy stirred up by the USPSTF subsequently died down, and apparently without anyone noticing that, new mammography recommendations aside, for the rest of the preventive healthcare services that exist in the universe, only those that have achieved a grade of A or B by the USPSTF will henceforth be covered, or even available.

When we look a little deeper, we find that the USPSTF’s new recommendations on breast cancer screening reveals to us something else that is quite important. It reveals the surprising extent to which the experts in the government’s medical panels are willing to engage in scientific legerdemain, in order to settle upon the answers that are most soothing to the Central Authority. This revelation stems from the fact that the methodologies used by the USPSTF in making its new recommendations on mammography were fundamentally unsound. This is a disturbing observation, since it sets a precedent for future decisions which this and other expert panels will be making for all of us in the herd.

In rendering its decision on breast cancer screening, the USPSTF helpfully published a document laying out in detail the specific clinical studies it relied upon, and the rationale it used, to synthesize concrete recommendations. And by analyzing the USPSTF’s own written justifications, it is possible to derive at least four new “rules” – new precedents – upon which this and similar panels of experts can rely in the future.

1) The USPSTF now recommends that breast cancer screening should no longer be done for most women under the age of 50. But by the panel’s own words, screening mammography in women in the 40 – 49 age group appears to be just as effective at reducing mortality as it is in women 50 and older, and the panel indicates this fact several times within its own document. And as nearly as I can tell, the panel’s only concrete rationale for dropping mammography for women under 50 is that it has found “a new systematic review, which incorporates a new randomized, controlled trial that estimates the ‘number needed to invite for screening to extend one woman’s life’ as 1904 for women aged 40 to 49 years and 1339 for women aged 50 to 59 years.”

This rationale implies the following rule, Rule 1: If you have a preventive measure which is equally effective across a large population of patients, you can withhold that preventive measure from any arbitrary subgroup within that large population, as long as performing the effective measure in that arbitrary subgroup is more costly than it is for some other arbitrary subgroup.

2) In its public justification for withholding mammogram screening for women aged 40 – 49, the USPSTF did not emphasize cost savings, but rather, emphasized the fact that screening in this age group results in more false positive tests than for older age groups, and thus in more unnecessary biopsies, along with the potential for more unnecessary emotional trauma. While this is certainly true, the traditional response to such a circumstance would be for doctors to carefully review the pros and cons of screening with each woman, so as to allow the individual to decide whether the possibility of needing an unnecessary biopsy outweighs the possibility of diagnosing breast cancer while it is still curable.

But instead, the panel established Rule 2, the herd medicine rule: Rather than allowing individuals to apply their own values when weighing healthcare decisions which reasonable people could decide either way, it is legitimate for expert panels to make those decisions from on high for all patients; and furthermore, it is legitimate for the panel to make different decisions for different and arbitrary subgroups of patients (e.g., one decision for women 40 – 49 years of age, another decision for women 50 or older).

3) The USPSTF now recommends that women not be taught breast self examination. In point of fact, since most doctors stopped teaching self-examination a long time ago, this recommendation will probably have little actual impact. But the panel came to this recommendation based on clinical trials conducted in backward, 3rd world healthcare systems (Russia and China), where the treatment of breast cancer is far less advanced than it is in the U.S., and where clinical outcomes in patients with breast cancer have little to do with outcomes in the U.S.

Perhaps more to the point, a similar tactic was used in deciding to withhold mammogram screening for women under 50. That is, the “new randomized controlled trial” the panel invoked to justify this decision was conducted in England, where outcomes for the treatment of breast cancer are substantially – and famously – worse than they are in the U.S.

So Rule 3 is established: It is legitimate to take the results of clinical trials conducted in backward countries with poor healthcare systems, or in less backward countries which nonetheless have demonstrably inferior outcomes, and directly apply those results to coverage decisions affecting American patients who are being treated in the American healthcare system. This is like performing a careful statistical analysis of outcomes from a Pee Wee football league, then telling the New England Patriots to abandon the forward pass, because the percentages just aren’t there.

4) The USPSTF now recommends that women 75 and older not get any breast cancer screening at all, despite the fact that (from the panel’s own words) breast cancer is the leading cause of death among women in this age group. The panel justifies this recommendation by noting that there are insufficient data from randomized trials in these elderly patients, and further, that “women of this age are at much greater risk for dying of other conditions that would not be affected by breast cancer screening.”

It is, perhaps, convenient that very few randomized clinical trials assessing preventive measures have ever been conducted in elderly populations, and further, that if such trials were conducted, any actual benefit that might accrue to the subset of relatively healthy older people who might benefit from preventive medicine would be diluted by the inclusion of large numbers of less healthy elderly patients. And, while doctors usually have little problem identifying those healthy 75-year-olds who are likely to survive another 10 – 15 years, and in whom detecting early breast cancer would likely be beneficial, the large, long-term, randomized clinical trials “proving” to the satisfaction of the USPSTF that these women deserve screening will, for all practical purposes, never be done.

So, Rule 4: Preventive measures should not be offered to old people, because they’re probably going to die pretty soon anyway.

Whether or not you agree with the substance of the USPSTF’s actual recommendations on breast cancer screening, it should be pretty obvious that the methodologies the panel used to reach those recommendations, and the four new rules those methodologies have established, are dangerous for all of us. Perhaps worse, the methods used by the USPSTF reflect an unfortunate mindset that seems apparent among members of this expert panel, in particular, regarding to what extent such panels may be willing to employ (for want of a better term) creative analytics, in order to produce recommendations likely to be pleasing to the Central Authority.

The USPSTF And Prostate Cancer Screening

More recently, the USPSTF created another hub-bub when they released their latest, updated recommendations on whether men should routinely have PSA testing for the early detection of prostate cancer. The USPSTF’s recommendation was simple and straightforward: No.

Proponents of PSA testing immediately complained because prostate cancer kills many men, and its early detection makes it easier to treat. Without PSA testing, the early detection of prostate cancer is difficult and often impossible. But those siding with the USPSTF point to randomized clinical trials showing no significant reduction in mortality in populations of men who have had PSA screening, and further, that men who have PSA screening end up having a lot of very unpleasant and expensive medical procedures which can leave them with life-altering side effects.

The document published by the USPSTF in justifying its PSA recommendation points out two major findings which it has gleaned from the extensive medical literature on PSA screening. First, when PSA screening is applied to large populations of men, it is difficult to demonstrate a reduction in overall mortality. Of two large clinical trials comparing men randomized to PSA screening to those randomized to “standard care,” one found that PSA screening yields a relatively small but statistically significant reduction in cancer-related deaths, but the other showed no mortality benefit. So, given a large population of men eligible for screening, doing PSA testing appears to yield a benefit that is either small or non-existent. And as a result, from a public health standpoint a recommendation to do widespread PSA screening is simply not justifiable based on current evidence.

This finding fully accounts for the USPSTF’s new recommendation to withhold PSA screening.

But the second major finding revealed by the medical literature (which the scientists on the USPSTF faithfully report, but then apparently discount) is that, for men in whom screening has actually detected early prostate cancer, subsequent treatment indeed significantly reduces mortality. This second finding addresses one of the big questions that has often been raised about early detection of prostate cancer, namely, whether the cancers detected by PSA screening actually require treatment. Many of these early cancers apparently never cause death, so many have speculated that “watchful waiting” might be a reasonable course of action rather than aggressive prostate treatment. But the USPSTF’s review of the relevant studies shows that when early-stage prostate cancer is identified, the best clinical trials available show a significant reduction in cancer-related death and all-cause mortality with treatment.

As the backdrop for its negative conclusion on PSA screening, the USPSTF’s document strongly emphasizes the drawbacks of screening. PSA screening often leads men to experience some very bad outcomes from prostate biopsies, or from therapy for prostate cancer. The very nasty complications resulting from these procedures are all too frequent, and are very difficult to even think about let alone experience. Furthermore, pursuing all those positive PSA tests with biopsies is extraordinarily expensive for the healthcare system. The reasoning offered by the USPSTF in making their new recommendation to withhold PSA screening relies heavily on the price which men must pay, in terms of complications, if they have to pursue the results of a positive PSA test – and on the financial cost to the healthcare system of doing so.

I have long been disturbed by the state of the art of both prostate cancer screening and prostate cancer treatment, by the lack of obvious progress in improving these things, and by the seeming complaisance with which many urologists seem to accept the status quo. PSA screening appears far too sensitive (too many false positives, leading to too many biopsies). Prostate biopsies often yield both false positive results (detecting cancers that are probably clinically meaningless) and false negative results (missing cancers that are clinically important). And the numerous treatments available for treating prostate cancer (all of which tend to be very unpleasant) have not been rigorously compared, leaving the various “camps” of urologists to argue that their pet treatment is the best one, and all those other urologists have their heads up their nether regions.

All this confusion and uncertainty places the individual faced with the prospect of whether to have a PSA test, or worse, with newly-diagnosed prostate cancer, in a complete quandary, and apparently with no objective means to resolve what he ought to do next. But despite all these shortcomings, the urology community has aggressively turned PSA screening and the cascade of uncertainties (and resultant procedures) that flow from it into a burgeoning industry, to the extent that one must wonder how badly these specialists really want to clarify the current muddle. And for this reason, it is difficult to take the loud objections being made by the American Urological Association against the USPSTF’s new recommendations very seriously.

So from a herd standpoint, the USPSTF recommendations on PSA screening may seem quite reasonable.

Still, one must consider carefully the second major finding from the USPSTF’s own analysis of the medical literature on prostate cancer screening: Even with all the drawbacks associated with PSA screening, and even with all the conjectures about whether these early prostate cancers really need to be treated after all, it turns out that if prostate cancer is detected by some screening technique, then treating that cancer saves lives. And we must further note that while the USPSTF dutifully describes this result in the body of their report, they do not mention it in the Abstract of their report, and they do not seem to have given it much weight, if any, in their final recommendations.

But clearly this is an important result, and ought to be taken into account. It should not be simply brushed off as irrelevant, or unworthy of notice. It begs to be explained.

How can it be that, on one hand, offering PSA screening to a large population of men does not seem to result in much overall mortality benefit, whereas on the other hand, if you do find prostate cancer when you screen for it, then treating that cancer significantly reduces mortality?

Most likely the explanation lies in the dilution effect. The moderate (but statistically significant) benefit of treating early prostate cancer is washed out when those patients are diluted within a much larger population of men who are eligible for screening, and who may or may not have prostate cancer, which may or may not be detected adequately by current screening techniques, and if it is detected patients may or may not opt for treatment.

To see how such a dilution effect might operate, let’s consider seat belts. Everyone knows that seat belts save lives. So how could we devise a study to prove it? One way would be to compare the mortality rates of people who are in automobile accidents, according to whether they were or were not wearing seat belts. Odds are it would be fairly easy in such a study to show a mortality benefit with seat belts. But now instead let’s imagine a study comparing the mortality rate of all drivers, over, say, a 5-year period, according to whether they routinely wear seat belts, regardless of whether or not they are in an automobile accident. I do not think you would be able to demonstrate an overall mortality benefit with seat belts in this second study.

The PSA screening studies that the USPSTF relied on to make their PSA recommendations are analogous to this second seat belt study. The prostate cancer treatment studies that did show a mortality benefit are analogous to the first seat belt study.

Please note that I am not directly comparing PSA screening to wearing seat belts. Wearing seat belts does not lead to a lot of unnecessary expense, nor does it create life-altering side effects. PSA screening, given the state of the art, is neither inexpensive nor benign.

But despite its major drawbacks, PSA screening does detect early prostate cancer. And if you measure outcomes from the point where the prostate cancer is actually diagnosed (instead of from the point where you decide to do PSA testing), survival is measurably increased by its early detection and treatment.

So the dichotomy is explained. From a herd standpoint, where you have to decide what the result will be on a large population of individuals if some screening test is implemented, it does not make sense to do PSA screening. But if you are an individual who might have prostate cancer, in whom the early detection of that cancer might save your life, then it might make sense to do the PSA screening. (Whether it does make sense or not depends on how you, the individual, assign relative weights to the notion of dying from prostate cancer vs. the inconvenience, expense, pain, and possibly horrible side effects from PSA testing and the procedures it might lead to.)

So while from a herd standpoint it would be a mistake to recommend widespread PSA screening, from an individual standpoint either decision – to have or to forgo PSA screening, depending on how you yourself weigh the tradeoffs – would be entirely reasonable.

But under our new healthcare system, individuals are not allowed to decide this for themselves. The USPSTF will make one decision for everybody. And while in the particular case of PSA testing, many of us may not be particularly sorry to see the new USPSTF recommendation, I submit that given the general nature of medical screening tests, it is child’s play to set up a clinical trial that would “prove” (given the expense of the test, the false positives, the false negatives, the side effects of the test itself, the side effects and expense of the follow-up tests needed to see whether a positive screening test is truly positive, the expense and side effects of the treatment that will be used if the diagnosis is actually confirmed, the relative efficacy and inefficacy of that treatment, not to mention the dilution effects of having to screen a large number of individuals to find the relatively few who actually have the condition of concern and will benefit from its treatment) that just about any preventive screening test will fail to produce an overall benefit to the population.

The whole process makes me wonder why we can’t just stop pretending that Obamacare is all about prevention, disband the USPSTF altogether, stop funding any screening tests whatsoever and any research to develop new ones, and call it a day? That would be much more transparent, not to mention cheaper, than stifling preventive medicine in the painfully slow and deceptive way we are doing it today.

The Media Jumps On Board

I am fairly cynical about the mainstream media, particularly when it comes to reporting on medical matters. So I have fully expected the brilliant people in the media to continue to be extremely surprised and disturbed each time some heretofore sacred preventive medical service is suddenly discovered by the all-powerful USPSTF to be, after all, useless.

So imagine my surprise when recently (October 29, 2011) the New York Times published a “news analysis” which begins to aggressively sell the public on the notion that medical screening tests are, in general, a bad thing to do.

Even I thought the Progressives would be somewhat circumspect about breaking such remarkable and counter-intuitive news to those of us in the herd – especially considering that they have just spent the last three decades teaching us just the opposite. But perhaps it should not be so surprising when you consider the Progressives’ smooth, unapologetic and entirely unremarked transition, around twenty years ago, from sounding the alarm about global cooling to caterwauling about global warming, or moving overnight from demanding that trans fats be placed into our food supply to demanding that they be removed. Even I must often remind myself that when you are a Progressive, history always began 10 minutes ago.

And this turns out to be a great convenience.

The Times article emphasizes that while medical screening tests do save lives, those lives are saved at great cost. There is the dollar cost, of course, but the main concern is the cost to individuals resulting from false positive screening tests, which often lead to expensive, sometimes dangerous, and often psychologically difficult follow-up testing. Our thinking has to change, the Times says, and the paper backs up this new discovery with quotes from sundry healthcare experts who have also seen the light. It turns out that there is a major downside to preventive medical services, a downside which doctors have rarely talked about in their unreasonable zeal to prevent disease, but which, thanks to enlightened thinkers whose voices are at last being heard, are now becoming very important. “[D]octors and patients are stuck in a sort of cancer time warp,” the Times alleges, and they need to get with the modern way of thinking.

There is, of course, nothing wrong with pointing out the hazards and disadvantages of preventive medical services. They are real, and they do substantial harm to many people.

But I must emphasize, once again, that this whole issue becomes a special problem only when we are forced into a paradigm in which preventive services either must be given to everybody, or must be withheld from everybody. It is usually not very difficult for an individual woman to decide whether the potential benefit of finding breast cancer while it is still treatable is worth the risk of possibly needing what might turn out to be an unnecessary and psychologically difficult biopsy. Individual patients may very reasonably decide either way.

But the “debate” which the New York Times suggests is taking place is not whether individuals should or should not opt for certain preventive medical services. That question, implicitly at least, has already been answered, and is not worth even mentioning. Individuals should not be making these decisions at all, but should instead just do what the experts say.

So, the Times indicates, the only real question that remains is whether the experts who will be making a universal decision for the herd should relent to the outdated and unreasonable pressures coming from doctors and patients stuck in a time warp, or rather, follow the dictates of good science, and cut back on those preventive services for everyone. The correct answer, the Times suggests, is obvious.

When we can only make medical decisions collectively, individual Americans will be systematically and predictably harmed. And that includes, according to the USPSTF’s own documentation, several thousand women and men each year whose early, currently treatable, but ultimately lethal breast and prostate cancers will no longer be detected early enough to do any good. This is a necessary result of herd medicine.

But most striking, to me at least, is that the New York Times has already “progressed” to a position where it is simply and naturally right that healthcare decisions should be made collectively – even decisions involving preventive medical services. Indeed, the issue is not even worth mentioning in a high-profile article about preventive medicine. I would have thought that the major media, having spent decades loudly selling all of us on the utter importance of preventive medicine, out of simple self-respect might have hung in there a little longer, at least on this particular aspect of Obamacare.

Silly me.