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AB 56 Would Require Health Insurance Cover Mammograms for Screening or Diagnostic Purposes

Existing California law mandates that health insurance companies that are regulated under the California Insurance Code (PPOs) must provide coverage for mammograms to screen for breast cancer according to a woman’s age as specified in statute.


AB 56 will require these health insurance companies to cover mammograms for screening or diagnostic purposes for breast cancer when it is ordered by a physician or other designated health professional.

The Insurance Code currently requires that insurers must provide coverage for a baseline mammogram when the insured reaches 35 years of age. At age 40 an insured is eligible for a mammogram every other year until age 50 when mammograms are to be made available every year.

There are at least nine categories of women who are at extreme risk of developing breast cancer. Many of these risks mean developing cancer at an early age in life. Under existing law these women can and have been denied a mammogram by their PPO insurance program. Some high risk women include:

  1. A woman who has had a personal history of breast cancer including ductal carcinoma in situ (DCIS).
  2. A woman who has been identified having the BRAC1 or BRAC2 gene mutation or is a first degree relative of someone identified as having the BRAC1 or BRAC2 gene mutation.
  3. A woman who has two or more first degree relatives with breast cancer diagnosed at an early age.
  4. A woman who has been diagnosed with any of the following: Li-Fraumeni syndrome, Cowden syndrome, or Bannayan-Riley-Ruvalcaba syndrome, or who has a first degree relative with one of these syndromes.
  5. Anyone identified with a lifetime risk of breast cancer of 20–25% or greater, as defined by BRCAPRO or other models that are largely dependent on family history.
  6. A woman who has experienced radiation to the chest between the age 10 and 30 years.
  7. An individual who has or has had Lobular carcinoma in situ (LCIS) or atypical lobular hyperplasia (ALH).
  8. An individual who has or has had Atypical ductal hyperplasia (ADH).
  9. A woman with Heterogeneously or extremely dense breast on mammography.

Scientific studies have determined that for many high risk women, their risk of developing breast cancer is not just age related. They can and often do, develop cancer at an earlier age than the general population. National breast cancer screening guidelines are now beginning to address this disparity.

AB 56 will require medical insurance companies regulated under the California Insurance Code to provide coverage for a mammogram when it is ordered by the patient’s health care professional when needed instead of based upon their age. This will allow health care providers to determine when a woman should have a mammogram based upon her specific risks of developing breast cancer.

Health insurance companies such as HMOs that are regulated under the Health and Safety Code are currently required to cover mammograms regardless of age when ordered by their health care provider. AB 56 takes the same requirement for HMOs found in the H & S Code and places it in the Insurance Code for PPOs.

The existing Insurance Code law was enacted 20 years ago and while it was an important step in helping to diagnose breast cancer, it is now outdated and needs to be changed. It is a “one size fits all solution” that is endangering the lives of younger women who are at high risk of developing cancer at a younger age than the general population.

Breast Cancer Screening Guidelines
Although some controversy continues about the appropriate age to begin screening and the frequency of breast cancer screening with mammography for women of higher than average risk, there is general agreement between the major guideline sponsors regarding the age to begin screening for average-risk women.

Several national guidelines now suggest an early start of mammography screening with or without shorter screening intervals for women with above-average risk of breast cancer.

However, due to differences in risk factors, none of the guidelines recommend a specific age to begin screening. The American Cancer Society (ACS) specifically recommends that for women with a 15%–20% lifetime risk, a mutual decision should be made between a patient and her clinician regarding annual adjuvant BMRI. Another organization (the American Society of Clinical Oncology [ASCO, 2006]) wrote a specific guideline for follow-up of women with a history of breast cancer.

Women at High Risk of Breast Cancer
The ACS recommends that the decision of when to initiate mammography screening for women age 30 years and older at high risk for breast cancer should be based on shared decision-making between the woman and her doctor, taking into consideration individual circumstances. ACS also recommends an annual adjuvant screening with BMRI if the woman has a lifetime risk of breast cancer of more than 20% or has a BRCA mutation. The American Society of Breast Disease concurs with the ACS BMRI recommendation.

Current clinical consensus finds that conventional mammography is the “gold standard” for breast cancer screening because of the evidence regarding its effectiveness based on controlled trials in large numbers of women.

The Young Survival Coalition states that “Young women CAN and DO get breast cancer. While breast cancer in young women accounts for a small percentage of all breast cancer cases, the impact of this disease is widespread: There are more than 250,000 women 40 and under in the U.S. living with breast cancer, and over 11,100 young women will be diagnosed in the next year. Breast cancer is the leading cause of cancer death in women ages 15 to 54.”

Younger women generally do not consider themselves to be at risk for breast cancer because only 5 percent of all breast cancer cases occur in women under 40 years old. However, breast cancer can strike at any age, and all women should be aware of their personal risk factors for breast cancer. (A risk factor is a condition or behavior that puts a person at risk for developing a disease. These risk factors have been incorporated into several risk factor models; the most well-known of these is the Gail Model.)

There are several factors that put a woman at high risk for developing breast cancer, including:

  • A personal history of breast cancer or high risk lesion found by biopsy
  • A family history of breast cancer, particularly in a mother, daughter, or sister
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  • History of radiation therapy
  • Evidence of a specific genetic chance (BRCA1/BRCA2 mutation) -- Women who carry defects on either of these genes are at greater risk for developing breast cancer.

What is different about breast cancer in younger women?
Diagnosing breast cancer women younger than 40 years of age is more difficult because their breast tissue is generally denser than the breast tissue in older women. In addition, breast cancer in younger women may be more aggressive and less likely to respond to treatment. Women who are diagnosed with breast cancer at a younger age are more likely to have a mutated (altered) BRCA1 or BRCA2 gene.

Delays in diagnosing breast cancer also are a problem. Many younger women who have breast cancer ignore the warning sign -- such as a breast lump or unusual discharge -- because they believe they are too young to get breast cancer. Many women assume they are too young to get breast cancer and tend to assume that a lump is a harmless cyst or other growth. Some health care providers also dismiss breast lumps in young women as cysts and adopt a "wait and see" approach.

Can breast cancer in younger women be prevented?
Although breast cancer might not be prevented, early detection and prompt treatment can significantly increase a woman's chances of surviving breast cancer. More than 90 percent of women whose breast cancer is found in an early stage will survive.

When women learn at a young age about the risks and benefits of detecting breast cancer early, they are more likely to follow the recommendations regarding clinical exams and mammograms. Young women also need to understand their risk factors and be able to discuss breast health with their health care providers.

Notification of when to start breast cancer screening
AB 56 will also require health plans under both the Health and Safety Code and the Insurance Code to notify women when they are should begin to be screened for breast cancer. The California Health Benefits review Program (CHBRP) made the following findings regarding AB 56.

  • Approximately 51% of insured women in California report receiving a mammogram at age 40 years—the age clinical practice guidelines recommend beginning screening with mammography for women of average risk for breast cancer. AB 56 seeks to increase the utilization rate of mammograms through notification of eligibility of such screening through health insurance plans. This mandate, through notification by a one-time, generic letter (addressed by name), is expected to increase the number of women who receive mammograms each year by approximately 20,000.
  • The USPTF concluded that 1,224 women need to be screened to prevent one death from breast cancer. Therefore, it is estimated that screening an additional 20,000 women with mammography would, over time, prevent approximately 16 deaths per year from breast cancer. It would take approximately 14 years following implementation of AB 56 for this reduction in mortality to be realized, although qualitative improvements, such as a decrease in the aggressiveness of the cancer and less treatment for metastatic disease would be expected sooner.

AB 56 has been amended to make notification by insurance companies easier to comply with. In addition to a written letter, the notice may be provided by publication in a newsletter sent to the insured, by publication in evidence of coverage, by direct phone call to the insured, by electronic transmission, or by any means that will reasonably give notice to the female insured that she should begin being screened for breast cancer.

There are an estimated 4,200 deaths each year in California due to breast cancer. An estimated reduction in 16 premature deaths each year would translate into a savings of 366 life years and 4.4 million dollars in lost productivity.

A recent cost-effectiveness study of women ages 40 years and older examines the long term cost savings associated with mammography (Stout et al., 2006). The study identified an incremental cost-effectiveness ratio (ICER) of $58,000 for screening in every two years and $47,000 for annual screening per quality-adjusted life-year (QALY) saved.

These estimates mean that the net cost, after accounting for all savings associated with the reductions in adverse health events, ranges from about $58,000 to $47,000 per additional QALY saved.

Although there is no consensus about the most appropriate threshold, policy makers have routinely accepted technologies with estimated ICERs much higher than these. These rates were based on the assumption of 100% mammogram rates and would be considerably lower given the current mammogram rates.

A sustained decrease in breast cancer mortality in the United States and California during the last 18 years is attributed, in part, to the increased use of mammography screening during the 1980s, as well as improvements in treatments and reduction of hormone replacement therapy. The National Cancer Institute estimated that screening reduced the total breast cancer mortality by 28%–65%, with treatment contributing to the rest of the reduction (NCI, 2008c).

AB 56 will require PPOs to cover mammograms like current law requires HMOs to cover them. They are a covered benefit when ordered by their health care provider. The decision to have a mammogram should not be based solely on age; it should be based upon the specific risks of a woman and used in consultation with her physician to determine when to begin screening. AB 56 will remove the arbitrary age-based utilization of mammograms contained in the insurance Code, especially where high risk women are concerned.


AB 56 will also require health plans to notify women when they are should begin to be screened for breast cancer. Studies have shown that notification not only increases the number of women receiving mammograms, it saves lives and decreases treatment costs.

Anthony Portantino

Assemblymember Anthony Portantino was elected to serve the 44th Assembly District in November, 2006. Anthony currently serves as the Chair of the Assembly’s Committee on Higher Education and is a member of the Transportation, Government Organization and Public Safety Standing Committees. He is also a member of the Assembly Select Committees on the Preservation of the California’s Entertainment Industry, Foster Care, and Community Colleges.

Reprinted with permission from the California Progress Report.