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Opinion: Medical Necessities

Poli Psy

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First came the mammogram flap. An independent panel of researchers, the U.S. Preventive Services Task Force, determined that most women don't need screenings until they're 50, and then they don't need them so often.

You'd think we'd be happy. Less uncomfortable breast squishing and a few bucks saved on health care (though the panel reviewed only clinical, not economic, data). Trustworthy players in the breast biz were delighted. The radical advocates' group Breast Cancer Action, for one, had long warned women of the risks and oversold benefits of mammograms. The renowned breast doctor and feminist Susan Love also welcomed the new guidelines.

So did I. Having endured two painful, scary and probably unnecessary biopsies, I'd been putting off my next mammogram to avoid another biopsy - my own defensive medicine. I'm sure I wasn't the only woman in this pickle.

But then women, and their presumptive friends, rose up. Republicans - those famous champions of women's rights - spread rumors of a Democrat-insurance industry conspiracy to save pennies on the backs of women. The press fanned the uproar. TV reporters strode down hospital hallways beside oncologists, who worriedly condemned the new advice; an "expert panel" - all radiologists - also nixed it. Unlike Democratic bean counters and insurance lobbyists, these docs were exonerated of any self-interest. Soon a Gallup/USA Today poll reported widespread "anger" among women, many of whom planned to ignore the guidelines. (Respondents also overestimated the likelihood of getting breast cancer in one's forties by as much as 50 times.)

Within days, Health and Human Services Secretary Kathleen Sebelius was dissociating the government from its own panel's recommendations. And a week later, Delaware Democratic Senator Barbara Mikulski proposed an amendment to the health care bill guaranteeing free screenings for women - not just yearly mammograms starting in their forties but also tests for such killers as heart disease and diabetes. Most liberals supported the amendment, which passed 61 to 39.

Then another assault on a women's health "need" surfaced: a proposed tax on elective cosmetic surgery to raise health care revenue. Middlebury College sociology professor (and my friend) Laurie Essig, whose forthcoming book American Plastic investigates the collaboration of the cosmetic surgery and consumer credit industries, blogged on True/Slant against the tax. You can't say whether cosmetic surgery is "necessary" or not, she said, given the tough labor and romance markets and women's place in them: "If someone is so depressed about the size of their boobs or their nose or their back fat that they stop going to work or school, is the surgery necessary?" Essig noted that such self-improvement is not the province of privilege anymore - a third of cosmetic surgery patients earn less than $30,000 - so the surcharge would be regressive, like cigarette taxes.

Similar outrage emanated from the National Organization for Women. Middle-age women "have to find work," NOW President Terry O'Neill told the New York Times. "And they are going for Botox or going for eye work, because the fact is we live in a society that punishes women for getting older." O'Neill decried women's inferior pay (as of the last census, 70 percent of American working women earned less than $20,000 a year) and higher health care premiums. "And now they are going to put a tax on middle-aged women in a society that devalues them for being middle aged?" she wailed.

(I was starting to feel a sympathetic hot flash coming on for my Botox-deprived sisters, when it occurred to me there might be a silver lining to women being crowded into the crappy end of the job market: You don't need an eyelid tuck to get hired as a chambermaid.)

Where does this entitlement end? Last week's Times Style section reported on a cosmetic procedure in which fat is transferred from a hefty body part - say, the thighs - to a scrawnier site, usually the breasts. The few docs who do the operation admit there are risks - "oil cysts, masses, nodules and scarring," for example (and sometimes the breasts just "go away"). But here's another problem: The immigrant fat can cause little chips of calcium to form in the breasts, and these can confound radiological readings. A "baseline" mammogram must be done before the fat transfer. The calcifications are harmless, but they sometimes signal cancer, so a biopsy may be needed. An elective (or socially necessary?) procedure leads to a necessary (or overly cautious?) one. Will Mikulski's amendment cover these tests, too?

Essig is right that the line between necessary and elective is not clear. But if health reform is to be sustainable, effective and fair, we're going to have to draw it. She suggests the taxes on cosmetic surgery should be levied on surgeons and credit companies, not patients. I agree that the rich should pay more to support the health care of those who have less. But taxes won't cover it all. There will be rationing. Indeed, there should be rationing - also known as rational choosing between interventions that are needed and those that are only wanted; those that justify the risks and costs and those that don't.

We do not have such a rational policy now, and the mammogram debate highlights the dysfunctional hybrid we do have - a "free-market" health care "system" driven by profit and consumer demand, with a soupçon of recognition of the right to care thrown in. So if the patient wants (or is persuaded to want) a procedure, and if she can afford (or finance) it, then she should have it, we apparently believe, whether it is a nose job at age 12 or a triple bypass at 92. Now we are making the transition to health care as a public good, not a private luxury - and, guess what, we can't have it all. We'll have to stop acting like spoiled customers at Saks.

Women should also heed the feminist health movement's time-tested skepticism of medicine, rather than adopting the dubious notion that all troubles are biological and should be fixed medically. Maybe that gal immobilized by back fat should take a vigorous walk every day, tutor at a public school or, hey, join NOW. For its part, NOW should quit defending her right to liposuction and start changing her - and men's - consciousness about age and beauty. Until that distant goal is won, feminists should hammer the government to fine the bejeezus out of employers who practice age or sex discrimination.

As for gender discrimination in health care, the reform bill would outlaw it, including higher insurance premiums for women.

In the health care debate, as in all politics, it is politically useful to slice the population into competing interest groups - old people, children, kidney dialysis patients, cancer sufferers - and win support bit by bit. But such Balkanization is antithetical to integrated policy; it undermines the goal of reform, which is to promote everyone's well-being.

Plus, such tactics can backfire. The GOP has belatedly become the defender of Medicare. But, mark my words: It will use the cost of Medicare as a reason to vote against reform. The price tag of Mikulski's amendment - about a billion dollars over 10 years - is another arrow in the opponents' quiver. And if reform passes with the amendment intact, the costs of elective tests for worried-well female patients will come out of someone else's care. Men also die of cancer, heart disease and diabetes. Must they get their own amendment?

There is, however, one medical procedure unique to women that cannot be jettisoned in the compromises reform will call for: abortion. Pregnancy happens only to women. Motherhood changes everything. These realities have been at the root of women's oppression since the beginning of time. Without control over our own reproduction, women can never achieve equality.

This makes it all the more depressing that women are up in arms about their rights to unnecessary mammograms, and only the stalwart pro-choice organizations have mobilized against the House's Stupak-Pitts amendment (a similar one from Nebraska Democratic Ben Nelson was defeated Tuesday in the Senate), which would effectively wipe out insurance coverage for the termination of an unwanted pregnancy. Such limited protest makes abortion look like the single-issue fetish of a few, rather than a bottom-line right for all women, whether they choose to exercise it or not. Compare Congress' response to this tepid resistance - numerous putatively pro-choice Democrats voted for Stupak-Pitts - with the stampede to support Mikulski.

Health care reform will force us to sort needs from desires. Since we can't have everything, we have to pick our battles. A nose job is an elective procedure; it is, frankly, not worth defending. A just-in-case mammogram is an elective procedure. We should cherish our mammo-free years.

And, unless the woman's life or health is at stake, an abortion is also a medically elective procedure. But, socially, politically and existentially, the right to have an abortion - and the affordability and accessibility on which the right depends - is not elective. Abortion is necessary to women's equality; it is necessary to women's freedom. Abortion is necessary to more than women's health.

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