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A False Appeal to Women’s Fears

Republican-leaning group claims health care legislation could lead to 300,000 deaths from breast cancer, but uses old statistics, faulty logic and false insinuations.

September 4, 2009

www.factcheck.org

Summary

A conservative group with Republican ties called the Independent Women’s Forum is airing an ad that says "300,000 American women with breast cancer might have died" if our health care were "government run" like England’s, citing the American Cancer Society as a source for the figure. In fact, a spokesman for the cancer society’s advocacy arm says that figure is "not reliable" and adds: "[I]t’s not one that we have ever cited; it’s not one that we would ever cite." Furthermore, an epidemiologist with the cancer society told us that the way this figure was calculated was "really faulty."

In addition:

The ad uses outdated survival rate statistics. More recent numbers show England’s survival rate to be closing the gap with that of the United States.
Experts with the American Cancer Society and the National Cancer Institute told us that mortality rates provide a much more accurate comparison. And the mortality rates for breast cancer for the two countries are similar.

And of course, nothing like England’s system is being considered currently by either house of Congress anyway, as we’ve often pointed out. We judge this ad’s main insinuation to be a false appeal to women’s fears.

Analysis

The Independent Women’s Forum is a nonprofit organization that’s conservative and Republican-leaning. Its Web site says that it supports "greater respect for limited government" and "free markets." In 2003, when IWF’s director was Nancy Pfotenhauer, an aide to Sen. John McCain during his 2008 presidential run, the group announced an affiliation with the conservative Americans for Prosperity, the group that’s now behind a misleading ad on health care.

This 60-second ad will air on a $750,000 buy from Sept. 4 through Sept. 9 on national cable stations, according to IWF. It also ran in late August on about a $1 million buy, as estimated by the Campaign Media Analysis Group of TNS Media Intelligence, in several states including Alaska, Arkansas, Colorado, Indiana, Louisiana, Nebraska and Nevada.

The ad features Tracy Walsh, a breast cancer survivor who says that she’s "worried about what Washington might do now" regarding health care. Walsh implies that if Congress passes a health care bill that includes a federal health plan, hundreds of thousands of breast cancer survivors might die. That implication requires several leaps in logic and the misuse of cancer statistics.

Here’s the reasoning: Walsh says that "many want to create a government run health insurance plan." She then says: "England already has government run healthcare, and their breast cancer survival rate is much lower. … Government control of healthcare here could have meant that 300,000 American women with breast cancer might have died."

That figure comes from applying the difference between the U.S. and England five-year survival rates in a 2008 report to the 2.5 million breast cancer survivors in the U.S., as estimated by the American Cancer Society. On screen, a graphic attributes the 300,000 claim to the British journal Lancet and the American Cancer Society. But the cancer society objects.

"The ad implies, intentionally or not, that we did come up with that figure. In addition to the fact that the figure is not a reliable figure, it’s not one that we have ever cited; it’s not one that we would ever cite," says Steven Weiss, senior director of media advocacy for the ACS Cancer Action Network. (Those 2.5 million survivors represent all people who have completed treatment of breast cancer and are alive today.)

The American Cancer Society’s Elizabeth Ward, vice president of surveillance and health policy research, told us: "It’s really faulty to take the survival rates from another country and apply them to the population of women with breast cancer in the United States. Women in the United States proportionally are diagnosed at an earlier stage, where their likelihood of survival is much greater."

We also contacted the Susan G. Komen for the Cure Advocacy Alliance, where Shelley Fuld Nasso, director of public policy, said: "It does seem to be over-simplified and kind of combining some apples and oranges in that calculation. … That 2.5 million includes women who were diagnosed 30 years ago" and women who were diagnosed recently. "So to apply that five-year survival rate … is really oversimplifying the issue." She adds that treatments and early detection have changed over that time. "So it doesn’t seem a valid (statistic)."

In fact, using IWF’s questionable formula on other survival rates would result in questionable claims. Rates even vary greatly within our borders. New York City’s five-year survival rate is 11 percentage points below that of Seattle, Wash., according to the Lancet report. Would IWF suggest that more women with breast cancer in Seattle might die if they moved to New York?

We asked IWF if any expert, such as an epidemiologist or biostatistician, backed up its 300,000 number. We haven’t received a response.

Straw Man

It’s true the 2008 Lancet report showed that England’s five-year relative breast cancer survival rate (69.8 percent) was lower than that of the U.S. (83.9 percent). But Congress isn’t considering anything close to a British-style system, in which the government is both the insurer and provider of health care for all citizens. The ad raises a classic "straw man" argument, attacking a seemingly easy target that has nothing to do with the subject at hand. And the English target isn’t truly so easy: More recent statistics for England show the breast cancer survival rate has increased substantially and is now closer to the United States’.

Instead of proposing a system like England’s, the House health care bill and the Senate Health, Education, Labor and Pensions committee bill propose a so-called "public plan," which would be one option among several private insurance plans in an insurance exchange. The exchange would be open to individuals who buy their own insurance and small businesses (those with 10 or fewer employees in the first year and 20 or fewer in the second year under the House bill). The bill leaves open the possibility of allowing more businesses into the exchange over time.

Estimates as to how many people would join the federal insurance plan differ greatly, depending on the version of the bill and whether the exchange would be open to all eventually. The Senate bill and the House bill as amended by the Energy and Commerce Committee would set up a "public plan" that would attract an insubstantial number of people to 20.6 million, according to different estimates.

Given that the legislation doesn’t propose a British-style system, the very premise of the ad is false, and its conclusions about survival rates are irrelevant. But there’s plenty of problems with the use of those statistics, too.

Even if IWF and Walsh believe that the "public plan" will be open to all some day, won’t be modified by the Energy and Commerce amendment, and will eventually be the source of insurance for every American, its England analogy doesn’t fit. It would be more apt to draw a comparison to Canada, where the government provides the insurance and physicians operate in the private sector. And Canada’s breast cancer five-year survival rate (82.5 percent) is similar to that of the U.S., according to the Lancet report. And that, too, would be a simplified look at survival rates.

IWF’s assumption that a government-run system brings down breast cancer survival rates ignores the fact that Sweden, Japan and Australia also have similar survival rates, according to the same report. And all have some form of nationalized or government-run health care. Cuba has a higher survival rate (84 percent) than the U.S., but we haven’t seen conservative groups claiming that we should adopt a health care system similar to that country. (The Lancet authors note that Cuba might not have accurate record-keeping – a problem that could affect other survival rate calculations as well.)

The Problem With Survival Rates

As we wrote in a recent post on the FactCheck Wire, one can’t assume that the type of health care system is the only or even a significant factor in apparent differences in countries’ cancer survival rates. Dr. Marie Diener-West, a professor of biostatistics at Johns Hopkins University Bloomberg School of Public Health, told us that one can’t draw too many conclusions. "There are many different factors that could be playing a role," she said. (A five-year survival rate is the percentage of people in a particular group who are alive five years after diagnosis. Calculating this requires one to follow the patients over five years.)

Stephen Finan, senior director of policy for the American Cancer Society Cancer Action Network (ACS’ advocacy affiliate), explains that one of the differences between England and the U.S. is that there’s a higher level of detection of breast cancer here, which increases the survival rate. "We see more breast cancer, and that’s because we place much more emphasis on screening than the U.K. system." (The U.K.’s National Health Service invites women for screening every three years starting at age 50, while the ACS recommends a mammogram every year starting at age 40.) More cancers detected earlier increases survival rates, even if it doesn’t affect mortality rates.

Ward, an epidemiologist with the American Cancer Society, says that the U.K.’s screening program has been expanding but much more slowly than the program in the U.S. The Lancet statistics pertained to women diagnosed in 1990 to 1994. "We know in 1990 and 1994 the mammography screening in the U.K. was only just being implemented" – (it began in 1988) –- and in a much more limited age group." That could further exaggerate the difference. If we knew the survival rate in the U.K. for 2001, it may be more comparable, she says, "because the screenings have been more comparable over time."

In fact, a 2008 report in the British Journal of Cancer examined survival rates for women in England and Wales diagnosed in the late 1990s, finding that their five-year survival rate was 80 percent. The report said that "[b]reast cancer survival rose rapidly and significantly during the 1990s" and predicted that the rate would be 80.9 for those diagnosed in 2000-2001. Data from the U.K.’s Office of National Statistics show a large increase in five-year survival rates: Those diagnosed in 1991-1993 had a 68.2 percent rate, while those diagnosed in 2001-2003 had an 80.3 percent rate. Rates in the U.S. have been increasing, too, but at a much slower rate: For those diagnosed in 2001, the five-year survival rate was 89.8, according to the National Cancer Institute Surveillance Epidemiology and End Results.

Finan also says that "one of the problems in post-cancer treatment, a person could die in a short period of time, but it could be totally unrelated to the cancer." For those reasons, he says, ACS epidemiologists will argue that the more accurate measure is mortality rates. "[W]hen you look at mortality rates … if a person dies from breast cancer, a person dies from breast cancer." A mortality rate (or death rate) is the number of people who died, in this case from breast cancer, in a certain group in a given year or time period.

The most recent mortality rates for breast cancer are 26.7 per 100,000 women in the U.K. (2007 numbers) and 25 per 100,000 women in the U.S. (2009 numbers), according to Cancer Research U.K. and the U.K.’s Office of National Statistics, and ACS Cancer Facts and Figures 2009. The mortality rates "aren’t that different," Finan says, "and it’s hard to parse out what causes that difference."

Weiss, of the ACS Cancer Action Network, told us that using mortality rates "has been a frequent practice of ours because of a long-held belief that survival rates … are not a very reliable comparison."

Other experts we contacted agreed. Dr. Kathy Cronin, a statistician with the Surveillance Research Program at the National Cancer Institute, says that screening can affect survival rates "in a bit of an artificial way." Cronin explains: "There’s someting called lead-time bias. Screening would increase survival even if it doesn’t affect mortality because you’re diagnosing it sooner. … And length bias, where screening tends to detect slower-growing tumors." That, too, would increase survival, even if it didn’t change outcomes. Mortality rates, she says, "would be a more direct comparison."

Ward, of the American Cancer Society, lists another complication with looking at survival rates. "Survival rate depends on the stage of diagnosis," she says. It varies from more than 90 percent for cases diagnosed at stage 1 to 20 percent for cases diagnosed at stage 4. "It’s very uncommon in cancer statistics … we do give overall survival rates, but if you really want to understand rates," she says, "you look at survival rates by stage and that gives you a better sense of the impact of treatment."

"I think it’s so easy to pull one statistic," Ward says, "to use one statistic just as a way to prove your point without really taking into account all the relevant information and all the relevant statistics … to make these kinds of judgments."

Even when looking at the more comparable mortality rates for two countries, differences can’t be pinned easily on one issue, such as the structure of a health care system. Nasso, of the Susan G. Komen for the Cure Advocacy Alliance, says: "We would agree that mortality rates are a better comparison … but even with two different countries, there are too many factors at play and too many variables to say that one factor could describe the difference between the two." Nasso told us cultural factors, differences in demographics, and the different types of breast cancer diagnosed would be some of the factors one would have to look at it determine why mortality rates between countries like the U.S. and England differed.

Finan makes another point about the health care legislation in the House and Senate: It encourages more prevention and early detection efforts. Under the bills, "prevention would be required in all health plans." They would have to cover essential prevention services, which includes mammography, he says, and "prevention services would have to be covered with little or no copays." Those two factors, he says, would result in increased use of mammography (and likely higher survival rates). That’s "one of the reasons we are very supportive of the prevention" measures in the bills.

"Wind Up" on Federal Insurance

The ad says: "Independent experts say tens of millions of Americans could lose their current health insurance and wind up on this public plan." Not exactly. For one, the study in question, by the Lewin Group, a subsidiary of UnitedHealth Group that operates independently, estimated that 103.4 million people would join the "public plan" – if it were open to everyone and if reimbursement rates for physicians were set at Medicare rates plus 5 percent (that’s the original House bill’s proposal). (IWF actually cites an older Lewin study that doesn’t pertain to any specific piece of legislation, but it should have referred to the more recent report.) Some of those whom Lewin predicted would switch are individuals who buy insurance on their own; others would be employed by firms that would decide to offer insurance through the proposed exchange. But even employees would have their choice among private insurance plans and the federal option. If they "wind up" on it, that would be because they selected it. Since the reimbursement rates would create an insurance plan that’s cheaper than private insurance, possibly significantly cheaper, many would chose this plan.

But that’s not the plan that’s in the House bill now. It’s been amended. And the plan wouldn’t necessarily be open to all; the House bill leaves that to the discretion of the secretary of Health and Human Services.

As the legislation stands now, it would likely have less attractive premium rates than originally proposed. The House Energy and Commerce committee passed an amendment that changes the structure of the plan, making the payment rates negotiable rather than related to Medicare payments. That would increase the federal plan’s costs, putting it more in line with private insurance and making it less of a draw for the public. The latest Lewin study didn’t examine the effect of that amendment, but the earlier report found such a scenario would prompt only 20.6 million to switch to the federal plan, if it were available to everyone.

In any case, Lewin’s estimates of the number likely to switch insurance are far higher than those put forth by the nonpartisan Congressional Budget Office. If the original House bill’s federal option were only open to individuals and small businesses, Lewin found 33.6 million would join; the CBO said 11 million to 12 million would sign up. In its analysis of the Senate HELP bill, which has a federal plan similar to the format proposed by the House Energy and Commerce Committee, CBO found that the federal plan "did not have a substantial effect on the cost or enrollment projections."

Bottom line: It remains to be seen how the federal insurance plan will be structured, if it’s part of the final legislation, and which estimates on enrollment turn out to be correct.

– by Lori Robertson, with Jess Henig

Sources

Weiss, Steven, ACS Cancer Action Network. Interview with FactCheck.org. 3 Sep 2009.

Ward, Elizabeth, American Cancer Society. Interview with FactCheck.org. 4 Sep 2009.

Nasso, Shelley Fuld, Susan G. Komen for the Cure Advocacy Alliance. Interview with FactCheck.org. 3 Sep 2009.

Finan, Stephen, American Cancer Society Cancer Action Network. Interview with FactCheck.org. 3 Sep 2009.

Cronin, Kathy, Surveillance Research Program at the National Cancer Institute. Interview with FactCheck.org. 3 Sep 2009.

Quinn, MJ, et. al. “Survival from cancer of the breast in women in England and Wales up to 2001.” British Journal of Cancer (2008) 99, S53 – S55.

Coleman, Michel P., et. al. “Cancer survival in five continents: a worldwide population-based study (CONCORD).” Lancet Oncol 2008; 9: 730–56.

U.S. House. "H.R. 3200." (as introduced 14 Jul 2009.)

Congressional Budget Office. Letter to Rep. Charles B. Rangel. 17 Jul 2009.

Congressional Budget Office. Letter to Sen. Edward M. Kennedy. 2 Jul 2009.

Focus on Health Reform, Health Care Reform Proposals. Kaiser Family Foundation. Accessed 17 Aug 2009.

Sheils, John and Randy Haught. “Cost and Coverage Impacts of the American Affordable Health Choices Act of 2009.” Lewin Group. 27 Jul 2009, amended 31 Jul 2009.

Sheils, John and Randy Haught. “The Cost and Coverage Impacts of a Public Plan: Alternative Design Options.” Lewin Group, 6 Apr 2009.

Government Watch

Health Action Now!

All Americans should have affordable health care choices. Join the HealthActionNow.org movement and tell Congress that NOW is the time for health reform!

AARP's Six Legislative Priorities for Health Care Reform

We Need Action on Health Care Now!

AARP believes any health care reform bill must address the following six priorities:

1) Guaranteeing access to affordable coverage for Americans age 50 to 64: Even before the recession began, the AARP Public Policy Institute found 7.1 million adults age 50 -64 were uninsured in 2007 – that is a 36 percent increase from 2000. Any proposal that covers 50 – 64 year olds must bar insurers from denying coverage and charging unaffordable rates based on age or health status; provide subsidies to people who need them and ensure access to plans that are affordable. AARP is calling on Congress to ensure any final health reform package provides people age 50 - 64 with a choice of quality health care plans they can afford.

2) Closing the Medicare Part D Coverage Gap or “Doughnut Hole:” The Medicare Part D “doughnut hole” is a major reason why nearly 20 percent of people who get their drug coverage through Medicare delayed or did not fill a prescription because of cost – higher than any other insured group. And under current law the hole keeps getting larger each year – it will double in size in 2016. AARP is calling on Congress to begin to close the doughnut hole so people are not forced to pay premiums while at the same time paying full cost for their drugs.

3) Lowering Drug Costs through Generic Biologics: Biologic drugs, which are used to treat serious conditions like cancer, multiple sclerosis, anemia, and rheumatoid arthritis, can cost up to $10,000 or more per month. Generic prescription drugs save consumers and health care providers billions of dollars each year, but unfortunately, no approved process for lower cost generic alternatives is available for biologic drugs. That’s why AARP is calling on Congress to pass the “Promoting Innovation and Access to Life-Saving Medicine Act” (H.R. 1427/S. 726), which will help make these life-saving generic biologic drugs much more available and affordable.

4) Reducing Costly Hospital Re-Admissions through a Medicare Follow-up Care Benefit: Follow-up care that would help people safely transition to home or another setting after a hospital stay will prevent costly, unnecessary hospital readmissions. The “Medicare Transition Care Act” (H.R. 2773) would provide a benefit that would offer the appropriate follow-up care needed to keep people out of the hospital. AARP is calling upon Congress to pass the “Medicare Transition Care Act.”

5) Long-Term Care (LTC): Developing a better system for LTC and people with chronic conditions would save money, improve quality of life for individuals who need these services, and better enable them to live at home. AARP is calling upon Congress to pass two bills that would improve access to home- and community-based services: the “Empowered at Home Act” (S.434), which would expand eligibility for services and provide states with additional federal money so more Americans could receive care at home and the “Retooling the Health Care Workforce for an Aging America Act” (H.R. 468/S. 245), which would provide training and support for family caregivers.

6) Helping Low-Income Americans: The “Medicare Savings Program Improvement Act” (H.R. 2716), the “Prescription Coverage Now Act (H.R. 1536)” and “Medicare Financial Stability for Beneficiaries Act (S. 1185),” are important bills that will help improve access to Medicare programs for low-income individuals. These bills will increase asset test limits so people who did the right thing and saved a small nest egg can still receive assistance; help pay premiums and limit out-of-pocket costs; and raise eligibility standards so more low-income Medicare beneficiaries can qualify for benefits. AARP is calling on Congress to pass these three bills.

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Health Care and Insurance Reform