Forgoing care

Dr. James Schlund knows cancer screenings save lives. It only makes sense that catching malignancies early—when smaller and more readily treated—offers a better outcome than late-stage, terminal diagnoses. Data bears this out.

Take breast cancer, Schlund’s specialty. Studies show screening mammograms have reduced death rates by 30 percent. He expects that number is closer to 50 percent for 3D mammography, the form of high-definition digital scanning Schlund and his radiologist partners use at the Chico Breast Care Center; those studies continue to be published.

Even just with the lower percentage, considering how 40,000 women are expected to die of breast cancer this year, screenings will prevent 13,000 women from succumbing to the disease, and there’s the prospect of saving nearly just as many more with wider acceptance by insurers of 3D mammograms.

“The prior history of slash, burn and poison in order to get you to cure doesn’t apply to the small cancers that we find now in the world of 3D mammography,” Schlund said. “In the social fabric of society, the people who are burdened with breast cancer are those who have to oversee the health and welfare of families, of children and themselves—and when you take that person out of society by allowing them to get a big advanced cancer because they’re not having screening services, that is a hit to society.”

Screenings and other preventative measures are keystones of the Patient Protection and Affordable Care Act, also known as the ACA, nicknamed Obamacare. Since the ACA’s implementation in 2012, cancer detection rates have increased. In California, for instance, 158,900 new cases were diagnosed in 2012, 160,925 in 2014 and 173,200 in 2016 (pending final data).

The four preceding years—during the economic downturn—California’s cancer rate dropped. A new study takes statistics from the California Cancer Registry, source of the previous totals, and found “incidence rates declines were greater during the recession/recovery than before.” Heading into 2008, cancer rates went down 0.7 percent for men and 0.5 percent for women; between ’08 and ’12, the decreases were 3.3 percent and 1.4 percent, respectively.

Researchers—headed by author Scarlett Lin Gomez of the Cancer Prevention Institute of California, in Fremont—did not conclude that cancer had decreased, just the number of diagnoses. The report states that rate declines “may be attributable to … unemployment in the recessionary period” and “decreased engagement in preventative health behaviors.”

The findings rang true for Schlund. The Chico Breast Care Center, of which he’s director, accepts patients across the socioeconomic spectrum.

“It’s not rocket science to understand that when people are in material depravity and don’t have money to deal with co-pays and/or deductibles, they’re going to forgo their own health care,” he said. “They’ve got to pay food bills, they’ve got to put clothes on their back and they’ve got to keep the lights on; that comes before their health care.”

Even in so-called good times, Schlund has had patients opt to receive results of a mammogram by telephone to save paying for another visit, even to a primary care provider whose charge would be nominal.

“One of the most life-altering results, for the cost of a co-pay, they’ll take over the phone—sometimes alone, without someone to talk it through and [help] understand the consequences of it or to even be there with family,” Schlund said. “And that’s not just a one-off, that’s a recurrent theme in the breakdown of care because of the cost structures of care.”

DeAnne Blankenship shares Schlund’s frustrations and concerns. She’s the Chico-based director of program services for the California Health Collaborative, a nonprofit focused on promoting wellness, particularly in underserved communities.

Her programs include cancer screenings. The California Health Collaborative contracts with the state, receiving federal grant funds, to run “Every Women Counts”—offering tests for breast and cervical cancers to those who aren’t on Medi-Cal or otherwise able to afford a screening. As enrollment in Medi-Cal expanded under the ACA, Blankenship said, the number of women relying on her program (and its counterparts nationwide) has decreased.

Both may be in jeopardy.

President Trump and Congressional Republicans long have had the ACA in their cross-hairs, and Trump multiplied the uncertainty factor by proposing to Congress deep slashes across federal agencies to increase defense spending.

“What’s being talked about now is cutting social service programs,” Blankenship said, “and this could be considered a social service program, breast and cervical cancer screening, at the federal level…. It’s not really ACA-related; it’s just another threat.”

The ACA does interest her organization, however. The California Health Collaborative helped lower-income residents sign up for coverage during the roll-out of Covered California, the state’s insurance exchange with subsidized policies, and expanded Medi-Cal.

Schlund says “ACA” should stand for “Access to Care Act” because that is its significant achievement, over affordability. Similarly, Blankenship said she’s “very concerned” about the prospect of people losing their insurance should Congress’ “repeal and replace” plan prove unrealistically expensive.

“We’re over one-third of our population covered by Medi-Cal here [in Butte County], so one of the fears with repeal is what that will look like because Medi-Cal is shared dollars with the feds,” she said. “Will people [added under the ACA] go back to not being covered?

“Tax credits are not that helpful for people who don’t make any money. You have to have enough money to put into a health savings account in the first place. Many people are living paycheck to paycheck, if they’re fortunate enough to be getting a paycheck.”

That harkens to the cancer study, which provides senses of both déjà vu and foreboding.

“If screenings are not covered or if fewer people have insurance,” Blankenship said, “then history shows that people will stop going in for screenings, cancers will be caught at a much later stage or not at all, and people will die.”