Yesterday it was reported, both on the "Today" show and in the Wall Street Journal (and probably in other places, but those are the ones I saw), that the CDC is somewhat concerned because the percentage of women getting mammograms has fallen over the past few years. I saw nothing in either report to indicate that anyone was advancing any theories as to why this would be the case, and I certainly have no real research to propose one myself. I will, however, make an observation. In my own experience -- which is limited to the greater New York City area -- it is actually not so easy to get a mammogram. Personally, I have "good" health insurance. If I want to get a routine mammogram that my insurance will cover, however, I generally have to schedule it months ahead of time. For a mammogram that is not routine (i.e., one that is recommended to investigate a specific potential problem), the wait is less; however, it can still be several weeks. I can get one faster if I am willing to pay out of pocket for it, but the test is certainly not cheap.
I am fortunate in that, as a partner in a law firm, I have the flexibility to take an hour or two in the middle of the day to go and have this test. I can also generally schedule things around the appointed date and time, so that I've never actually had to cancel and re-schedule the test (which would likely entail another long wait for a rescheduled appointment). But many (and I would venture to say perhaps even most) women are not as fortunate as I am in that regard.
A woman who does not have the kind of flexibility I have, and who cannot afford to "opt" for a more flexible appointment schedule by paying for the test out of pocket, may well be faced with a choice of either missing her appointment or missing a shift of work. If you factor in recently-reported trends among retailers such as Wal-Mart, who are now demanding more "flexibility" from their workers in lieu of giving them regular shifts (a trend I wrote about on this blog about a month ago), it would seem that there is likely a substantial population of people who could never possibly schedule this test without serious financial consequences. If you add to that the fact that those who lack insurance can only get the test on those occasions when it is offered for free, the problem becomes even more severe.
How would these factors lead to a decrease over time rather than simply a plateau? Again, I can offer only anectdotal theories. A few years ago one of the facilities that offered covered mammograms here in Manhattan stopped doing the procedure; this made it more difficult to get appointments at the others. I wonder whether anyone has investigated whether this -- or a shrinkage in the number of facilities that are accepting insurance -- is occurring more broadly. I also wonder whether trends in work schedules (including not only the number of hours people are working, but also the number of workers who have to keep two jobs in order to make ends meet) may have some bearing. And, of course, I would expect that trends in insurance coverage would be relevant as well.
My point, ultimately, is that I hope that the CDC's observation will result in something more than just another information campaign to try to "convince" women to get mammograms. I would suggest that what is needed is real progress toward making it feasible for women to follow that sound advise. Perhaps health care reform will help, but if the problem is that people's jobs are not giving them the minimum flexibility needed to take care of their health, then health care reform may be only half of the answer.