Mis-SHAPEing Public Health Policy

Abstract

On June 19, 2009, the Heart Attack Prevention Bill, a bill mandating health insurance coverage of radiographic screening tests to detect asymptomatic atherosclerosis, was passed through the Texas legislature and enacted in September.1 The bill, written by the SHAPE (Screening for Heart Attack Prevention and Education) Task Force and championed by Representative Rene O. Oliveira, was first introduced in 2007, but failed at that time because of a lack of scientific data. However, without further evidence or modification, the bill was recently reintroduced and passed, requiring health insurance companies to cover the costs for either cardiac computed tomography (CT) scan to measure coronary artery calcium score or ultrasound to measure carotid artery intimal thickness every 5 years for all men aged 45 to 75 and women aged 55 to 75, along with persons of any age who have diabetes mellitus or an intermediate Framingham Risk Score.1 The Heart Attack Prevention Bill introduces complex questions about the level of scientific evidence needed to support legislative mandates for medical coverage. Neither screening test has demonstrated clinical efficacy in preventing acute myocardial infarctions nor is supported as a primary prevention strategy by any of the major guideline committees.2 In the absence of validating data, mandating medical coverage for these procedures raises concerns of unwarranted costs or harm to patients and potential for conflicts of interest. This article (1) considers the rationale for mandating insurance coverage, (2) considers criteria for evaluating the merits of such policies, and (3) applies these criteria to evaluate the rationale and merits of the Heart Attack Prevention bill, including the political, economic, and social forces at play. As health coverage and payment reform efforts gain increasing momentum, it is critical that legislative coverage mandates qualify as effective public health policy. Currently, most health insurance coverage decisions …