Access to Mammograms for Low-income Women

Low-income, Little Healthcare: The Ethical Inequities of Healthcare for Women With Low-incomes

By Julia Messerman

This paper will explore access to mammograms for women with low incomes and who should be responsible to ensure that all women have access to the medical technology that they need. I looked into the different types of groups that could help provide assistance to women who need access to this technology and who wouldn’t otherwise be able. I additionally looked into the difference between 2D and 3D mammograms and how accessible 3D mammograms can be to low-income women.  

Image source: Pixabay

Table of Contents

• Introduction/Abstract
• Barriers that Make it Difficult to Receive a Mammogram
• Challenges Getting 3D Mammograms When 2D Mammograms are Offered
• Access to Mammograms Prior to COVID-19 Within Minority Groups
• How Location of Clinics Impacts People’s Access to Screenings
• How Are Black Women Impacted When It Comes to Diagnostic Screenings?
• AI Aiding Breast Cancer Diagnoses
• The Ethics of the Cost of Healthcare For Women With Low-incomes
• The Values and Framework
• Conclusion

Suppose you are a 40-year-old mother of three, you have a 2-month-old newborn, a 3-year-old toddler, and a 7-year-old who just started first grade. You work at the front desk at a local hotel (NJ). Despite the long hours, you do not make more than minimum wage and cannot afford child care. Your mom who lives with you takes care of your children during the day and after school. One day a coworker from the hotel mentions that she needs to get a mammogram. You realize you have not gotten one and should get one soon. While looking at the locations near you, you realize that they are far away and the screenings are very expensive and out of your price range, since you do not have insurance. Additionally, when you ask your manager for a day off from the hotel to get the screening, he tells you that you do not have any more sick days and there will be no paid time off. You feel like a screening is necessary, breast cancer is common in your family and you have not had a mammogram. However, the mammogram itself is very expensive and now you will not have paid time off to go get the screening. You ultimately decide that the screening, although critical, is too expensive. 

This is the reality for many women with low incomes and no insurance. Despite wanting preventative diagnostic scans, like mammograms, financial insecurity often gets in the way. There are several barriers to preventative screenings, most often they include inaccessibility, cost, and the inability to take time off. Mammograms should be accessible to anyone who reasonably wants one and feels that it is necessary. Furthermore, financial insecurity should not prevent women from getting a diagnostic screening that can save their lives.

In this paper, I will discuss whose responsibility it is to ensure that women with low incomes are able to access necessary preventative screenings. I will delve into the positives and negatives of having different groups responsible for paying for these screenings. First, it is important to acknowledge all of the challenges that women with low incomes face which prevent them from getting screenings. The United States of America has never made universal healthcare a social right for citizens. The healthcare system in the U.S. is made up of private and public coverage. The private sector of health care is a combination of employer-based coverage and out-of-pocket spending. Some preventative screenings that women receive like 3D mammograms fall into this category. Despite not making universal healthcare a right, the Affordable Care Act, also known as the ACA, was put in place to make health insurance more affordable and equal.

“Despite this, it was built upon a legacy of existing stratification that had long excluded people by class, occupation, race, ethnicity, gender, and sexuality.”

– M. Mulligan and Castañeda Ed. 35

Therefore, while the Affordable Care Act allowed many individuals not previously covered to get medical insurance, many others continued to be uncovered and burdened by the costs or excluded from care. Throughout my paper, I will discuss the medical expenses that women with low incomes may face and whose responsibility it is to make sure that everyone can access the care that they need. I looked at this question through a consequentialist framework, as I felt it would help to best ensure I account for all people involved. Through my research, I support the belief that women with low incomes should have access to preventative technologies. Despite the burden that this places on the government and communities, I nonetheless, feel that women with low incomes must be provided with the healthcare that they need even if they are unable to pay and lack medical insurance.

In general, the American Bar Association, as well as, other medical journals shared that women require more healthcare services than men; this is because women are more likely to have chronic conditions which need continuous medical treatment. The American Bar Association also found that women have higher rates of mental health issues and are more likely to require prescription drugs. As a result, this additional care and treatment often results in higher costs. The American Bar Association found that “on average most women have lower incomes than men-in part due to pay inequities- and are more likely to live in poverty or extreme poverty than men” (Borchelt American Bar Association). In 2021 women from the age of 18+ were living in consistently higher poverty rates than men.

“This makes women particularly vulnerable to health care costs.”

– Borchelt American Bar Association

The financial burden that receiving health care brings, leads many women in poverty to sacrifice essential care. In 2017, 25% of women postponed or canceled their diagnostic scans due to the financial burden that it caused. Overall, women have higher medical costs than men and sacrifice important medical screenings and appointments due to financial burdens that they cannot bear. 

The healthcare system also shows many disparities between minority groups, two groups that have significantly less coverage are the “black and Latino population[s]”(Riley PubMed Central). Without health insurance, women face many risks, these risks include “fewer preventative services, poorer health outcomes, higher mortality, and disability rates, lower annual earnings because of sickness and disease, and the advanced stages of illness when diagnosed”(Riley PubMed Central). Many of the uninsured people are “disproportionately poor, young, and from racial and/or ethnic minority groups”(Riley PubMed Central). Many of the reasons for being uninsured are due to the cost of insurance, one study found, “Half of uninsured women reported going without healthcare in 2016 because of cost”(Riley PubMed Central). This results in many receiving little to no preventative care, including mammograms. With less preventative care, women increase the likelihood of poor health outcomes and are likely to have their disease diagnosed at more advanced stages.

The impact of this is significant, uninsured women “have higher mortality rate[s].” 

-Riley PubMed Central

 However, with proper insurance and increased availability of screenings, more low-income women would have improved health care which would positively impact both their quality of life as well as their life span. Another issue that some women with low incomes face is the ability to take time off of work for an appointment. Health care for many women with low-paying jobs/minimum-wage jobs can lead to financial insecurity and added financial burdens, which have a large toll on their financial well-being. Many women who work hourly paying jobs, cannot take the time off of work for medical care, while others are not paid for sick leave. One source states that “They will suffer financial losses – or lose their job – if they miss work for medical treatment or illness”(Borchelt American Bar Association). A report from 2016 stated that 1 in 4 women “report[ed] trouble paying medical bills…”(Borchelt American Bar Association). Some low-income women who miss work for medical care face losing their jobs, resulting in the undesirable outcome of women losing their steady income. Steady incomes for women who are in a low socioeconomic bracket are critical and allow them to put food on the table and support themselves as well as their families. 

Throughout the United States healthcare field, some women of color have had less access to high-end healthcare because of financial insecurity.

“Over the last 10 years, women of color, as well as women with less education and lower income, have had less access to 3D screening mammograms compared to white women and women who are more educated and well-off financially.”

– DePolo Breast Cancer.org

Mammograms are an essential part of a breast cancer diagnosis and it is critical that all women have access to them. Mammograms take an X-ray picture of a breast and help doctors find early signs of breast cancer.

There are two different types of mammogram machines that are used in the field, one is a 2D machine which can also be referred to as a conventional digital mammography. The other type is a 3D machine which is known as digital breast tomosynthesis. The 2D machine takes two pictures of each breast, one from the side and one from above. A 3D machine takes multiple photos of each breast from different angles, then a computer is able to combine those images into a three-dimensional picture of the breast. This gives doctors a clearer view of the breast tissue.”(Fox Chase Cancer Center Temple Health). If a 2D mammogram is used, there is a higher likelihood of false positive results. When this happens, the woman is highly encouraged to get another follow-up scan. 

Insurance plays a large role in why some women with low incomes choose to receive 2D instead of 3D mammograms. Not all insurance companies will cover 3D mammograms. Therefore, many women settle for 2D because paying out of pocket is not affordable. 

Additionally, not all facilities have 3D mammogram machines because they are expensive. In 2011 the Food and Drug Administration approved 3D mammogram machines, but despite these machines being approved over a decade ago, some of the facilities do not have the equipment to make their machines capable of a 3D screening(Food and Drug Administration). “To start offering 3D mammograms, facilities must purchase new mammography machines or add to their existing machines to make them 3D capable. So not all facilities have been able to make the switch to 3D mammography because of large up-front costs for equipment. In other cases, facilities had rental agreements for 2D mammography equipment and had to wait until those leases ended to upgrade.”(DePolo Breast Cancer.org). Oftentimes the offices that are located in areas where women have lower education and lower average household incomes, do not have these 3D mammograms available. This means that women would need to find a new facility that is further from where they live. Barriers to seeking out better 3D machines include having to take time off from work to travel further, additional transportation, and, potentially, childcare limitations. 

3D mammograms are more effective than 2D mammograms. They limit the possibility of false positives, as well as, showing more types of cancer than 2D mammograms, all of which can help women get treatment faster and sooner, preventing their disease from further progressing. If women with low incomes were able to receive 3D mammograms conveniently and at an affordable cost, the number of false positives would be reduced, and therefore fewer appointments would be necessary, resulting in fewer days missed from work.

Data was collected in the United States, between 2011 and 2017 from 92 imaging facilities which “were [all] part of the Breast Cancer Surveillance Consortium, a database of breast cancer screening records that is funded by the National Cancer Institute”(DePolo Breast Cancer.org). Records from these screening facilities showed that in 2011 only 3.3% of mammogram testing facilities were offering 3D imaging, but by 2017 the number had increased to 82.6%. The age of women receiving mammograms ranged from 40-89 years of age.

Of these women, “63.1% were white, 13.1% were Black, 6.5% were Hispanic, 11.6% were Asian, and 5.7% were ‘other’.”

– Breast Cancer.org

The data from this shows that minority women are far less likely to receive 3D mammograms. I wanted to investigate the reasons why this was happening, but when I was looking into studies, I came across one that was conducted during COVID-19. During the COVID-19 pandemic, many healthcare providers became overwhelmed with COVID-19 patients and followed recommendations to put a temporary hold on “elective procedures and non-essential surgeries.”(Poulose National Library of Medicine) This included putting a pause on many women’s mammograms who did not have any “concerning symptoms”(Poulose National Library of Medicine). The delays proved to be more challenging for certain minority groups. Prior to the pandemic, Black and Hispanic patients faced screening delays. During the pandemic, these delays became even more pronounced. This in turn led to a decreased rate of cancer detection in Black and Hispanic women. Later it became clear that because of these delays, the detection of cancer was lower for many Black and Hispanic patients but not because cancer had decreased but rather because it was simply going undetected. There are several reasons why the screenings decreased. First, hospitals and facilities put their limited resources towards helping emergency patients and COVID-19 patients and therefore canceled non-elective procedures such as mammograms. Additionally, lack of insurance became an added barrier during the pandemic because many individuals lost their jobs, especially Black and Hispanic women, and without jobs, they lacked insurance.

The location of women to the facility in which they are getting their screening greatly impacts if women end up going to the screening. A study showed that women who had not missed any mammogram appointments lived within 15 minutes of the nearest facility. Women who missed more appointments lived about 27 minutes from screening facilities. Diagnoses are difficult to make if one does not live near a facility and cannot go to appointments. Often primary care clinics are “not easily accessible in the geographical areas where low-income populations live”(Tsapatsaris National Library of Medicine). This study shows that women who live in lower-income areas need more access to convenient clinics but are often the ones living the furthest. 

Transportation during COVID-19 also impacted many women’s access to appointments; the public transport system, though open during the “stay-at-home order”(Tsapatsaris National Library of Medicine), had varied and limited hours.

“And lower-income patients may have been hesitant to use public transportation due to changing information about COVID-19 transmission and mortality.”

– Tsapatsaris National Library of Medicine

Additionally, the COVID-19 pandemic was more prevalent and transferable in densely populated areas, “and racial and ethnic minorities are more highly concentrated in urban areas in the United States”(Tsapatsaris National Library of Medicine). Thus meaning, many ethnic and racial minority women were sidelined during the COVID-19 pandemic from getting their diagnostic screening.

The National Library of Medicine states that in the United States, the second most common cause of cancer mortality among Black women is breast cancer. Black women have a somewhat lower risk of getting breast cancer than their white counterparts. However, despite being lower risk, Black women are 40% more likely to die from breast cancer than white women. The higher rate can be caused because of “biological factors, health insurance factors, less mammography screening,…advanced cancer stage at diagnosis, more aggressive tumor type, differences in cancer treatment quality, and poorer response to cancer treatment”(Tejeda National Library of Medicine). The “advanced stage at diagnosis” is due to “less mammography screening”; without regular screenings, women were getting diagnosed after their cancer had been forming for a while. Mammograms are crucial to helping detect breast cancer and giving a woman a higher chance of survival, however, a study found that “of 44 U.S states, Black Medicaid-insured women in 30% of the states were significantly less likely to complete breast cancer screening.”(Tejeda National Library of Medicine).

“Black women experience below-average survival rates related to breast cancer” compared to their white counterparts.

– Dobson and Yedjou Pubmed.gov

The survival rate is decreased by ten percent for black women because they have more advanced stages of breast cancer when they are diagnosed. Mammography is one of the most effective ways to screen for breast cancer and prevent more advanced stages. However, women with low incomes who use Medicaid are 30% less likely to have mammograms. It is important that all women who need a mammogram are able to gain access to that care. 

Digital Breast Tomosynthesis/3D mammograms have been increasing rapidly in the United States, however, it is not clear if this has developed as rapidly or at all across different populations in the U.S. The populations that are not seeing as much growth with 3D mammograms are women who are “Black race, Hispanic ethnicity, lower education, or lower income level”(Dobson and Yedjou PubMed.gov). All of these groups have higher rates of “morbidity and mortality” “than their less disadvantaged counterparts.”(Dobson and Yedjou  PubMed.gov) These groups have far less access to new medical technologies which are often more accurate but also more expensive.

AI can now be used to detect possible cancerous areas on women’s mammograms that doctors previously would not have noticed. The NY Times shared that “Advancements in A.I. are beginning to deliver breakthroughs in breast cancer screening by detecting the signs that doctors miss. So far, the technology is showing an impressive ability to spot cancer at least as well as human radiologists.” (Adam Satariano and Cade Metz New York Times)

Hungary was the first country to have massive breakthroughs with AI cancer detection, but the United States and Britain are following. Although this technology can help aid diagnoses it cannot be used to replace a doctor. However, more studies are showing that AI  could be used as a supplemental check to a medical practitioner. Before it is universally adopted, AI needs to pass some hurdles. It must prove that it can work with “…women of all ages, ethnicities and body types”(Adam Satariano and Cade Metz New York Times). Additionally, some people fear that solely using AI technology would undermine the trust of patients. However, when used in conjunction with a medical practitioner AI could be beneficial. Many doctors and scientists in the field hope that AI can be used to not only “cut down on false positives that are not cancerous”(Adam Satariano and Cade Metz New York Times) but to actually go further. Specifically, some believe that AI could, at some point, be used to detect diseases and illnesses like breast cancer in mammograms without the need for radiologists, others do not. The New York Times suggests while this groundbreaking AI technology has the potential to be incredibly helpful, the cost of such technology can not be overlooked. Cost of using AI must be a consideration because if the cost is prohibitive, it will implicitly exclude certain groups who may not be able to afford the expense. Additionally, the role of insurance with respect to AI and whether it will defray the cost for all or just some must be evaluated. The use of AI should not be dismissed but who it will benefit and how it will be applied in the case of mammograms must be thoroughly considered.

The stakeholders in this include women with low incomes, their families, doctors, insurance companies, the community, the government, and people who pay out of pocket for these screenings. The primary stakeholder is the women with low incomes. In many countries, health care is a right, in the United States it is a privilege. However, some women need diagnostic screenings like 3D mammograms, which can be very expensive and unaffordable to many. In these situations, women with low incomes will have to opt out of screenings. Is this safe? Fair? Responsible? These are the three values I considered carefully while looking into this topic.

I explored this topic and came to my decision by looking through the consequentialist framework. I felt that the consequentialist framework would be the most appropriate framework for considering all stakeholders and the potential consequences of each possible solution.

The framework looks at which “outcomes are desirable in a given situation, and consider[s] ethical conduct to be whatever will achieve the best consequences.”

– Brown.edu

Government Support:

The first potential solution that I chose to examine is full government responsibility for all healthcare. Many Americans believe that the federal government has the ethical responsibility to ensure health care for all Americans, no matter their race, ethnicity, or socioeconomic status. While we do not have a system in the United States which covers all healthcare, other countries do. By adopting this method, low-income women would be able to have access to the care that they need. However, this does bring up some potential issues, what type of healthcare would people receive? How do we determine what healthcare is considered necessary? Another potential issue relates to women with children who may not have the ability to pay for someone to watch their child while they go to an appointment. This presents the question of who is responsible to take care of the children so that low-income women can go to necessary appointments. Another issue that arises is that low-income women are less likely to live close to medical care facilities, and low-income women are less likely to have access to transportation. How should this be resolved? Based on the numerous burdens that this would place on the government, I believe that full government responsibility/funding is not realistic or the best solution. 

Private Support:

 Other experts believe that the government should not be responsible for funding health care but rather people should donate and volunteer their time so that low-income women can get the care that they need. However, this brings up the issue that donations and philanthropy will not be enough to ensure that all women have the access that they need. I believe that volunteers and donations within the community would be well situated to help with some of the barriers to access. For instance, the community could help with childcare and transportation. This could be through helping with child care or transportation. However, solely using private responsibility would leave low-income women’s health care in the hands of donations and philanthropy. The negative impact of this is that by allowing people to solely donate and support lower-income women, these lower-income women are dependent on others’ direct donations to pay for the screenings which cannot be promised. Additionally, I do not believe that it is realistic to assume that private donations and volunteers could make enough. This could lead to many women still not having the proper access that they need. However, it would keep the incentive to work for better health care.   

Partial Government Support Partial Private Support:

I believe that having a combination of both government and philanthropy would have the best outcome. This would allow the government to fund low-income women with the baseline of proper care and the resources that they would need as well as having support from within the community. The government would help to pay for the 3D screenings for women who would not otherwise be able to afford them, while the community would help to support the women so that they can have transportation to appointments and child care during the appointment. Innovative ways to approach health care for low-income women, could change the outlook from being burdensome to being inspirational and something people want to be a part of. For example, mobile mammogram clinics could visit low-income neighborhoods making accessibility easier. On those days, the local school could run an aftercare program allowing working moms to get a screening before picking up their children. Additionally, pairing a mobile children’s library with a mobile mammogram could give children a place to be while their mothers get screened. People in the community with skills in related areas could volunteer some time and each person using the service could provide a half hour of her time to help the next person. Instead of viewing it as a burden, it could be seen as an opportunity. This is one way that the government and community could work together to provide improved health care to those most in need.

Women in low-income areas are not able to get the health care they need without additional support. While this responsibility should not fall disproportionately on any one sector and cause an extreme burden, it is the responsibility of both the government and the community to work in partnership for the well-being of its citizens. As a result, low-income women would be able to get the screenings that they would need with the most accurate technology. Mammograms should be the standard of care and be available to everyone. As a result, minority women would not have a lower mortality rate because of the lack of screening. Additionally, it is important to take into consideration the values of safety, fairness, and responsibility when determining access to mammograms. Better health care for the more vulnerable population is the obligation of the government and society and actually has a long-term benefit to both. It requires considering access and limitations that arise such as childcare, time off, proximity, and cost. While access must be improved, competing concerns such as cost, profitability, and innovation must be balanced.