Two bills Governor Kim Reynolds signed on May 1 will make advanced testing for breast cancer and other diseases more accessible to Iowans with health insurance coverage.

House File 2489 requires certain types of private health insurance policies to cover supplemental or diagnostic breast examinations such as magnetic resonance imaging (MRI), ultrasound, or contrast-enhanced mammography. House File 2668 requires public and private health insurance to cover biomarker testing for some cancers and other diseases or conditions. Both bills take effect on January 1, 2025.

DETECTING BREAST CANCER WHERE MAMMOGRAMS MAY FAIL

The federal Affordable Care Act (better known as Obamacare) requires private and government insurance programs to cover breast cancer screening for women, beginning at age 40. A mammogram is the usual standard of care, but may not identify tumors in women with dense breast tissue.

Under House File 2489, which House and Senate members unanimously approved, coverage for diagnostic or supplemental breast examinations “shall not be less favorable than coverage a health carrier offers for screening mammograms.”

Brigid Greening, co-president of Iowa Army of Pink, explained via email the significance of that language: “supplemental and diagnostic breast imaging will be covered at the same level as a screening mammograms, i.e. not against the deductible, no copay, no coinsurance. Previously, when insurance covered these imagings, women had to pay their deductible and then either copay or coinsurance. This was a major obstacle for many women.”

During the Iowa House debate on this bill in February, Democratic State Representative Tracy Ehlert shared that a mammogram had not detected her own breast cancer, which was found in 2023 through an MRI. When the Senate took up the bill in April, State Senator Cherielynn Westrich recalled “many, many stories” she had heard from cancer survivors. Some of those women faced advanced disease or even death because mammograms failed to find their breast cancers early.

Democratic State Representative Megan Srinivas noted during the House debate that about one in eight U.S. women will develop breast cancer at some point in their lifetimes, and the rate is even higher in Iowa.

According to the Iowa Cancer Registry’s Cancer in Iowa 2024 report, “Iowa ranks 9th highest in the rate of new cases of female breast cancer in the U.S.” Breast cancer is expected to account for about 2,930 new cancers diagnosed in Iowa this year, roughly 14 percent of the expected total new cases, and more than any other type of cancer.

In addition to women with dense breast tissue, the new law will help others in high-risk groups, Greening noted. Those include people with a family history or personal history of breast cancer, a genetic mutation associated with a higher risk of breast cancer, past radiation to the chest, or anyone whose screening mammogram indicated a need for additional testing.

Greening cited her own sister as an example of someone who could benefit.

She has never been diagnosed with breast cancer but I am a survivor. She has heterogeneously dense breast tissue. We have an aunt on both sides of our family and a cousin who are all breast cancer survivors. Using this internationally recognized risk assessment, her lifetime risk is over 30%. Her breast specialist has recommended that she have the same annual screening that I do, screening mammography and then 6-months later, breast MRI. This is her recommended annual screening and it will now be covered as the average women’s screening mammography is covered at no out of pocket cost. 

Clearly not every woman needs this level of screening but if we are committed to finding breast cancer early, when it is most easily treated and with the best chance of survival, we need to commit to the necessary breast imaging. 

It’s worth noting that HF 2489 won’t apply to every health insurance policy. The fiscal note prepared by the nonpartisan Legislative Services Agency determined that the bill would impact about 807,000 Iowans, roughly 25 percent of the state’s population. Affected Iowans have health insurance through “individual coverage, fully insured small and large employer groups, self-insured public employees, and the State of Iowa Plan.”

The law won’t apply to an estimated 736,868 Iowans who receive employer-provided health insurance not covered by state insurance laws, such as self-insured companies like John Deere. It also won’t help 126,000 Iowans with no health insurance and won’t apply to Medicare, Medicaid, or other public health insurance programs, which cover more than 1.5 million Iowans combined. (Some Medicare policies already cover diagnostic mammograms or medically necessary breast ultrasounds, however.)

MORE COVERAGE FOR “GAME-CHANGING” BIOMARKER TESTING

House File 2668 requires health insurance policies to cover biomarker testing “for the purposes of diagnosing, treating, appropriately managing, or monitoring a disease or condition in a covered person when the biomarker testing has demonstrated clinical utility.” The law defines “clinical utility” as “sufficient medical and scientific evidence indicating that the use of a biomarker test will provide meaningful information that affects treatment decisions and guides improvement of net health outcomes, including an improved quality of life or longer survival.”

Jackie Cale, Iowa government relations director with the American Cancer Society’s Cancer Action Network, told Bleeding Heartland via email,

Biomarker testing has become a game-changing part of cancer care in recent years. Testing is a necessary first step in opening the door to precision medicine and targeted treatments which can lead to improved survivorship and quality of life. After a cancer diagnosis, biomarker testing can help connect patients with the right treatment at the right time. As a result, patients may be able to avoid unnecessary treatments with potentially life-altering side effects. 

Currently, many Iowans don’t have access to the biomarker testing they need, because their health care insurance plan doesn’t cover the most appropriate test. Despite the enormous proven benefits, some insurers have failed to keep pace with innovations and advancements in biomarker testing and treatment. This results in some patients being forced to decide whether to pay out-of-pocket or go without the needed testing. This bill will require Medicaid and state-regulated insurance plans to cover biomarker testing when medically appropriate.

Cale said biomarker testing can “inform treatment of many different kinds of cancer, including breast, lung, melanoma, prostate and colorectal, among others.” (Those are the most common types of cancer occurring in Iowa.)

After signing the bill, Reynolds told reporters that her husband, Kevin Reynolds, benefited from biomarker testing following his lung cancer diagnosis last year, Galen Bacharier reported for the Des Moines Register. The American Cancer Society has posted videos of many patients who had life-changing results from biomarker testing.

In addition to cancer treatment, biomarker testing can improve “the diagnosis and treatment of a range of chronic diseases, such as diabetes and osteoporosis,” according to the National Association of Chronic Disease Directors. Research has also shown benefits for assessing autoimmune and rheumatic diseases.

When the Iowa House debated HF 2668 in March, Republican State Representative Brian Lohse commented that the bill “has taken a long time to get to the floor.” He said it would help patients receive more effective care and reduce costs throughout the health care system. Lohse cited a study sponsored by CVS Health, which found that treating lung cancer patients who had gone through biomarker testing cost an average of $8,500 less per month.

The Senate approved this bill unanimously. In the House, only Republican State Representative Mark Cisneros voted against it. He didn’t respond to an email seeking to clarify his reason for opposing the bill.

A wide range of medical and public health organizations lobbied for the bills on breast screenings and biomarker testing. Although insurance companies often oppose new mandates, no corporations, industry associations, or other entities had lobbyists registered against either bill while the legislation was moving through the House and Senate this year.

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Top photo depicting doctor with patient near imaging machine is by VesnaArt, available via Shutterstock.