What else could we buy with the billions we spend on cancer screening?

We are five days away from a very consequential U.S. election, and living in Pennsylvania, I'm reminded of that every time I pass a billboard on the highway, turn on the television, or look at my cell phone. (Dear campaigns: I've decided whom I will be voting for. Please stop texting me. Please.) Few reporters or bloggers have been paying much attention to the most serious threat to the Affordable Care Act's no-cost preventive services mandate since it became law in 2010. You can take a deep dive into this drawn-out and somewhat convoluted legal odyssey by reading two recent editorials in JAMA, the first one co-authored by JAMA editor-in-chief and former U.S. Preventive Services Task Force Chair Kirsten Bibbins-Domingo, PhD, MD, and the second one by a pair of Harvard Law School professors. In a related Health Affairs Forefront commentary, Richard Hughes explored the "uncertain future" of uniform preventive care recommendations, from legal obstacles to the real possibility that a second-term Trump administration appoints the outspoken anti-vaxxer Robert F. Kennedy, Jr. as Secretary of Health and Human Services.

The spectrum of primary preventive care endorsed by the USPSTF is broad, and includes services such as fluoride varnish application to prevent cavities in children age 1 to 5 years. Wait, don't dentists do that? Yes, but many families with health insurance don't have dental coverage and can't afford the out-of-pocket cost of this periodic service. A recent study showed that the mandate's implementation in January 2015 was associated with a higher likelihood of a privately insured young child in Massachusetts receiving fluoride varnish during a medical visit.

For the sake of argument, let's assume that the courts invalidate the requirement for insurers to cover preventive services without cost-sharing. Fewer people will receive timely screening for cancer. Although it's unclear how many lives will be lost prematurely (the most conservative estimate, none, strikes me as being overly pessimistic), cancer screening costs at least $43 billion annually, and some of that money would presumably become available to spend on other things that improve health.

How about tuition-free medical school for all? My alma mater, NYU, started the trend of multimillion-dollar philanthropy for this purpose, and though $43 billion probably isn't enough of an endowment for all 200 M.D. and D.O. degree granting schools to be tuition-free in perpetuity, it's a pretty sizeable down payment. The problem is, as I predicted in 2019 and reiterated in a recent article in The Atlantic, tuition-free schools (which now include NYU's Long Island School of Medicine, Albert Einstein College of Medicine in the Bronx, Cleveland Clinic Lerner College of Medicine, and Johns Hopkins University) aren't producing more primary care-oriented graduates and "could perversely be making it harder for low-income and underrepresented minority students to go to medical school":

In the year after NYU went tuition-free, the number of applicants shot up by 47 percent. Because the number of slots did not increase proportionally, this made getting admitted dramatically more difficult. High-income applicants have extensive advantages at all levels of higher-education admissions, so making a school more selective virtually guarantees that its student body will become more wealthy, not less, which is exactly what happened at NYU.

So here's another idea: instead of gifting hundreds of thousands of dollars to young adults who are going to become high-earning doctors, what about giving money to people who actually need it? Former Democratic Presidential candidate Andrew Yang highlighted the potential benefits of universal basic income, which he called the "freedom dividend," in his 2020 campaign. He proposed that every American over the age of 18 be given $1000 per month, regardless of income or any other factor. The federal government tested a scaled-back version of this strategy during the COVID-19 pandemic by issuing three rounds of economic impact payments, better known as "stimulus checks." According to the Center on Budget and Policy Priorities, these cash payments, along with other programs such as continuous Medicaid coverage and free school meals, kept 17 million people out above the poverty line.

Pretty much everyone short of the uber-wealthy could probably find something to spend a few thousand dollars on that would make their lives better (including buying something for someone else). But do cash benefits make health better? In 2020, Chelsea, Massachusetts held a lottery in which 1746 of 2880 low-income residents were randomly issued debit cards each month for 9 months, with values ranging from $200-$400 depending on family size. An analysis of what was effectively a randomized, controlled trial showed that persons who received debit cards had significantly fewer emergency department visits overall (217 vs. 317 visits per 1000 persons), including fewer ED visits leading to hospital admission and fewer related to behavioral health and substance use. Interestingly, the intervention group was not more likely than the control group to visit primary care or outpatient behavioral health, so the benefit's mechanism of action is unclear.

Recall that this experiment occurred in the context of the pandemic, with the control group presumably having access to the broader scope of federal benefits mentioned above. I earnestly hope that the defenders of the USPSTF prevail in court and preserve universal access to evidence-based preventive services, including cancer screenings. But if I had to spend the $43 billion on something else that improves health, a monthly cash benefit would be my choice.