Political Considerations for Changing Medical Screening Programs

An effective medical screening program provides presumptive identification of individuals with unrecognized disease by applying rapid and simple tests or examinations to differentiate asymptomatic persons who probably have a disease from those who do not. The article in this issue of THE JOURNAL by Yawn and colleagues¹ questions the effectiveness of routine scoliosis screening in the school setting. Twenty-six states have laws that mandate scoliosis screening, and other states without such laws may still provide state-supported screening programs or have screening programs conducted voluntarily in communities by local agencies. States with scoliosis screening activities will need to reevaluate the effectiveness of this screening and determine whether any changes in screening activities are needed. In those states that do mandate screening, the decisions are more meaningful and any changes will require more effort. Individual physicians and the organizations that represent them can be instrumental in assisting states with this decision-making process.

The first decision involves determining the value of scoliosis screening. States need to compare scoliosis screening with established criteria for effective medical screening programs. Underlying principles of an effective screening program include the following: the condition screened for is an important health problem; there is an asymptomatic phase of the disease during which screening is the only means to identify affected individuals; tests or examinations are simple, reliable, and acceptable to the population being screened; there is an accepted and effective treatment for the condition; and benefits from treatment outweigh costs of the screening.² States must decide whether the new information provided in the article by Yawn et al¹ is generalizable to their population, and with the above criteria in mind, whether these data provide a convincing enough argument to challenge the value of scoliosis screening.

The process for determining whether scoliosis screening is ineffective may vary from state to state. For instance, in Oregon, the article by Yawn et al will be evaluated by relevant state agencies including the Oregon Health Division, the Oregon Health Council, and the Department of Education. If these organizations believe there is enough evidence to support further review, they will solicit input from the Oregon Medical Association and from those organizations representing appropriate specialists (ie, pediatricians, family physicians, orthopedic surgeons, and nurse practitioners). These state agencies and organizations will carefully review the article and weigh it against other research on scoliosis screening. They also will rely heavily on the recommendations of national-level organizations if available, and position statements by the US Preventive Services Task Force, the Federal Maternal and Child Health Bureau, and the American Medical Association would carry substantial weight in Oregon's decision-making process. If there is consensus that the overall body of evidence shows scoliosis screening is not effective, state agencies would feel confident in recommending the adoption of this position. If consensus is not reached, both the governor's office and the legislature would make a final determination after considering the input from all those involved.

In some states, the executive branch of government will not take the initiative to reconsider the value of scoliosis screening. In that case, for a decision to be made, a bottom-up approach must occur. Individuals with strong opinions on this issue can make their concern known to those with influence over state laws and programs, primarily state legislators, the governor's office, or appropriate state agencies such as the health department or department of education. Physicians would be excellent candidates for bringing this health-related issue to the attention of policymakers. While individual physicians can make a difference, there is greater power in numbers. Health care professional organizations such as state medical associations and broad-based coalitions composed of a cross-section of voters and interest groups can be particularly effective in getting the attention of state-level policymakers.

If state policymakers agree that scoliosis screening is not effective, their next step is to consider changes necessary to make practice consistent with this new finding. In states such as Oregon that do not have laws for mandatory scoliosis screening, changes can be made at the departmental-policy level. The development of a state-level policy, followed by the endorsement from appropriate state agencies and health professional organizations and by the wide dissemination of the information to health care practitioners and schools, is all that would be required to effect the change. Discontinuing any state funding for screening would be consistent with this policy and usually can be accomplished by an administrative action within the funding agency.

States with scoliosis screening laws face a more substantial question since they must decide whether legislative action to repeal the law is warranted. What will happen if nothing is done to change the law? Policymakers must decide whether the repeal of a health screening law is worth the investment of political capital. Simply eliminating program funding can be an alternative to changing the law, and both the legislative and executive branches of government regularly modify state agency activities through the state's budget-making process. However, this strategy can present a potential liability issue in that citizens can allege that legally mandated services are not being funded and provided.

Not everyone will agree that laws requiring screening should be repealed. Virtually all laws and programs have supporters, and in some cases, these supporters may be quite influential. Legislative strategies should anticipate opposition and include efforts to deal with it. For example, the American Academy of Pediatrics (AAP) currently recommends scoliosis screening.³ If a state's chapter of the AAP endorses this position, and particularly if that position is bolstered by other entities (eg, education-related organizations), it would be much more difficult to mount a successful repeal. Efforts to work with organizations and agencies with opposing views to find common ground or compromise can be energy well spent. Even if consensus cannot be reached, the attempt itself may be viewed as a positive step. Parents also may perceive that screening is effective and insist that their children not be denied something they believe is valuable. Proactive work to educate and change opinion, such as a parent information campaign using the media, parent-teacher associations, and school officials, could go a long way to reduce or remove this potential grassroots opposition. It is always more effective to deal with opposition before the issue is addressed formally by the legislature than it is to fight a pitched battle after the lines are drawn.

If policymakers determine that repeal of a scoliosis screening law is necessary, a bill must be introduced into the legislative process, which varies from state to state. A physician may choose to contact his or her elected representative directly for assistance with this process or work with a professional organization such as the state medical association. State medical associations usually have full-time lobbyists who have established relationships with legislators and have vast knowledge about the inner workings of the legislative process. These lobbyists often have a great deal of influence with legislators because of the credibility and strength of the physician organizations they represent. Individual physicians who are willing to give up valuable time from their practice to support a legislative cause also can exert a powerful influence, particularly on elected representatives in their area. Legislators are elected by their constituents, and consequently, constituent concerns carry more weight than others. Most legislators will make time to meet with people from their district and will seriously consider issues brought forward by them.

The legislative process is not necessarily a logical one in which good ideas turn into law; rather, success is usually based on relationships, timing, hard work, and luck. In addition to explaining the merits of a proposal, advocates must be willing to spend time finding common ground, explaining motivations, establishing credibility, and building trust with legislators. Good working relationships with legislative members and their staff facilitate access to the legislative process and provide opportunities to obtain necessary information for influencing outcomes. Access to and information about the legislative process are critical because it is a complicated system in which a variety of barriers can derail an effort. Knowing deadlines, anticipating obstacles, using opportunities, and avoiding dead ends are often as critical as the merits of the proposal itself.

The study by Yawn et al will make Oregon and other states enter a reevaluation process that may lead to a decision to repeal laws or discontinue screening programs. This is somewhat unusual because new scientific information more often brings with it a charge to implement new services rather than to discontinue existing ones. Many of these concepts apply equally to efforts to initiate new screening services. Someone must first build consensus among key stakeholders as to the merits of the service, and a critical piece is to evaluate any proposal against established criteria for medical screening programs. Someone must determine if laws are needed to require screening or whether the same outcomes could be accomplished through programmatic and fiscal avenues. If statutory changes are needed, someone must build a coalition of supportive legislators and state agencies and must be mindful of potential opposition. Someone must recognize how to work within the legislative system, including the use of professional lobbyists when appropriate, and be willing to usher the bill through the entire process.

This someone does not need to be a bureaucrat. Whether it is an initiative to repeal a law or an effort to create new programs, an individual does not have to be a governor, a legislator, or a state health officer to effect state-level policies and decisions. Individuals with a good idea, who have the passion to see their idea through, with a willingness to learn how to work through the legislative process, and who possess the necessary energy and time can become effective forces to effect legislative change. Physicians are excellent candidates to become champions for legislative issues, including the repeal of scoliosis screening laws, if solid data support this decision and if this is the direction they choose to take for their patients.