14-05-2025
N.C. lawmakers again consider making insurers cover more breast cancer tests
For the second time in two years, the North Carolina House has voted to require insurance companies to cover supplemental breast cancer exams — but it remains to be seen whether the bill will make it through the Senate.
Why it matters: For many women with dense breast tissue, a yearly mammogram that is covered by insurance can miss tumors and produce false negatives.
Often, a different test, like an MRI or ultrasound, can pick up the cancer a traditional test misses.
Those other tests are not typically covered by insurance, though, which makes patients less likely to pursue them and health care providers less likely to suggest them, advocates argue.
Between the lines: While the House has seemed willing to pass a requirement, the Senate passed rules this year limiting insurance coverage mandates, saying they drive up costs, WUNC reported. To add a new mandate, legislators would have to repeal one of the 58 existing mandates.
Thirty-four states require private insurers to offer additional coverage, but North Carolina isn't one of them.
Lauren Horsch, a spokesperson for Senate leader Phil Berger, said the Senate has not discussed what bills it will consider yet, but noted leadership believes mandates drive up costs.
"While this is a mandate bill, Senate Republicans will evaluate the policy through the lens of expanding access while driving down healthcare cost," she added in an email.
Zoom in: The lack of progress on mandating coverage of these supplemental tests has been extremely frustrating for Sheila Mikhail, one of the Triangle's most successful CEOs and a breast cancer survivor.
Mikhail, who guided the Durham biotech AskBio to a $4 billion sale to Bayer, has been one of the loudest advocates in the state for expanding coverage of supplemental tests.
Like nearly half of women, she has dense breasts, which kept her mammogram from spotting a tumor at annual checkups. When it finally was discovered in 2022, it was already at Stage 2.
Despite having the money to pay for her tests, she was never offered supplemental screenings. She believes doctors are less likely to push for them because they aren't covered.
What they're saying: "It's absurd that to get the necessary breast cancer screenings covered we would have to take coverage away [from] something else," Mikhail said of the Senate's rules.
Especially, she added, since Medicaid in North Carolina already covers MRIs for women with dense breasts.
By the numbers: Mikhail, who has taken her arguments to lawmakers in Raleigh and D.C., argues it makes financial sense for insurers to cover the tests.
She says that not only does finding cancer earlier lead to higher survival rates, but it also saves money.
The average cost per patient with an early breast cancer diagnosis was $60,000, according to one study. For those found at Stage 1 and 2, it was $82,000, and it was even higher for those found at later stages.
The big picture: Mikhail said the lack of a mandate for supplemental coverage makes the state less welcoming to all women.
