When “free” isn’t free: the coverage gaps undermining breast cancer screening

Levy is a board-certified obstetrician/gynecologist and certified menopause provider. She has more than 40 years of experience in direct care, research, and physician training in women’s health care. Levy is currently chief medical officer of Visana Health and chief medical officer of Uroshape, LLC. In addition, she is vice-chair of the American Medical Association’s Current Procedural Terminology Editorial Panel, past chair of the American Medical Association Resource-Based Relative Value Scale Update Committee, and past vice president of health policy at the American College of Obstetricians and Gynecologists for more than 7 years. She has published more than 100 studies and peer-reviewed articles.

For decades, women have been told that mammograms are essential, routine, and, thanks to the Affordable Care Act (ACA), free. Medical groups now recommend regular screenings beginning at age 40 to detect breast cancer as early as possible.

Yet across the country, women continue to face surprise charges, confusing bills, cash-pay add-ons, and pressure to undergo additional imaging they didn’t agree to and often can’t afford—or risk having breast cancer. That leaves millions of women asking the same question: What’s a woman to do?

The promise of “free” screening—and the reality

Under the ACA, insurers must cover screening mammograms with no cost-sharing for the patient. However, the reality is that many women are being quoted $800 or more for a standard screening, with follow-up screening costing as much as $3500 for some women annually.¹

Adding to the surprise, out-of-pocket costs are artificial intelligence (AI) overreads. Many women are being charged for AI overreads of the mammogram without being given advance notice or choice. It could be in the fine print of the forms that patients are signing at check-in, but it’s an exploitation of a system that unfairly affects the women these screenings are intended to serve.

Aside from the fact that mammograms have become unaffordable for the very women they were designed to protect, there is a big issue with them: They're not very effective, and they certainly aren’t preventive. Here’s what I mean: A mammogram looks for cancer that is already there. At best, it can tell you that something exists in the breast, not what it is. Much like a freckle on the skin, a finding may be entirely benign or something far more serious. The mammogram itself cannot make that distinction, and determining whether a finding is cancerous requires additional testing.

The dense breast dilemma

Complicating the issue further: nearly half of all women have dense breasts, and for them, mammography is less sensitive and often inconclusive. For this population of women, additional screening is almost always needed, which can lead to out of pocket costs and surprise bills. Yet, mammograms remain the only universally recommended screening tool.

Dense breasts are categorized as heterogeneously dense (41% of women) or extremely dense (8% of women). For the 8%, mammograms miss more cancers, and follow-up imaging is more common than in women without dense breasts. But that doesn’t mean additional tests, such as MRI or ultrasound, are always the answer.

The evidence is complicated and, frankly, limited. There is only one randomized clinical trial offering MRI to women with dense breasts. In this study, although MRI detected cancers earlier, long-term outcomes did not differ significantly from those in the mammogram-only group.² So, more evidence would be needed to demonstrate that additional screening improves diagnosis. Until we have proof that additional detection improves outcomes, health insurers will classify it as not medically necessary, leaving women paying for a diagnostic odyssey triggered by a screening they were told was free.

That’s not to say mammograms aren’t valuable. Early detection matters. But overdiagnosis is real: One study estimated that about 20% of cancers detected through screening would never have become harmful.³ Yet those women undergo treatment, carry survivor labels, and believe screening “saved” them—reinforcing the cycle of fear and overtreatment.

So, what’s a woman to do?

It shouldn’t be this hard. Women deserve clarity, consistency, and financial protection for preventive care mandated by the health care system. But here we are. So, here are a few practical principles for women:

• Pay attention to your body. Mammograms matter, but symptoms matter too.

• Get screened regularly, every year or every 2 years—whatever your clinician recommends, and your insurance coverage provides.

• Ask about your expected out-of-pocket costs before the test, especially for AI add-ons or additional imaging.

• Know your breast density. It can inform risk and guide decisions about supplemental imaging.

For most women, especially those with a higher risk of breast cancer, invest in risk reduction. What does that look like? Exercise, limit alcohol, and maintain a healthy weight. Knowing your risk, paying attention to your body, staying up to date on your screenings, and making lifestyle changes to reduce risk matter more than any imaging technology.

The path forward

A 2015 research article in Health Affairs shocked the health care industry when it reported that false-positive mammograms and breast cancer overdiagnoses cost the industry $4 billion annually.⁴ Ten years later, little has changed except the cost of care, which continues to rise.

Real solutions will require coordinated action. There are steps payers, providers, and government officials can take to improve mammogram screening for women, as follows:

1. Federal reform mirroring the colonoscopy fix: requiring coverage for all clinically indicated follow-up stemming from a screening mammogram.

2. Transparency mandates for health systems, provider groups, and imaging centers so that AI tools, additional imaging, and diagnostic reclassification are clearly disclosed.

3. Insurance modernization to reflect evolving evidence around dense breasts and risk-based screening.

Better tools are coming. More accurate, less invasive, lower-cost screening methods are on the horizon. But until then, women are stuck navigating a system that is confusing at best and financially punishing at worst.

Mammograms shouldn’t be a financial gamble. They shouldn’t require fine-print sleuthing. And they shouldn’t leave women choosing between the recommended screening and their monthly budget.

Until the system catches up with science, women have every right to ask: What’s a woman to do?

REFERENCES

1. Morgenson G. They were told to get extra breast cancer screenings. then they got stuck with the bill. NBC News. February 25, 2025. Accessed May 27, 2026. https://www.nbcnews.com/health/health-care/told-get-extra-breast-cancer-screenings-stuck-bill-rcna191446

2. Levy B, Kaunitz AM. Appropriate cancer screening for women with dense breasts. OBG Management. 2022;34(3):41-45. doi:10.12788/obgm.0179

3. Ong MS, Mandl KD. National expenditure for false-positive mammograms and breast cancer overdiagnoses estimated at $4 billion a year. Health Affairs. April 2015. Accessed on May 27, 2026.

https://www.healthaffairs.org/doi/10.1377/hlthaff.2014.1087