Senate Affirms Screening Mammography for 40-Year-Olds

Dec. 3, 2009— -- After a slow start to floor debate on the healthcare reform bill, senators approved an amendment on Thursday that would require health insurers to cover mammograms for women ages 40 to 49.

In a 61-to-39 vote, the Senate dealt a significant blow to the power and credibility of the U.S. Preventive Services Task Force (USPSTF), by essentially deciding to disregard the task force's recent recommendation that women under 50 shouldn't undergo routine mammograms.

The bipartisan amendment, sponsored by Barbara Mikulski (D-Md.) and Olympia Snowe (R-Maine), would increase coverage and eliminate copays for more women's preventive services than was contained in the underlying bill.

Snowe, two other Republicans, and the two independents joined the Democrats in voting for the amendment.

But it was an amendment to that amendment that trumped the USPSTF's latest recommendations. Late Wednesday, senators quietly approved, without a roll-call vote, an amendment to Mikulski's amendment offered by David Vitter (R-La.).

The Vitter amendment specifically set aside the most recent USPSTF guidelines, noting that "those issued in or around November 2009" were not to be used in determining coverage requirements.

The USPSTF recommendations on any given procedure are important because the healthcare reform bill that was passed by the House and the bill being considered by the Senate would require insurance companies to cover all medical services that receive a grade of "A" or "B" from the USPSTF.

In its recent recommendations, the task force downgraded mammography in women under 50 to a "C" grade, which means there is limited evidence to support its use.

That would mean that insurance plans wouldn't be required to cover screening mammography for those women, unless the secretary of Health and Human Services (HHS) used her discretionary power to require plans to cover services with lower grades.

The Vetter amendment to Mikulski's amendment would make the USPSTF's 2002 guidelines, which gave a "B" grade to screening mammography in women ages 40 to 49, the operative ranking -- thus requiring their coverage, without a copay.

"My amendment guarantees screening for breast cancer, yes, mammograms," Mikulski said in prepared statement issued when she first introduced her amendment earlier in the week. "We don't mandate that you have a mammogram at age 40. What we say is discuss this with your doctor, but if your doctor says you need one, my amendment says you are going to get one."

The underlying bill already eliminates copays for certain preventive services and requires insurance plans to cover preventive services recommended by the USPSTF.

Under the Mikulski amendment, insurance plans would also have to use recommendations from the Health Resources and Services Administration (HRSA) to determine which preventive services to cover.

"As I reviewed the bill, I felt we could do more to enhance and improve women's healthcare," Mikulski said in a statement.

According to Mikulski, her amendment would direct insurance plans to cover annual mammograms for women under 50, "cervical cancer screenings for a broad group of women," pregnancy and postpartum depression screenings, screenings for domestic violence, and other annual health screenings, which could include testing for heart disease and diabetes.

Planned Parenthood, which lauded the amendment's approval, said the underlying bill didn't eliminate copays for regular well-women visits, breast exams, and contraceptive services, but the Mikulski amendment does.The amendment would cost $940 million over a decade, the Associated Press reported.

Immediately following the Mikulski vote, senators rejected a Republican amendment by a vote of 41 to 59. That amendment, sponsored by Sen. Lisa Murkowski (R-Alaska), would have essentially banned the government from relying on the guidelines from the USPSTF.

Although the USPSTF has been accused of playing politics in deciding to downgrade mammograms from women under 50, the two chairs of the task force told a congressional panel on Wednesday that politics played no role in their decision. Diana Petitti, MD, MPH, vice chair of the USPSTF, said she didn't even know that the task force was referenced in the healthcare reform bills.

The American Cancer Society (ACS), which opposed the new USPSTF guidelines, also opposed Murkowski's amendment. A spokesman for the ACS said the group doesn't want to see the USPSTF eliminated.

"We're supportive of the task force per se, but we'd like to see provisions that clarify the way they operate," said Stephen Finan, senior director for policy for the American Cancer Society Cancer Action Network. "What we want to see is an essential benefits package that is evidenced-based."

The Senate will continue to vote on several other amendments throughout the day, and Sen. Harry Reid said debate on the healthcare bill is expected to last weeks. He told senators to plan to work through upcoming weekends.