[Congressional Record Volume 143, Number 59 (Thursday, May 8, 1997)]
[Senate]
[Pages S4242-S4243]
From the Congressional Record Online through the Government Publishing Office [www.gpo.gov]

      By Mrs. FEINSTEIN (for herself, Ms. Mikulski, Mr. Wellstone, Mr. 
        Johnson, and Mrs. Murray):

  S. 727. A bil to amend the Public Health Service Act and Employee 
Retirement Income Security Act of 1974 to require that group and 
individual health insurance coverage and group health plans provide 
coverage for annual screening mammography for women 40 years of age or 
older if the coverage or plans include coverage for diagnostic 
mammography; to the Committee on Finance.


     PRIVATE INSURANCE UNIFORM COVERAGE OF MAMMOGRAPHY LEGISLATION

   Mrs. FEINSTEIN. Mr. President, I am introducing a bill today 
to try to bring some uniform coverage of mammography to private 
insurance, Medicare and Medicaid, consistent with the American Cancer 
Society and the National Cancer Institute guidelines. Joining me as 
cosponsors are Senators Mikulski, Wellstone and Johnson.
  I am introducing this bill because I believe mammography is our best 
tool for finding breast cancer early and women will not get mammograms 
without good insurance coverage. We now have the two leading 
organizations, the American Cancer Society and the National Cancer 
Institute, agreeing on screening guidelines and we cannot assume that 
insurance companies will rush to follow those guidelines. In the 
current highly competitive climate of managed care, with plans and 
providers reducing services and benefits, with employers cutting back 
on coverage, only congressional action will guarantee women the health 
care they need, especially preventive services like this.


                          Breast Cancer's Toll

  Breast cancer is the most common cancer among women, after skin 
cancer. In 1996, 184,300 new cases were diagnosed and 44,300 women 
died. Breast cancer is the second leading cause of cancer deaths among 
women, after lung cancer. Breast cancer is the leading cause of cancer 
death in women between ages 40 and 55.
  Most women diagnosed with breast cancer are over age 50. For women 
age 40 to 44, the incidence rate is 125.4 per 100,000 women; for women 
ages 50 to 54, it jumps to 232.7 per 100,000.


                      Early Detection Saves Lives

  The sooner breast cancer is detected, the better the survival rate. 
If breast cancer is diagnosed when it is local--

[[Page S4243]]

confined to the breast--the 5-year survival rate is 96 percent. If 
diagnosed later, when cancer has metastasized, the survival rate is 20 
percent.
  Regularly scheduled mammography screening offers the single best 
method of finding breast cancer early. Mammograms, while never 
absolutely certain, can detect cancer several years before physical 
symptoms are obvious to a women or her doctor. Mammography has a 
sensitivity that is 76-94 percent higher than that of a clinical breast 
exam. Its ability to find an absence of cancer is greater than 90 
percent. For women over 50, mammography can reduce breast cancer 
mortality by at least 30 percent.
  Earlier this year, the National Cancer Institute recommended that 
asymtomatic women in their 40s have a screening mammogram every one to 
two years. The American Cancer Society recommends that all women over 
age 40 should have annual screening mammograms.
  A February 1997 CBS poll found that 71 percent of women think early 
detection of breast cancer significantly increases a woman's chances of 
surviving. 85 percent believe mammograms are safe and 88 percent trust 
the accuracy of mamograms. Between 1987 and 1992, the National Health 
Interview survey found that there was at least a two-fold increase in 
the percentage of women of all ages who had a recent mammogram.


                     Compliance with Guidelines Low

  So women by and large understand the need for mammograms. However, a 
study by the Centers for Disease Control found that only 41 percent of 
women age 40 to 49 reported having a recent mammogram. Only half of 
women aged 50 to 64 had a recent mammogram. And only 39 percent of 
women over age 65 reported a recent mammogram.


                     Lack of Insurance a Deterrent

  So the question is, if women understand the importance of mammograms, 
why is adherence to the guidelines so low? The CDC study said, ``Health 
insurance coverage and educational attainment were both strongly 
associated with [mammograms] for women 40-49 years of age.''
  A survey by the Jacob Institute of Women's Health likewise found that 
56 percent of women in their 40's and 47 percent of women in the 50's 
were meeting the ACS screening guideline. After lack of a family 
history, the cost of a mammogram was the principal reason for not 
having a mammogram.
  The lack of insurance coverage, the CDC study found, is an important 
factor in determining which women follow the recommended guidelines. 
Among commercially insured women, more than half were following the 
guidelines. However, for women in government insurance programs, 
between 58 percent and 66 percent were not following the guidelines. 
For women with no insurance of any kind, 84 percent were not in 
compliance with the guidelines.
  The cost of a mammogram also varies widely, depending on the 
radiologist's technique, the location, the interpretation needed. One 
unofficial estimate of cost is that a mammogram ranges from $75.00 to 
$200.00 per visit. A $200 medical charge is not something most 
Americans want to bear out of pocket. They expect their insurance plan 
to cover medically necessary services.


                         Coverage Varies Widely

  Commercial insurance coverage for mammograms varies widely, differing 
in terms of the age of the covered person and frequency of the service. 
Many plans follow the American Cancer Society's guidelines, but this is 
not documented. At least 38 states have mandated some type of coverage 
for commercial plans, but again the details vary. Medicare covers 
mammograms every other year. Federal law does not require Medicaid to 
have specific coverage. A 1993 Alan Guttmacher study attempting to 
describe coverages of commercial health insurance coverage of 
reproductive services is aptly titled ``Uneven & Unequal.'' So in 
summary, insurance coverage is ``all over the map.''


                                The Bill

  The bill addresses private commercial group and individual insurance 
plans, Medicare and Medicaid. It would--
  Require private plans that cover diagnostic mammograms for women 
under 40 to also cover annual screening mammography.
  Require Medicare and Medicaid to cover annual screening mammography 
for women over age 40. (Medicare now covers biannual screening. Federal 
law does not require State Medicaid programs to cover mammography for 
any age and State approaches vary widely.)
  Prohibits plans from denying coverage for annual screening 
mammography because it is not medically necessary or not pursuant to a 
referral or recommendation by any health care provider;
  Deny a woman eligibility or renewal to avoid these requirements;
  Provide monetary payments or rebates to women to encourage women to 
accept less than the minimum protections of the bill;
  Financially reward or punish providers for withholding mammographies.


                          Support for the Bill

  The bill is supported by the American Cancer Society, the National 
Breast Cancer Coalition, the Susan B. Komen Breast Cancer Foundation, 
the Breast Cancer Resource Committee, the Association of Women's 
Health, Obstetrics, and Neonatal Nurses.
  I believe this bill will put some important principles into insurance 
coverage for this very necessary service. I hope my colleagues will 
join me in promptly moving this bill to enactment.
                                 ______