[Congressional Record Volume 144, Number 51 (Thursday, April 30, 1998)]
[Senate]
[Pages S3933-S3936]
From the Congressional Record Online through the Government Publishing Office [www.gpo.gov]

      By Mr. D'AMATO (for himself, Ms. Mikulski, Ms. Snowe, Mr. 
        Moynihan, Mr. Chafee, Mr. Daschle, Mr. Inouye, Mr. Bingaman, 
        Mr. Johnson, Mr. Dodd, Mr. Kennedy, Ms. Moseley-Braun, Mrs. 
        Feinstein, and Mrs. Boxer):
  S. 2017. A bill to amend title XIX of the Social Security Act to 
provide medical assistance for breast and cervical cancer-related 
treatment services to certain women screened and found to have breast 
or cervical cancer under a Federally funded screening program; to the 
Committee on Finance.


          The Breast and Cervical Cancer Treatment Act of 1998

  Mr. D'AMATO. Mr. President, I rise today to introduce bi-partisan 
legislation which will allow states the option of providing Medicaid 
coverage to women who have been diagnosed with breast and cervical 
cancer through the federal government's breast and cervical cancer 
early detection program.
  Currently, the CDC breast and cervical cancer program provides low-
income, uninsured women with coverage for cancer screening, covering 
mammographies and pap smears. While this program begins to fill a 
crucial need, this legislation allows Congress to make this program 
even better. The result has often been that uninsured women are 
diagnosed with cancer and then left to scramble to find treatment.
  In 1990 Congress passed a bill that was a breakthrough for the early 
detection of breast and cervical cancer in women. The Breast and 
Cervical Cancer Mortality Prevention Act of 1990 authorized the Center 
for Disease control to increase screening services for women who are 
low-income. From July of 1991 to March of 1997, CDC's program provide 
mammography screening to over 500,000 women and diagnosed nearly 3,500 
cases of breast cancer. During this same period, the program provided 
over 700,000 Pap tests and found more than 300 cases of invasive 
cervical cancer. This is good news for the early detection of cancers 
in women.
  But the bad news is that all women are not getting treated for 
cancer. Screening does not prevent cancer deaths; it must be coupled 
with treatment. Congress tried to ensure that women would get 
treatment, by requiring that state programs seek out services for the 
women they screen. But wherever I've traveled in New York, I've been 
hearing reports that programs are over burdened. Volunteers are working 
over time. Program administrators are having to rely on public 
hospitals and charity care. Women are having to hold bake sales to get 
treatment. This is wrong. It's not what Congress intended when it 
passed the Cancer Prevention Act in 1990.
  Now, a newly published study of the program documents that approaches 
for delivering treatment services are fragmented, and in danger of 
breaking down. I am very concerned, Mr. President, that the program is 
over burdened and needs help. The women of America need this program. 
Early detection saves lives. However, Mr. President, if we are unable 
to treat the women who are diagnosed with breast cancer, we have failed 
them.
  I commend the local programs that are working hard to line up 
treatment services for women. These programs are doing whatever they 
can to see that women with cancer get care. But the fact is that these 
solutions are labor-intensive and have long-range consequences of the 
program itself. The CDC study shows that programs are having a hard 
time recruiting new providers and must limit the number of women 
screened. Today the program serves only 12 to 15% of all women who are 
eligible nationally. And this percentage is likely to decrease. The 
study also shows that fewer physicians will be able to offer free or 
reduced-fee services in the future, because of changes in the health-
care system. My point is, and the study shows, that whatever fragile 
delivery systems for treatment are in place now are in jeopardy and 
overburdened. Women are not getting the treatment they need.

  In June 1997, Senator Moynihan and I were successful in including an 
amendment in the Budget Resolution that addressed this and would have 
solved this problem. Unfortunately, that amendment was passed by the 
Senate but later died in conference. Mr. President, we must not let 
these women fall through the cracks any longer. This legislation 
provides a mechanism to fix the problem that these under served women 
face.
  Mr. President, I began the fight in 1992 for more research funding 
for breast cancer. With the help of the National Breast Cancer 
Coalition and the

[[Page S3934]]

women of New York--women like Barbara Balaban, Geri Barish, and Doctor 
Susan Love, Senator Harkin and I started a research program in the Army 
that has grown to over $750 million and continues to provide research 
dollars for the latest, cutting edge technologies and research.
  We must not abandon the women of America who are diagnosed with 
breast and cervical cancer, only to find that there is no way to pay 
for their treatment. Congress has responded to the call for more 
research money for breast cancer, we must now continue that fight to 
provide increased treatment for every woman diagnosed with breast and 
cervical cancer.
  The National Breast Cancer Coalition has made me very aware of the 
problems that women are facing regarding treatment after diagnosis 
under the CDC program. And I am concerned that the problem is getting 
worse.
  We make speeches and wear pink ribbons to show our commitment to 
fight breast cancer--but now is the time to act to support a simple 
amendment that will make real contribution to the fight against breast 
cancer. It will save lives and ensure that women, when diagnosed 
through the federal program, will not have to hold bake sales to get 
treatment.
  I join my colleagues, Senator Moynihan, Senator Snowe, and Senator 
Mikulski, in sponsoring legislation that will establish a mechanism for 
women's treatment. This is a targeted measure that will allow states 
the option of providing Medicaid to women who have participated in the 
CDC program and have been diagnosed with breast and cervical cancer. I 
am determined to solve this problem before Congress is adjourned this 
year. It is irresponsible of the federal government to do otherwise.
  Mr. President, I ask unanimous consent that the text of the bill be 
printed in the Record.
  There being no objection, the bill was ordered to be printed in the 
Record, as follows:

                                S. 2017

       Be it enacted by the Senate and House of Representatives of 
     the United States of America in Congress assembled,

     SECTION 1. SHORT TITLE.

       This Act may be cited as the ``Breast and Cervical Cancer 
     Treatment Act of 1998''.

     SEC. 2. OPTIONAL MEDICAID COVERAGE OF CERTAIN BREAST OR 
                   CERVICAL CANCER PATIENTS.

       (a) Coverage as Optional Categorically Needy Group.--
     Section 1902(a)(10)(A)(ii) of the Social Security Act (42 
     U.S.C. 1396a(a)(10)(A)(ii)) is amended--
       (1) in subclause (XIII), by striking ``or'' at the end;
       (2) in subclause (XIV), by adding ``or'' at the end; and
       (3) by adding at the end the following:

       ``(XV) who are described in subsection (aa)(1) (relating to 
     certain breast or cervical cancer patients);''.

       (b) Group and Benefit Described.--Section 1902 of the 
     Social Security Act (42 U.S.C. 1396a) is amended by adding at 
     the end the following:
       ``(aa)(1) Individuals described in this paragraph are 
     individuals who--
       ``(A) are not described in subsection (a)(10)(A)(i);
       ``(B) have not attained age 65;
       ``(C) satisfy income and resource requirements to be 
     treated as a low-income woman for purposes of being given 
     priority under section 1504 of the Public Health Service Act 
     (42 U.S.C. 300n); and
       ``(D) are not otherwise covered under creditable coverage, 
     as defined in section 2701(c) of the Public Health Service 
     Act (45 U.S.C. 300gg(c)).
       ``(2) For purposes of this title, the term `breast or 
     cervical cancer-related treatment services' means services 
     that are medically necessary or appropriate for the treatment 
     of breast or cervical cancer and complications arising from 
     such treatment and for which medical assistance is made 
     available under the State plan to individuals described in 
     subsection (a)(10)(A)(i).''.
       (c) Presumptive Eligibility.--
       (1) In general.--Title XIX of the Social Security Act (42 
     U.S.C. 1396 et seq.) is amended by inserting after section 
     1920A the following:


    ``presumptive eligibility for certain breast or cervical cancer 
                                patients

       ``Sec. 1920B. (a) State Option.--A State plan approved 
     under section 1902 may provide for making medical assistance 
     for breast or cervical cancer-related treatment services 
     available to an individual described in section 1902(aa)(1) 
     (relating to certain breast or cervical cancer patients) 
     during a presumptive eligibility period.
       ``(b) Definitions.--For purposes of this section:
       ``(1) Presumptive eligibility period.--The term 
     `presumptive eligibility period' means, with respect to an 
     individual described in subsection (a), the period that--
       ``(A) begins with the date on which a qualified entity 
     determines, on the basis of preliminary information, that the 
     individual is described in section 1902(aa)(1), and
       ``(B) ends with (and includes) the earlier of--
       ``(i) the day on which a determination is made with respect 
     to the eligibility of such individual for services under the 
     State plan, or
       ``(ii) in the case of such an individual who does not file 
     an application by the last day of the month following the 
     month during which the entity makes the determination 
     referred to in subparagraph (A), such last day.
       ``(2) Qualified entity.--
       ``(A) In general.--Subject to subparagraph (B), the term 
     `qualified entity' means any entity that--
       ``(i) is eligible for payments under a State plan approved 
     under this title and provides breast or cervical cancer-
     related treatment services; and
       ``(ii) is determined by the State agency to be capable of 
     making determinations of the type described in paragraph 
     (1)(A).
       ``(B) Regulations.--The Secretary may issue regulations 
     further limiting those entities that may become qualified 
     entities in order to prevent fraud and abuse and for other 
     reasons.
       ``(C) Rule of construction.--Nothing in this paragraph 
     shall be construed as preventing a State from limiting the 
     classes of entities that may become qualified entities, 
     consistent with any limitations imposed under subparagraph 
     (B).
       ``(c) Administration.--
       ``(1) In general.--The State agency shall provide qualified 
     entities with--
       ``(A) such forms as are necessary for an application to be 
     made by an individual described in subsection (a) for medical 
     assistance under the State plan, and
       ``(B) information on how to assist such individuals in 
     completing and filing such forms.
       ``(2) Notification requirements.--A qualified entity that 
     determines under subsection (b)(1)(A) that an individual 
     described in subsection (a) is presumptively eligible for 
     medical assistance for breast or cervical cancer-related 
     treatment services under a State plan shall--
       ``(A) notify the State agency of the determination within 5 
     working days after the date on which determination is made, 
     and
       ``(B) inform such individual at the time the determination 
     is made that an application for medical assistance under the 
     State plan is required to be made by not later than the last 
     day of the month following the month during which the 
     determination is made.
       ``(3) Application for medical assistance.--In the case of 
     an individual described in subsection (a) who is determined 
     by a qualified entity to be presumptively eligible for 
     medical assistance for breast or cervical cancer-related 
     treatment services under a State plan, the individual shall 
     apply for medical assistance under such plan by not later 
     than the last day of the month following the month during 
     which the determination is made.
       ``(d) Payment.--Notwithstanding any other provision of this 
     title, medical assistance for breast or cervical cancer-
     related treatment services that--
       ``(1) are furnished to an individual described in 
     subsection (a)--
       ``(A) during a presumptive eligibility period,
       ``(B) by a entity that is eligible for payments under the 
     State plan; and
       ``(2) are included in the care and services covered by the 
     State plan;

     shall be treated as medical assistance provided by such plan 
     for purposes of section 1903(a)(5)(B).''.
       (2) Presumptive eligibility conforming amendments.--
       (A) Section 1902(a)(47) of the Social Security Act (42 
     U.S.C. 1396a(a)(47)) is amended by inserting before the 
     semicolon at the end the following: ``and provide for making 
     medical assistance for breast or cervical cancer-related 
     treatment services available to individuals described in 
     subsection (a) of section 1920B during a presumptive 
     eligibility period in accordance with such section''.
       (B) Section 1903(u)(1)(D)(v) of such Act (42 U.S.C. 
     1396b(u)(1)(D)(v)) is amended--
       (i) by striking ``or for'' and inserting ``, for''; and
       (ii) by inserting before the period the following: ``, or 
     for medical assistance for breast or cervical cancer-related 
     treatment services provided to an individual described in 
     subsection (a) of section 1920B during a presumptive 
     eligibility period under such section''.
       (d) Enhanced Match.--Section 1903(a)(5) of the Social 
     Security Act (42 U.S.C. 1396b(a)(5)) is amended--
       (1) by striking ``an'' and inserting ``(A) an'';
       (2) by adding ``plus'' after the semicolon; and
       (3) by adding at the end the following:
       ``(B) an amount equal to 75 percent of the sums expended 
     during such quarter which are attributable to the offering, 
     arranging, and furnishing (directly or on a contract basis) 
     of breast or cervical cancer-related treatment services; 
     plus''.
       (e) Limitation on Benefits.--Section 1902(a)(10) of the 
     Social Security Act (42 U.S.C. 1396a(a)(10)) is amended in 
     the matter following subparagraph (F)--
       (1) by striking ``and (XIII)'' and inserting ``(XIII)''; 
     and

[[Page S3935]]

       (2) by inserting before the semicolon at the end the 
     following: ``, and (XIV) the medical assistance made 
     available to an individual described in subsection (aa)(1) 
     who is eligible for medical assistance only because of 
     subparagraph (A)(ii)(XV) shall be limited to medical 
     assistance for breast or cervical cancer-related treatment 
     services''.
       (f) Conforming Amendments.--Section 1905(a) of the Social 
     Security Act (42 U.S.C. 1396d(a)) is amended in the matter 
     preceding paragraph (1)--
       (1) in clause (x), by striking ``or'' at the end;
       (2) in clause (xi), by adding ``or'' at the end; and
       (3) by inserting after clause (xi) the following:
       ``(xii) individuals described in section 1902(aa)(1),''.
       (g) Effective Date.--The amendments made by this section 
     apply to medical assistance furnished on or after October 1, 
     1998, without regard to whether or not final regulations to 
     carry out such amendments have been promulgated by such date.

  Ms. MIKULSKI. Mr. President, I rise today as an original cosponsor of 
a bill that will put an end to the half-promise the federal government 
has made to women screened under the National Breast and Cervical 
Cancer Protection Program. When Congress first passed this program as 
the Breast and Cervical Cancer Mortality Prevention Act in 1990, it was 
a breakthrough for early detection of breast and cervical cancer. And I 
was proud to be its chief Senate sponsor. There is still good reason to 
be proud of this program. By March of 1997, the program had provided 
mammography screening to over 500,000 women and Pap tests to over 
700,000. Nearly 3,500 women have been diagnosed with breast cancer and 
an additional 300 women with invasive cervical cancer. In Maryland 
alone, by December 1996, the state had provided more than 35,000 
mammograms and 21,000 Pap tests, and diagnosed nearly 300 women with 
breast cancer and 13 women with invasive cervical cancer.
  But when we passed that program we expected--and demanded--assurances 
that women who are found to have breast cancer be provided the 
necessary diagnostic services, including breast biopsies and treatment 
services. The program has not lived up to the promise. While a variety 
of innovative strategies have emerged across the country at the state 
and local levels to help women get treatment, the reality is that the 
system is overloaded. Some state programs require providers to arrange 
for treatment before they can participate in the program; a very few 
like Maryland have been able to come up with a small pool of general 
revenues, but generally these funds are available for breast diagnostic 
services, not treatment. In others, program administrators have to rely 
on public hospitals, donated services and charity care. In the end, 
thousands of women who run local screening programs are spending 
countless hours finding treatment services for women diagnosed with 
breast cancer.
  This is not what we had in mind. Not at all. The system for 
obtaining treatment services--which at its best was an ad-hoc 
patchwork--has broken down. Of those women diagnosed with cancer in the 
United States, nearly 3,000 women have no way to afford treatment--they 
have no health care insurance coverage or are underinsured. These women 
want to pay for their services, but they often simply don't have the 
financial resources on their own.

  It's a cruel and heart breaking irony for the federal government to 
promise to screen low-income women for breast and cervical cancer, but 
not to establish a program to treat those women who have been diagnosed 
with cancer through a federal program. Screening alone does not prevent 
cancer deaths; but treatment can.
  A recent study of the program done for the Centers for Disease 
Control and Prevention found that while treatment was eventually found 
for almost all of the women screened, some women did not get treated at 
all, some refused treatment, and some experienced delays. The study 
also underscores the terribly labor intensive efforts that go into 
finding treatment for these women--often at the expense of screening. 
The lack of coverage for diagnostic and treatment services has also had 
a very negative impact on the program's ability to recruit providers, 
further restricting the number of women screened. It is sad that 8 
years after enactment, the program serves only 12 to 15 percent of all 
women who are eligible nationally. And this is likely to get worse. The 
study shows there are already additional stresses on the program as 
increasing numbers of physicians do not have the autonomy in today's 
ever increasing managed care system to offer free or reduced-fee 
services.
  Breast cancer advocates from across the country are reporting that 
local programs are so badly strained that they have resorted to holding 
bake sales and community lunches to raise money for treatment services 
for the women they serve. Others have cobbled together the funds at 
great effort--when they are sickest--and most in need of taking care of 
their health. One woman in Massachusetts reported that she cashed in 
her life insurance policy to cover the costs of her treatment.
  It is clear that the short-term, ad-hoc strategies of providing 
treatment have broken down: for the women who are screened; for the 
local programs that fund the screening program; and for the states that 
face increasing burdens. Because there is no coverage for treatment, 
state programs are having a hard time recruiting providers, volunteers 
are spending a disproportionate amount of time finding treatment for 
women, and fewer women are receiving treatment. We can't grow the 
program to serve the other 78 percent of eligible women if we can't 
promise treatment to those we already screen.

  Women shouldn't have to hold a bake sale to get treated for breast 
cancer--especially if the federal government has held out the promise 
of early detection. It is an outrage that women with cancer must go 
begging for treatment. That's why I'm cosponsoring this bill. It will 
establish a mechanism for women to be treated. It will guarantee 
Medicaid coverage for necessary treatment services to women who are 
eligible for the CDC program, and found to have breast cancer or 
cervical cancer. Although I wish the bill would require the States to 
provide the benefit, the reality is such that we have made this program 
for now, an optional benefit, and place the responsibility on the 
States to choose to participate. By doing so, states would in effect, 
extend the federal-state partnership that exists for the screening 
services in the CDC program to treatment services.
  This bill is the best long-term solution. It is strongly supported by 
the National Breast Cancer Coalition representing over 400 
organizations and 100,000's of women across the nation. I urge my 
colleagues to join in and cosponsor this critical piece of legislation 
and make good on the promise of early detection.
  Mr. MOYNIHAN. Mr. President, I rise today to introduce with my 
colleague Senator D'Amato, and with Senators Mikulski and Snowe, 
legislation important to ensuring that women with breast cancer and 
cervical cancer will receive coverage for their treatment. The Centers 
for Disease Control and Prevention (CDC) has a successful nationwide 
program--National Breast and Cervical Cancer Early Detection program--
that screens low-income uninsured women for breast and cervical cancer. 
However, CDC's program does not have funding to treat these women after 
they are diagnosed.
  The women eligible for cancer screening under the CDC program are 
low-income individuals and yet are not poor enough to qualify for 
Medicaid coverage. They do not have health insurance coverage for these 
screenings and for subsequent cancer treatment.
  From July of 1991 to March of 1997, the CDC program provided 
mammography screening to almost 600,000 women and diagnosed nearly 
3,500 cases of breast cancer. During this same period, the program also 
provided over 700,000 pap smears and found more than 300 cases of 
invasive cervical cancer.
  The CDC screening program has had to divert a significant amount of 
time and funding in order to find treatment opportunities for the women 
found to have breast and cervical cancer. The lack of subsequent 
funding for treatment has, therefore, jeopardized the programs' primary 
function: to screen low-income uninsured women for breast and cervical 
cancer. Currently, the program screens about 12 to 15 percent of all 
eligible women.
  A recent study conducted at Battelle Centers for Public Health 
Research and Evaluation and the University of Michigan School of Public 
Health on treatment funding for women screened

[[Page S3936]]

by the CDC program found that, although funding for treatment services 
were found for most of these women, they often experienced time delays. 
In addition, during the search for treatment funding, the CDC program 
lost contact with several women. The study also found that the sources 
of treatment funding are uncertain, tenuous and fragmented. The burden 
of funding treatment often fell upon providers themselves. The 
uncertainty and delays worsen the stress of coping with cancer. Some 
women, upon learning that they have cancer, must hold lunches and bake 
sales to raise funds to cover their needed treatment.
  Our legislation would provide treatment coverage for the women 
screened and diagnosed through the CDC program and who are uninsured. 
States will have the option to provide this coverage through its 
Medicaid program. If a state chooses this option, they will receive an 
enhanced match for the treatment coverage, similar to the federal match 
provided to the sate for the CDC screening program.
  Mr. President, the Senate has approved this proposal in the past. A 
similar provision was included in the Senate version of last year's 
Balanced Budget bill. It is my hope that the Senate will again support 
this important legislation.
                                 ______