Can he support a public option if states could opt out of the plan, as the current bill provides? “The answer is no,” he says in an interview from his Senate office. “I feel very strongly about this.” How about a trigger, a mechanism for including a public option along with a provision saying it won’t be used unless private insurance plans aren’t spreading coverage far and fast enough? No again.

So any version of a public option will compel Mr. Lieberman to vote against bringing a bill to a final vote? “Correct,” he says.

Consequently, we’re left with 41 senators likely to oppose cloture for a bill with a public option, meaning that unless one of these senators changes his or her stance, there’s no way such a bill can win the 60 votes necessary to overcome a filibuster and receive a final up-or-down vote.

Either someone’s going to have to budge, or we’ll see a revised bill that lacks a public option (but might contain a trigger or another mechanism to pressure insurance companies to contain costs) — or Democrats could attempt to pass a public option through the budget reconciliation process, which requires a simple majority.

Keep checking the Senate Public Option Scoreboard for the latest updates.

The senator has yet to announce a date, but with the health reform debate likely to occupy the upper chamber for most of December, scheduling the hearing this year would be a tricky proposition.

Last week, 22 senators representing both sides of the aisle had written to Harkin and Sen. Michael Enzi (Wyo.), the senior Republican on the HELP panel, urging the committee to examine the new mammogram guidelines, which recommend that women get screenings less frequently and later in life — an overhaul of existing protocols.

In the House, Rep. Frank Pallone (D-N.J.), who heads the Energy and Commerce health subcommittee, has already announced his intention to hold a December hearing on the new mammogram recommendations. From a scheduling standpoint, Pallone has the advantage: the House has already passed its version of the health reform bill.

“These recommendations, which have been widely criticized by patients and doctors alike, could prove devastating for women at risk of breast cancer,” the lawmakers wrote to Sens. Tom Harkin (D- Iowa) and Michael Enzi (R-Wyo.), the leaders of the Senate Health, Education, Labor and Pensions Committee.

Breast cancer screenings and advances in technology have reduced the mortality rate of patients who develop this devastating disease, but early detection of breast cancer is absolutely critical. To alter these recommendations, and to contradict the advice provided by countless doctors, will only serve to cause confusion and alter the behavior of patients, may (sic) of whom may be at a high risk of contracting breast cancer.

Spearheaded by Sen. Lisa Murkowski (R-Alaska), the Nov. 20 letter was also signed by GOP Sens. Olympia Snowe (Maine), David Vitter (La.), Jon Kyl (Ariz.), Mike Crapo (Idaho), Jim Risch (Idaho), Jim Inhofe (Okla.), John Thune (R-S.D.), Kay Bailey Hutchison (Texas), John Ensign (Nev.), Saxby Chambliss (Ga.), Richard Burr (N.C.), Pat Roberts (Ks.) and John Barrasso (Wyo.); the Democratic co-signers were Sens. Barbara Mikulski (Md.), Ben Cardin (Md.),  Barbara Boxer (Calif.), Amy Klobuchar (Minn.), Arlen Specter (Pa.), Charles Schumer (N.Y.), Kirsten Gillibrand (N.Y.) and Patrick Leahy (Vt.).

No word yet about Harkin’s plans, but Rep. Frank Pallone (D-N.J.), chairman of the House Energy and Commerce health subpanel, has already said that he’ll hold a hearing on the topic early next month.

Sen. Charles Grassley (Iowa), senior Republican on the Senate Finance Committee, has asked the Joint Committee on Taxation to analyze the future effects of the Democrats’ tax increase. Specifically, Grassley is wondering why the proposed hike isn’t indexed to inflation, leaving more and more Americans to fall subject to the increase each year.

“The unintended consequences could be significant,” Grassley warned.

If that scenario sounds familiar, it’s because the Alternative Minimum Tax — designed decades ago to target just a tiny sliver of high-income households — was similarly not indexed to inflation. As incomes have risen over the years, more and more upper-middle-class families have fallen into the bracket under which they have to pay the AMT. Some liberals don’t see a problem with that. But Congress, fearing a backlash at the polls, has stepped in each year with the so-called AMT patch, providing billions of (borrowed) dollars to prevent the tax from hitting those families.

The Democrats’ motivations are easy to surmise: Had they indexed the tax to inflation they would have generated much less revenue to pay for their health-care reform bill. And the proposed payroll tax increase is much less than the AMT. Still, it’s not too far a stretch to imagine that the lawmakers of the 2030s, also wanting to appease the voters, would also find it tempting to come up with the Medicare-payroll patch.

With Congress out of town for the Thanksgiving break, there’s been little to distract Washington’s prognosticators from offering their predictions over the public plan’s fate. Truth is, no one is quite sure how this saga is going to play out. Based on comments from several of the four moderates since Saturday’s vote, it’s tempting to argue that Democratic leaders will at the very least have to scale back the public plan to pass the larger bill. Then again, the way Landrieu melted Saturday at the chance to secure millions of federal dollars for Louisiana indicates that there’s much more at play here than mere principle.

With all of that in mind, Sen. Sherrod Brown (D-Ohio) offered his own optimistic take on how the drama over the public option will end, telling CNN yesterday that the historical significance of the reform vote will ultimately be enough to sway the four moderates in favor of the bill.

In the end, I don’t want four Democratic senators dictating to the other 56 of us and to the country, when the public option has this much support, that it’s not going to be in it. [...]

I don’t think they want to be on the wrong side of history. I don’t think they want to go back and say, you know, on a procedural vote, I killed the most important bill in my political career. I don’t think they want to be there on that. So I think in the end, we get them.

Let’s be clear: the task force’s recommendation will have absolutely no impact on the bills we in the Senate write, debate or vote on.  [HHS Secretary Kathleen Sebelius] has also assured me there that nothing in Medicare or Medicaid will change as a result of the recommendation, and that’s the way it should be.

Yet the Senate bill says explicitly that, as a part of newly proposed minimum benefits requirements, every insurer  ”shall provide coverage for … evidence-based items or services that have in effect a rating of ‘A’ or ‘B’ in the current recommendations of the United States Preventive Services Task Force.” The House bill contains a nearly identical provision.

The task force guideline recommending that women between ages 50 and 74 receive biennial routine mammograms, instead of annual checkups, received a “B” rating.

That in no way means that women wouldn’t have access to annual mammograms. Again, the essential benefits package represents the minimum coverage insurers would have to offer. The task force is clear that the ultimate decision on the frequency of screenings should be made by women and their doctors.

Still, there’s also the fear that private insurers will lean on the task force recommendations to justify a scaling back of coverage for routine mammograms. Julius Hobson, former lobbyist for the American Medical Association and now a senior policy analyst at the Washington law firm Bryan Cave, said it’s “inevitable” that private insurance companies will look at those guidelines, and may change their coverage policies based on what they see. Certainly, they would like the potential cost savings if women were getting routine mammograms every two years instead of every one.

“It’s almost inevitable that that’s going to happen,” Hobson said last week. “The government doesn’t move that fast, but the health insurers do.”

That has some members of Congress concerned about the threat to women’s health. As Rep. Jerrold Nadler (D-N.Y.) said in a phone interview last week, “Cancers can progress very far in two years.”

Senate Majority Leader Harry Reid, Speaker of the House Nancy Pelosi (WDCpix)

The Democrats downplaying the gravity of new recommendations for breast cancer screening have left out an inconvenient fact: their health care bills would automatically adopt them.

Both the House and Senate health reform proposals would force insurance plans to follow the new mammogram guidelines for women ages 50 to 74 as part of a minimum swath of services deemed by the legislation to be medically essential. The recommendations were an unexpected wildcard in the middle of an already contentious health reform debate, and they’ve caused Democrats to de-emphasize their significance at the same time that some in the party are calling for a legislative fix to nullify them.

Image by: Matt Mahurin

The mammogram episode has also revealed the influence of a previously obscure preventive-medicine panel, raised questions about the effectiveness of the Democrats’ reform proposals to weed out unnecessary medical procedures, and highlighted the potential complications when the entrenched habits of patients and providers are called into question by medical science.

“These new recommendations,” breast cancer specialist David Gorski wrote this week, “are a classic example of what happens when the shades of gray that characterize the messy, difficult world of clinical research meet public health policy, where simple messages are needed in order to motivate public acceptance of a screening test.”

The controversy ignited on Monday, when the U.S. Preventive Services Task Force, a federally appointed panel of independent medical experts, released guidelines suggesting that women should not seek routine mammograms before the age of 50 — 10 years later than current protocols dictate. The task force also concluded that annual mammograms are unnecessary for any age group, suggesting biennial screenings instead.

Critics in Congress and the medical community were quick to pounce, arguing that the recommendations would jeopardize the lives of women, particularly those aged 40 to 49. Democrats moved swiftly to divorce their health reform proposals from the new guidelines, maintaining that they merely represent a non-binding data-bank for lawmakers to consider as they craft coverage policies, both public and private.

“I don’t think there’s any general acceptance of what was proposed,” House Speaker Nancy Pelosi (D-Calif.) told NPR Thursday.

“These individuals do not determine federal policy,” Rep. Rosa DeLauro (D-Conn.) added in a statement. “They have simply made recommendations.”

Yet the health reform language moving through Congress tells a different tale. Both the House and Senate bills create an “essential benefits package” which all insurance plans would have to offer. Neither chamber’s proposal specifies what those services would be, instead, empowering the Department of Health and Human Services to make those decisions at a later date. But the bills do outline broad categories of minimum services, including a mandate to cover those recommendations of the task force rated “A” or “B.” The new biennial-screening guidelines for 50 to 74 year-olds are rated “B.”**

The 16 members currently on the panel were all appointed by the Bush administration. None specializes in oncology.

A number of Democrats have blasted the findings. Rep. Debbie Wasserman Schultz (D-Fla.), a breast cancer survivor, said the guidelines are “causing mass confusion” among women accustomed to screening more frequently and earlier in life. Rep. Frank Pallone (D-N.J.), chairman of the Energy and Commerce health subcommittee, has already indicated that he’ll hold a hearing early next month to examine the recommendations. And Rep. Jerrold Nadler (D-N.Y.) is pushing legislation to require insurance companies that cover diagnostic mammograms also to cover routine, annual mammograms to women beginning at age 40.

“Cancers can progress very far in two years,” Nadler said Friday, criticizing the panel’s recommendation for biennial screenings.

The White House has also been wary, quickly indicating that the new recommendations would have no bearing on public policy. In a statement issued Wednesday, HHS Secretary Kathleen Sebelius played down the task force as “an outside independent panel of doctors and scientists who make recommendations.”

“They do not set federal policy,” she added, “and they don’t determine what services are covered by the federal government.”

Yet they certainly can have influence. Indeed, in May, when HHS announced the controversial decision not to pay for virtual colonoscopies under Medicare, the agency leaned heavily on the judgments of the Preventive Services Task Force, which had concluded earlier that the radiation risks outweighed the benefits of the less intrusive cancer-detection procedure.

The HHS declined to comment this week on why the agency was so quick to dismiss the panel’s new mammogram recommendations.

By issuing their report in the middle of a contentious debate over health care reform, the task force didn’t do the Democrats any favors. Republicans are already blasting the reform bills for their funding of comparative effectiveness research, which compares different treatments of the same ailment to discover which work best. The critics fear that the effectiveness data could tempt insurers — both public and private — to deny coverage of certain drugs, devices and other treatments. In the eyes of the GOP, the new mammogram recommendations are just another threat to patients’ access to care.

“This is how rationing starts,” Sen. Jon Kyl (R-Ariz.) said Friday. “Delay of care … then denial of care. At first, it’s guidelines, then the insurance companies … adopt those guidelines with respect to coverage decisions.”

Private insurers, for their part, say they often use the task force recommendations to make coverage determinations. But they deny that the mammogram findings will have any effects — at least not immediately. “Whatever we do today, we’ll continue to do — as far as we can tell,” said Gloria Barone, spokeswoman for Cigna.

Susan Pisano, spokeswoman for America’s Health Insurance Plans, the industry lobby group, pointed out that the task force recommendation against routine screenings for 40-somethings is hardly an outright moratorium, instead leaving the decision to women and their doctors. “I don’t see this as limiting coverage,” Pisano said.

Under Medicaid, states have leeway to set their own coverage rules. Ann Kohler, director of the National Association of State Medicaid Directors, said state officials use the task force guidelines “often.” “However in this case,” she added, “I think they will not change their historical policy.”

Julius Hobson, former lobbyist for the American Medical Association and now a senior policy analyst at the Washington law firm Bryan Cave, suggested that the members of the task force had crunched their numbers without consideration of the broader effects of their recommendations. “They missed the psychological and social impact of what they were saying,” Hobson said.

Their timing, he added, was also a bit suspect. “You’d have to be deaf, dumb, blind and crazy not to know that Congress has spent the whole year working on health reform.”

**Clarification: An early version of this story implied that the recommendations for 40- to 49-year olds would also be adopted by the Democrats bill. That would not be the case. That recommendation is rated “C.”

Under the Senate legislation as it is currently written, Americans with employer-provided coverage, whose income is below 400 percent of the federal poverty level and whose premiums are between 8 and 9.8 percent of their total income will be exempt from having to purchase health coverage but will not be able to access the exchange to qualify for government assistance to purchase insurance.  The agreed to amendment will make it possible for these individuals to convert their tax-free employer health subsidies into vouchers that they can use to choose a health insurance plan in the new health insurance exchanges.

Critics contend that the proposal will cause a flood of young, healthy workers to flee employer-sponsored plans, hiking rates for the older, sicker folks who remained. But a number of Senate Democrats had recently joined Wyden in urging adoption of the so-called “free-choice” amendment.

The Congressional Budget Office estimates that the change will cover an additional 1 million people, Wyden says.

It’s a ridiculous set of recommendations. It’s causing mass confusion among women, because we have been trained to know that, when we’re 40 years old, we should get a mammogram routinely.

Wasserman Schultz also criticized the suggestion that women between the ages of 40 and 49 should simply talk with their doctors to gauge their breast-cancer risk.

About 75 percent of women who have breast cancer didn’t have any risk, weren’t in a higher-risk category. I was in a higher-risk category, didn’t even know it until I found my lump myself and went to the doctor.

So, these recommendations are really patronizing, because they’re presuming that women can’t handle more information and make a rational decision with their health care provider.

The congresswoman’s office hasn’t returned calls this week about whether Congress needs to enter this fray legislatively.

“This weekend, I will vote for the motion to proceed to bring that debate onto the Senate floor,” Nelson says. “The Senate should start trying to fix a health care system that costs too much and delivers too little for Nebraskans.”

Nelson has previously indicated that his vote for passage of a final bill is far from certain, but his announcement today removes one potential Democratic roadblock on the path to a final vote. TPM also reports that two other fence-sitting Demoratic senators, Mary Landrieu of Louisiana and Blanche Lincoln of Arkansas, remain uncommitted on tomorrow’s vote but have hinted they intend to vote in favor of sending the bill to the floor to debate.