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.”

Sen. Jay Rockefeller (D-W.Va.) (Photo by Mark Murrmann/ZUMA Press)

The Democrats’ proposal to terminate the Children’s Health Insurance Program would hike health care costs for some of the country’s low-income families, likely increasing the number of uninsured kids in the name of expanding coverage, several health policy experts and state health officials warned Friday.

Under the sweeping health reform bill passed by House Democrats last weekend, CHIP would cease to exist at the end of 2013, instead shuffling those kids into Medicaid or private insurance plans on a proposed insurance marketplace, called the exchange.

Image by: Matt Mahurin

Stan Dorn, senior health policy researcher at the Urban Institute, said there are certain advantages to scrapping CHIP. Both Medicaid and exchange plans, for example, would never require congressionalreauthorization — a process CHIP is subjected to every few years, he pointed out. But due to CHIP’s affordability, Dorn said “it’s clear” that kids “are much better off” under CHIP than they would be under private exchange plans.

“It’s not even a close question,” Dorn said during a children’s health care forum on Capitol Hill Friday.

Studies suggest Dorn’s concerns are valid. One analysis, conducted by Watson Wyatt Worldwide, an actuarial research firm, found that families living between 175 and 225 percent of the federal poverty level pay just 2 percent or less of treatment costs under CHIP. Under the proposed exchange plans, researchers found, those same families would pay up to 35 percent of their children’s health costs.

Nate Checketts, director of Utah’s CHIP program, noted that the move to more expensive exchange plans would only discourage low-income families already pinching pennies in the economic downturn. “Unless there’s a mandate, I don’t think those low-income families will sign up for it,” saidChecketts.

CHIP was created in 1997 with broad bipartisan support and renewed for five additional years last February. The popular program is designed to cover children in low-income families that are ineligible for Medicaid. The House bill would both expand Medicaid and dismantle CHIP, sending some kids currently covered under the program into Medicaid plans and others into private plans on the exchange.

The Senate Finance Committee also initially proposed to terminate CHIP when it unveiled its legislation in September. However, the committee last month approved an amendment, sponsored by Sen. Jay Rockefeller (D-W.Va.), to reauthorize the program through 2019.

Supporters of the House proposal argue the advantages of centralizing control over CHIP coverage. Because CHIP is managed by states, there is a fear among some lawmakers that lean economic times could lead to sharp CHIP cuts in some spots, leaving those kids without any coverage at all. Those fears were almost realized earlier this year when California, facing a severe budget squeeze, temporarily froze new CHIP enrollment. Some health policy experts have pointed out that it’s probably not a coincidence that many House Democrats pushing the CHIP repeal are from California, including Speaker NancyPelosi, Rep. George Miller, who chairs the Education and Labor Committee, and Rep. Pete Stark, who heads the Ways and Means health subpanel.

Rep. John Dingell (D-Mich.) has also defended the plan to terminate CHIP, arguing in a recent email that “enrollment of kids increases when the entire family can be enrolled under one plan.”

Checketts agrees, pointing out the difficulties that can arise when family members’ health coverage is scattered across different programs. “It is a good goal,” he said, “to get families on a single source of coverage.”

Yet some analysts have concluded that affordability is the more significant factor to ensuring coverage.

The advantages of providing families with low-cost access to health coverage for their kids, Dorn said, “significantly outweighs the benefits of putting parents and kids in the same health plan.”

Other children’s health care advocates are agnostic. Jocelyn Guyer, co-executive director at Georgetown University’s Center for Children and Families, said Friday that, while CHIP has proven “a great success,” getting affordable coverage for kids is more important than what program provides it.

Ron Pollack, executive director of Families USA, a consumer health care group, also indicated that affordability is more critical for ensuring children have health insurance. “What are the out-of-pocket costs, and what is the care that they’ll receive?” Pollack asked, without endorsing either the House or Senate approach to CHIP.

If an analysis by the Congressional Budget Office is correct, the Senate’s plan to salvage CHIP is the more affordable option. Examining the Senate Finance Committee’s initial proposal to repeal CHIP, CBO Director Douglas Elmendorf noted last month that “some of those children would be eligible for subsidized coverage in the exchanges but would not be enrolled in an exchange plan.”

The reason, Elemndorf explained, is “at least in part to the higher premiums and higher out-of-pocket costs that they would typically face in such a plan.”

In an interview with Detroit News, the 57-year-old Catholic warned that “the other side is playing with fire,” if they try to remove his amendment during later negotiations with the Senate.

If they are going to summarily dismiss us by taking the pen to that language, there will be hell to pay. I don’t say it as a threat, but if they double-cross us, there will be 40 people who won’t vote with them the next time they need us—and that could be the final version of this bill.

Of course, there are about 40 abortion-rights supporters in the House who are vowing to kill the bill if the Stupak language stays.

There are countless perks that come with being part of the congressional leadership. Resolving stalemates like this is not one of them.

Anti-abortion protesters in front of the U.S. Capitol (Flickr: John Stephen Dwyer)

On Saturday, 64 Democrats backed Rep. Bart Stupak’s (D-Mich.) amendment to prevent abortions from being funded with taxpayer money in the comprehensive House health care bill. On Wednesday morning, House Majority Whip James Clyburn (D-S.C.) attempted to soothe the jangled nerves of pro-abortion rights activists who were lighting up switchboards and issuing not-another-dime fund-raising threats against the party for letting it happen.

“It was not 40 votes that we were trying to get with this amendment,” Clyburn said in an interview with MSNBC. “It was 10 votes. And that’s the fact.”

Image by: Matt Mahurin

In interviews with TWI, Republicans and activists explained their theory behind a contentious–and in the end, rewarding–heat-of-the-moment decision to back an amendment to a bill that all of them want to see go down in flames. The move to back Stupak’s amendment came after lobbying from a bevy of anti-abortion rights groups, including–perhaps most importantly–the U.S. Conference of Catholic Bishops. And while some conservatives are still critical of the party for not killing the amendment and trying to sink the bill with it, most are coming around to the view that the alliance with conservative Democrats had, in the words of one long-time conservative activist, “dropped a bomb” in the Democratic conference.

“If defeating Stupak wouldn’t [have changed] the outcome on Saturday,” said Brad Dayspring, a spokesman for Minority Whip Eric Cantor (R-Va.), “then it is clearly evident that having it in and sparking a civil war amongst the Democrats is the best way to stop the overall bill.”

The Republican rush to support Stupak’s amendment was controversial from the very moment it occurred. Rep. John Shadegg (R-Ariz.), who was in the end the only Republican to vote “present” on the amendment, scorched fellow members of the minority for not joining him and sinking it. National Right to Life Committee warned Republicans it would score a “present” vote as a “no.”

“The Stupak amendment gave political cover to Democrats who voted for Nancy Pelosi for Speaker,” Shadegg said in a statement. “If Republicans had voted ‘present’ as a group, since we are the party of Life, we would have defined the ‘present’ vote as the pro-life vote. Doing so would have denied the purported pro-life Democrats cover. Given the extremely narrow margin of victory for the bill, it’s highly likely that without the Stupak language, it would have been defeated.”

Several other conservatives made this same argument to TWI, and criticized anti-abortion rights groups like the Family Research Council, National Right to Life, and Americans United for Life for backing the amendment and counting “aye” votes as “pro-life” votes. But in a lengthy Monday blog post for The Weekly Standard, John McCormack captured much of the thinking of Republican staffers and strategists–that Democrats were going to win the vote no matter what, and that to vote down the Stupak amendment would have been hypocritical and cynical. “Bringing down Stupak,” wrote McCormack, “would have seriously hurt the effort to defeat Obamacare.”

Anti-abortion rights groups backed up that assessment. “If the pro-life members of the House suddenly, cynically, pulled out the rug from under Stupak,” said Doug Johnson, the legislative director of the National Right to Life Committee, “they would have been asking for defeat. I mean, that would have been a terrific gift to the left. Pro-abortion groups–I’m including pro-Obama front groups who claim to be pro-life groups–would have shouted from the rooftops: ‘You see, they don’t really care about the abortion issue, and when they had a chance they torpedoed it!’ It would have been a train-wreck.”

Marjorie Dannenfelser, the president of the anti-abortion rights Susan B. Anthony List, agreed with Johnson. Her group marshaled 300,000 emails and phone calls to Congress to back the amendment. “For every single Republican save one to insist on a vote on this, then kill it with ‘present’ votes, would have been cynical beyond words,” Dannenfelser said. The situation for Republicans now, she argued, is a “win-win,” as it forces Democrats to stiff dozens of key members. Only one Republican, Rep. Joseph Cao (R-La.), voted for the bill, doing so after backing the Stupak amendment.

“Think about [Speaker of the House Nancy] Pelosi looking at two letters on her desk,” said Dannenfelser. “I’ve got one letter saying if I don’t take it out, 41 Democrats will vote against it. I’ve got another letter saying keep it in or pro-life Democrats will vote against it. Either way you come up with coalition that can defeat it.”

The ripples of the Stupak vote are hitting the Senate before they can hit Pelosi. A major reason for Republican and conservative self-congratulation about the amendment is the puzzle it’s created for Sen. Harry Reid (D-Nev.). A semi-reliable vote against abortion rights until he became his party’s Senate leader in 2004, Reid is in the position of crafting language that can appeal to Sen. Ben Nelson (D-Neb.)–who has said he approves of the Stupak amendment–provide cover to Democrats like Sen. Bob Casey (D-Penn.), and avoid losing pro-abortion rights votes like that of Sen. Kirsten Gillibrand (D-N.Y.)

“They’re in a major bind,” said Michael Franc, director of government relations at the Heritage Foundation. “The only way to get out of it is for one of the two Democratic camps to go against something they believe deeply. There has to be intellectual flanking movement, somebody convincing them that the future of party at stake, they can’t let this 100-year achievement flounder over this one thing.”

For anti-abortion rights activists, the muddle is a victory nine months in the making. “If it hadn’t been for National Right to Life working in the trenches since January,” said Douglas Johnson, “this legislation would have passed sooner and by a larger margin. Remember, the president and the speaker and much of the mainstream media had been saying all year long that abortion wasn’t in the bill. If they had been able to pull off this smuggling operation, it would have moved faster and passed sooner.” It happened, said Johnson, because of “the tenacity of pro-life Democrats like Stupak.”

None of the anti-abortion rights groups that supported an “aye” vote on the Stupak amendment will support the final bill. Dannenfelser and Johnson pointed to so-called “rationing,” that Conservatives fear would empower bureaucrats to deny care to some patients, and the exclusion of conscience provisions in the health care bill as surefire reasons why “pro-life” activists would be unable to support it. At the same time, they and Republicans suggested that if the health care bill survived with much of the Stupak language intact, it would be a victory unthinkable just a few months ago.

“If the Stupak amendment is in there, I would definitely define it as one of most important life votes in more than a decade,” said Johnson. “You’d have to go back to 1993. Clinton comes in. Everyone thinks the Hyde amendment [former Rep. Henry Hyde's (R-Ill.) legislation that banned federal funds paying for abortions] is gone, and they are absolutely shocked the day we renew Hyde on the floor of the House.”

This article has been updated for clarity.

Right up until Saturday, passage was still in doubt due to resistence from conservative-leaning Democrats, who wanted stronger assurances that the proposal wouldn’t allow federal funding of abortions. Behind Rep. Bart Stupak (D-Mich.), those conservatives urged a floor vote on an amendment explicitly prohibiting such funding. They got it. And it passed 240 to 194.

That didn’t please the abortion-rights crowd — “to force insurance companies to deny a woman access to a legal procedure, would be a very disturbing step backwards,” said Rep. Earl Blumenauer (D-Ore.) just before he voted no – but it did clear the way to passage of the overall bill.

The Washington Post hits the highlights of the legislation:

Starting next year, private insurers could no longer deny anyone coverage based on preexisting conditions, place lifetime limits on coverage or abandon people when they become ill. Insurers would be required to disclose and justify proposed premium increases to regulators, and could not remove adult children younger than 27 from their parents’ family policies.

For the elderly, the group that has been most skeptical of Obama’s initiative, the House package would immediately offer discounts on prescription drugs and reduce a gap in Medicare prescription drug coverage, closing it entirely by 2019. Uninsured people who cannot get coverage could join temporary high-risk insurance pools, and unemployed workers would be permitted to keep their COBRA benefits until the public plan and insurance exchanges started in 2013.

Most Democrats — beginning with President Obama — hailed the bill’s passage as a watershed moment in the nation’s history. The proposal, Obama said, “would finally make real the promise of quality, affordable health care for the American people.”

Not all Democrats were convinced. Rep. Dennis Kucinich (D-Ohio), who voted against the measure, said it represents a giveaway to the same insurance industry that’s helped make the health care system dysfunctional. “We cannot fault the insurance companies for being what they are,” he said. “But we can fault legislation in which the government incentivizes the perpetuation, indeed the strengthening, of the for-profit health insurance industry, the very source of the problem.”

The ball is now in the Senate’s court, where lawmakers are expected to begin debate on their own enormous health reform proposal this month. That floor procedure, though, will take much longer than a single day.

No shocker here. America’s Health Insurance Plans has long feared the consequences to business if Congress created a public insurance plan to compete with private companies — a public plan like the one contained in the Democrats’ bill. Indeed, that seems to be the central reason for AHIP’s opposition.

“We share the concerns that providers, employers, and patients have raised about the significant disruption a new government-run plan would have on the current health care system,” AHIP President Karen Ignagni wrote in the letter. “A new government-run plan would bankrupt hospitals, dismantle employer coverage, exacerbate cost-shifting from Medicare and Medicaid, and ultimately increase the federal deficit.”

Ignagni can at least be happy that liberal Democrats have abandoned their push for a single-payer system.

U.S. Capitol Police arrested 10 people this afternoon after the Capitol Hill Tea Party crowd stormed Congressional office buildings.

Sgt. Kimberly Schneider, public information office for the Capitol Police, told TPMDC the arrests happened in the Cannon House building as tea partiers attempted to protest Speaker Nancy Pelosi about health care.

They were charged with unlawful entry (entering a Congressional office and refusing to leave when told to do so) and/or disorderly conduct (yelling in the hallway outside an office) at Room 235 in the Cannon House Office Building.

Room 235 is Speaker Nancy Pelosi’s office for district business, not where she conducts her duties as Speaker. That’s handled at an office in the Capitol building.

Also of note, Tea Partiers apparently view themselves as the vanguard of a modern civil rights movement.

[P]rotesters in the crowd watching the arrests were furious. They shouted “Let them go!” and one man yelled at the police that “Martin Luther King” was being dishonored and shouted “Letter from Birmingham Jail!”

I guess Nancy Pelosi would be Bull Connor in this analogy.

In a little-mentioned move, Democratic leaders stripped the so-called doc-fix provision — which costs $210 billion over 10 years — out of the larger bill in order to keep costs below the magical $900 billion ceiling established by the White House earlier in the year. AMA is endorsing the idea that both would be passed simultaneously. From the letter:

Concurrent passage of [the two bills] represent a critical step in the legislative process that will enable further refinement of policies to lay a solid foundation for achieving our shared goal of assuring high-quality, affordable health care coverage for all Americans.

As a cautionary tale, the Senate tried to pass the doc fix separately last month, and it didn’t go so well.

Speaker Nancy Pelosi (D-Calif.) told reporters Thursday morning that she hasn’t reached any conclusions. “We may not have any amendments,” she said. “That decision has not been made.”

She’s running out of time. Democratic leaders hope to stage the vote Saturday night.

“Like many other important reforms included in the underlying bill, the Kucinich amendment is the object of attack by the insurance industry,” Kucinich wrote in a letter. “Unlike other reform measures, Leadership has chosen to strip the Kucinich amendment of the protection it deserves.”

Kucinich’s provision, which would allow states to set up single-payer health care systems modeled after Medicare, passed the House Education and Labor Committee in July, but was stripped out by Democratic leaders as they pieced together their final bill from the various committee proposals. Kucinich concedes that the provision represents “incremental reform.” “But,” he adds, “it allows the country to move incrementally in the direction that is needed.”

If Education and Labor Chairman George Miller (D-Calif.) is right about there being no floor amendments, this plea could be Kucinich’s last shot.

Update (4:46 p.m.): Democratic Reps John Conyers (Mich.), Eric Massa (N.Y.), Neil Abercrombie (Hawaii), Janice Schakowsky (Ill.), Lynn Woolsey (Calif.) and Raúl Grijalva (Ariz.) have also signed the letter.