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The Fate of Lady Parts in the Senate Bill

It’s certainly been a big news week for lady parts, as some of my lady colleagues at TNR have pointed out today. But while the conservative fear-mongering about “government rationing” is an obvious political ploy, some vital questions about how much women will have to pay for preventative care in the Democratic health-care bill have yet to be resolved.

Reid’s merged Senate bill left out part of an amendment that Barbara Mikulski had successfully introduced into the Senate HELP legislation, which requires insurance companies to include women’s preventative services as part of all minimum benefit packages, for little or no cost. Mikulski argued that women of child-bearing age end up paying an average of 68 percent more in out-of-pocket costs, partly due to reproductive health needs, and often ended up delaying or forgoing care (like mammograms) because of the expense. The provision—which was in neither the House nor Finance Committee legislation—was slated to be in Reid’s bill this week, but “CBO decided at the last minute there was a problem and it was removed until that is resolved,” Mikulski spokesperson Rachel MacKnight said in an email today.

The problem, according to sources familiar with the issue, was that the Mikulski’s amendment wasn’t specific enough in terms of how it would determine which services would be covered, simply saying that it would be it up to the discretion of HHS to set the guidelines for coverage. As such, the provision was so broad that CBO ended up having to give it a very high—i.e. expensive—score, and Reid ended up leaving the language out of the bill.

According to MacKnight, Reid and Mikulski “are working on a solution to include her amendment” and strengthen provisions for women’s preventative services in the final bill. But given the tempest surrounding the new mammography recommendations—along with today’s news about Pap smears—this might not be an easy task. In all of the bills, HHS uses the U.S. Preventative Services Task Force serve as a basic guide to determine what should be covered at little or no cost as part of a minimum benefits package. (Of course, as I've reported, HHS can choose to go beyond the task force recommendations.)

However, in defending themselves against the GOP’s “rationing” attack—and warding off public anxiety about the new recommendations—some Democrats have dismissed the USPSTF’s findings out of hand, rather than recognize them as a potentially valuable contribution to an ongoing scientific and medical debate. While no single government commission should unilaterally decide which services should be covered, Reid’s exclusion of Mikulski’s earlier, overly expensive amendment makes it clear that there need to be some guidelines for deciding how to appropriate limited resources. So on what basis should the government be making these decisions?

Yesterday, for example, Mikulski announced plans to introduce an amendment to the Senate bill that would guarantee women universal, affordable access to mammograms beginning at age 40—soundly rejecting the task force’s call to begin screenings at 50. It’s entirely reasonable, of course, for legislators to vocalize their concerns about the new findings and the role of the task force in shaping policy, as they’ve been joined by many medical professionals, patients, and researchers. But to insert such a legislative prescription seems premature, to say the least—the medical debate over this issue is constantly evolving, based on the latest information. The bill, in its current state, gives HHS the discretion to set regulations about coverage based, in part, on a constant inflow of ongoing scientific research. And to cut out that step in the process would be a blow against the value of evidence-based medicine.