that age range may not be allowed to have a mammogram. k@@ health benefit advisory committee which will determine what is and is not covered in the essential benefits package. i think we should ask ourselves how likely is that one benefit advisory committee will

recommend including services in the essential benefits package that another government board, the task force, has recommended not be covered. it is important to know that all private plans in the exchange will have to meet the essential benefits package. but, they cannot exceed it. a private insurer cannot add additional benefits above and beyond what the government requires in the essential benefits package except to premium plus plans and then only if the added benefit is approved by the health benefits commissioner. so, for example of the essential benefits package did not cover routine mammograms for women aged 40 to 49 insurance plans would be for bidded from covering them. it requires all plants cover mammograms for women aged 40 to 49. with this bill were to become law in the secretary were to adopt these breast cancer screening recommendations as is as part of the essential benefits package pennsylvania would either have to change its

benefit mandates law or reimburse the government for the added cost of screening this population. these recommendations should be a wake-up call that a government-run health care will come between patients and their doctors. i look forward to hearing our distinguished witnesses, thank you cannot yield back my time. >> thank you mr. pitts. the gentleman from florida, ms. castor. >> thank you mr. chairman very much for the hearing today because it's not only gives us an opportunity to further understand the recommendations as to breast cancer screening but affords us an opportunity to raise awareness about the real issue involving women's health in america and that is access to care, plain and simple. for women in america, access to care, affordable health care, including screenings of all

kinds, eclipses' the debate over what age when men and their doctors should begin routine mammograms. for millions of women across america, this debate has no application whatsoever. they are not receiving screenings at age 50. they are not receiving screenings at age 60. they simply do not have access to affordable health care because our health care system in this country is broken. it is very basic. we know that if you do not have affordable health care you are less likely to receive the vital preventative screenings that women with insurance have. the american cancer society reports that in my home state of florida, if you don't have health insurance yours simply not going to receive any screening whatsoever. women in this country just do not have access to affordable

care. maybe one quarter of women in the state of florida that do not have health insurance will receive some mammogram during v-8 40 to 60 and it is much worse if you are african-american or latino. the disparities in screenings, diagnosis, treatment exist and i think this is a critical issue that dr. christenson has raised that really deserves a great deal of attention and debate and it is the proper place for our outrage over women's health in america, because regardless of your insurance status if you are african-american you are 1.9 times more likely to be diagnosed with an advanced stage of breast cancer than white women and hispanic women are almost 1.5 times more likely to be diagnose than white women because of the real concern here and the proper place for outrages access to care in and

of itself. are broken system prevents millions of women in america from even being part of this debate over screening. fortunately due to the efforts of many over the past year, we are on the road to correcting this problem and i hope that we can focus on the true issues of our broken health care system in america. it affects brass cancer screening but it really is the heart of the problem in our fight to making america a healthier country. thank you. >> i thank the gentleman. next is the gentleman from michigan, mr. rogers. >> thank you mr. chairman. science is a whole host of disciplines and now this one of them. when you look at what the task force recommendations have done, it is absolutely disingenuous to say costed not play a role. let me quote from the american cancer society. the task force says screening

1,003 and 39 women in their fifties to save one life makes the screening worthwhile yet the task force also says screening 1,904 women ages 40 to 49 in order to save one life is not worthwhile. when you look at their executive summary clinical breast examinations talk about cost, the principal cause the vaisse the e is the opportunity cost incurred by the patient and counter. clearly cost of the consideration. digital mammography is more expense and then fell mammography and talks about the cost benefit analysis. magnetic resonance imaging, magnetic resonance imaging is much more expensive than film or digital mammography. to say that cost is not a factor in this is not being on this. it is just not. it clearly was the reason than to say they don't have any authority, wait until the insurance company comes out and

says we based it on this task force, a government task force recommendation says i don't have to pay for mammography for women between the ages of 40 and 49. as a matter affecting your 2,000 page bill that is exactly what you do. they health benefitted fisa recommitting is created to do exactly that. how do we know that? the national institute of clinical effectiveness, the nice board in great britain is the very organization that limits things like pap smears. they raised it from 23 to 25 for young women. why did they do it? because science told them, to save money. what the math part of your si antiquation is, we think that we are willing to accept that more women will be diagnosed later on in the later stages of cancer, we are willing to accept the higher mortality rate to save

money. that is what this report says and that is what we are getting to foist on the american people. that is not a scare tactic, that is reality and it happens in great britain and it happens in canada and it happens in france. what we are saying is we can and should do better. i am a cancer survivor because of early screening. i know mr. blunt is a cancer survivor because of the early screening. buy we wit voice to this kind of an ugly system and hide behind the fact that we will have more deaths, more mortality because of it is beyond me. what we are saying is this 2,000 page bill and its 118 new boards, commissions and other government agencies that will dictate your health care policy is wrong and we can and we should by these women in their 40's do much better and that would yield back the remainder of my time mr. chairman.

>> thank you mr. rogers. next is-- i am having a hard time seeing who is here. the gentlewoman from illinois, ms. schakowsky. >> thank you mr. chairman for moving so quickly to convene a hearing on the recommendations of the preventive services task force. i appreciate it. this committee has talked a lot about the need for evidence-based science of the the last year but it is important particularly when it comes to something as critical as breast cancer screenings that we do look carefully into the justification for these recommendations and their ramifications for individual women. many of my constituents have questions as to i and i look forward to asking them but i do want to say right now that this is not something that should become a political football or in my view an attack on the need for health reform that

guarantees access to comprehensive health care for women. we all want to ensure women, especially women threatened with life-threatening diseases like breast cancer and make sure that they have access to the health care that they need. without preexisting condition exclusions, gender rating and denials that exist today but among the questions that have been asked is how do we reduce the number of unnecessary screens while insuring that we do not provide disincentives for mammograms that will save women's lives? how do we empower women to ask for a screening when they suspect a problem? how do we ensure we are getting their research and science on breast cancer prevention and treatment right? what improvements are needed to obtain more accurate screenings? how did the grades provided by the task force mash with the recommendation that doctors and

there patients be able to make individual choices particularly when it comes to high risk women and how do we make sure inadequate coverage or high cost-sharing don't prevent barriers to screening in all appropriate follow-up care. women across the country are getting, are concerned about getting access to mammograms and other essential services and women's groups across the nation have endorsed comprehensive health reform for this very reason, because they know that millions of women's lives depend on it. i am eager to hear from our witnesses and discuss the task force's recommendation and again mr. chairman thank you for having this hearing and i yield back. >> thank you. the gentleman from arizona, mr. shadegg. >> thank you mr. chairman and thank you. i want to also thank you for holding this hearing so quickly on this important topic.

i believe i have mentioned to this committee that my older sister is a 20 year breast cancer survivors so i have a keen interest. the guidelines released on november 16th by the u.s. preventive services task force that created a firestorm across the country giving rise to concerns about women's access to lifesaving screening. some of commented these recommendations are merely guidelines for insurance company-- companies and government officials to assess the relative value of mammography, a clinical breast exams and breast self-exams. in a written statement health and human services secretary kathleen sebelius said the guidelines had caused a great deal of confusion and worry among women and families across this country and stressed they were issued by an outside independent panel of doctors and scientists who do not set federal policy and don't determine what services are covered by the federal government. i am here to tell you today and

to tell every woman in america that under this bill, h.r. 3962 which has already passed this congress, that statement will not be true. indeed, under this bill, the recommendation would become binding law. and if so, it would be devastating to access mammograms and nothing short of catastrophic for women's health in this country. in their recent report, mammograms for women aged 40 to 49 or given a grade of c. under this bill and the procedure given a grade of less than a or b cannot be covered by the public plan. so the women that my colleague worried about you have no access to care today for mammograms could not legally get mammograms

once this bill becomes law. but the panel also found insufficient evidence to determine whether it is worth screening women over the age of 74. again, because the grade was neidert and a or a b, it was an i, insufficient under this bill those women could not get mammogram screening legally under any public plan budget is important to understand precisely how far this bill goes. because it does not just prohibit mammogram screening. if this were the finding of the same task force after h.r. 3962 becomes law, it would prohibit private insurers, making it illegal for private insurers to provide mammogram coverage to women in these age groups. that is what the law says. let me explain. under the house bill, private

insurers can offer for health plans. one, a basic plan. two, an enhanced plan. three, a premium plan and for a premium plus plan. under section 303 of the h.r. 3962 women purchasing insurance under the first three categories, basic, enhanced or premium would not be allowed to purchase because the insurance company would not be allowed to offer a policy covering mammogram services. that is right. it would be illegal for a private insurance company in any one of those first three categories, the basic common hamster premium to offer coverage for mammograms because mammograms were not given either an a or 8b freighting. with regard to the top category, a plan, and insurance company could offer coverage for mammograms but if and only if

the health choices commissioner specifically allow the policy to cover mammograms. i don't suspect that many of my colleagues on the other side of the aisle understand that aspect of this bill and i hope before this bill or anything like it were to become law they would study it closely and recognize what is wrong with it. certainly having the government prohibit people who choose to be able to buy mammogram coverage is not what was intended by the authors of this legislation but in fact that is what the bill does. the government would prohibit the millions of women from buying coverage for mammograms. the government would forbid private plans from offering mammogram coverage to millions of clements. pour in middle-class americans would be prohibited from getting mammogram coverage under the insurance exchange. >> the gentleman is two minutes over. >> i thank the gentleman for his

indulgence and had not realized i had gone over time. >> thank you. the gentleman from maryland, mr. sarbanes. >> thank you very much mr. chairman for holding this hearing. i expect we are going to hear a lot about rationing today from the other side. to me, the discussion today is not about rationing. it is about being a rational in looking at all of the evidence that is available to us and making smart decisions about what kind of treatment we should deploy and what kind of coverage there should be and i think the jury is out on this. that is why we are having a hearing. barabas and recommendations that have been put forward. they appear to me to be based on very extensive studies, research and science and i think we ought to approach them with an open, with an open mind.

i am glad we are having this hearing. this is exactly the kind of thing we should be doing, and the fact of the matter is that as science advances, it causes us to revisit treatment, and that is a good thing. now there may be other considerations in play here. one of them is clearly the high attention that there is to mammography screening and the education effort that is going on with women across this country to make them more sensitive to this as a screening tool so all of those considerations ought to be fed into the mix and i would expect that the secretary of hhs will be considering all of those going forward. but to put our head in the sand and not look to the science it seems to me would be a serious mistake. so we ought to review these

recommendations with a sober and dispassionate consideration. i think that is what we are called upon to do. i would assume that that is what the health benefits advisory committee would do in receiving recommendations from any other government body. the notion that-- and we have heard this theme again as well today, the notion that one government body will accept without any kind of independent judgment or redo the recommendations of another government body. i don't think it makes any sense. i think the health benefits advisory committee will look at all of the factors in determining what ought to be the policy when it comes to treatment. so, i think this is a good conversation to be having and i thank the commission for putting their recommendations forward,

for basing them on science and now we are going to have to consider those in the light of many many factors in judging how to move forward. so i look forward to the testimony of the witnesses and the yield back my time. >> i thank the gentleman. the gentlewoman from tennessee, ms. blackburn. >> thank you mr. chairman and i want to say thank you so much to where witnesses for being here. i am really appreciative of the opportunity for us to have this hearing today and i have a formal statement that i will submit for the record but i do want to make a few comments as we began this. this is an issue of tremendous concern to me. i think all of us are concerned about the welfare and the health of women. we are concerned about what you well as the task force brought forward. sure we are concerned about the science and i want to discuss with you that science, where you

true that from an your process. i also want to explore with your task force structure and look at the linkages that you bear and what would happen if h.r. 3962 were to be passed and read into law. you all have a portfolio of 105 topics. that gets to the heart of the issue. because, when you start reading on h.r. 3962, on page 1296, into title iii and you look at section 2301 of this bill, the decisions you make to end up having the weight of law placed behind them, and when you read specific leon pages 1317 end 1318, you see exactly what is going to happen with your

recommendations. and then you go in and you look at how it becomes the standard of the block, so i encourage everyone to take this bill down and read it and read that title. look at section 3101, look at section 2301. go back in look gun pages 110 to 112, at how what you do and how you give priority and preference to certain treatments and certain categories is going to carry the weight of law. now eating is of concern to me by members of congress that we are going to deploy certain treatments or certain health care. that ability should rest with the patients and their physician. we do not need a bureaucrat and that exam room. and yes indeed, when you read

this bill we do have concerns, that it will lead to rationing, because the decisions appear that they are being made on costs, and not on health care, so i welcome you all. i appreciate your time. we are going to have a link the number of questions and mr. chairman i yield the balance of my time. >> i thank the gentlewomen. chairman dingell, the gentleman from michigan. >> i flew back this morning from michigan, hoping to have a rather informed hearing on a very important point. i find that i have come back to listen to some very tales coming from the other side of the aisle. and i find myself of then did by the lack of attention that my republican colleagues have given to the health bill. and i find myself very much offended to listen to the kind

of distorted logic and reasoning with which i am being afflicted as i enter this room. i have great affection and respect for my friends on the other side of the aisle and i am willing to assume that their behavior this morning in making the comments i am hearing about these recommendations and how they will play with the bill is a lack of attention, steadied, knowledge or diligence and understanding idid the bill or the recommendations of the u.s. preventive services task force. it has been a little bit like listening to the fairytales of the brothers grimm, but to set the record straight i want my colleagues to understand the bill does not in its provisions be made as my republican colleagues would have us believe. it does not use these kinds of

recommendations to suppress treatment or interfere with the relationship between the patience and the doctors. this is the kind of scare tactics that i have heard from that side of the aisle, always with great personal offense. they talk about how we are going to pull the plug on grandma, how we are going to push euthanasia forward, how we are going to deny health care to deserving people because of this legislation. these recommendations that we are going into this morning our recommendations and nothing more. and to say anything different than that is either to transmit the grossest kind of carelessness, and i hope this is not the case, or to just plain it out right deceit. it is time for us to look at these recommendations as they are.

the recommendation of the scientific panel created to make advise on what is the best medical and how we can see to it that we best protect our women with regard to things like pap smears and mammograms. now i will yield to no one on either subject because this committee and the oversight subcommittee, when i was chairman of each, were responsible for seeing to it that both mammograms and pap smears were made in the safest way for the benefit of patients i lost a mother to cervical cancer, and i have lots lots of friends to breast cancer and other things, and i am grossly offended by the statements that i've heard coming from the other side in which they tell us how

these recommendations and the health bill which we are working so hard are going to deny women mammograms, proper mammography and pap smears and other needed services. that is offensive. it is just plain wrong. it is absolutely false and i would urge my friends on the other side to go off and take a look at the bill, to read it carefully and if they need any assistance in understanding what the bill does i will be happy to volunteer to provide time so that they may come to have a better understanding of what the bill does and they made then make more informed statements on these matters. we need to deal with our health problems in a responsible way. we need to see to it that we address the honest defects which

are in the bill. but not to manufacture a lot of fears and faults which do not exist. i am affronted mr. chairman and i hope that this record and this hearing will correct some of the unfortunate misapprehensions' and misstatements that have been flowing thickly from the other side of the aisle this morning. i ask unanimous consent to revise and extend my remarks. ordered. ranking member, the gentleman from texas, mr. barton. >> thank you chairman palone for holding this hearing. i listened with great affection and with great interest to my good friend from michigan, former chairman and current chairman emeritus dingell's opening statement. i think it goes without saying the personal esteem and professional respect that i have

for him. having said that, there are no fairytales being told on this side of the aisle this morning. here is the bill. it passed the house. i want to, in this bill, on page 1762, the u.s. preventive services task force is given the authority, and i quote, to determine the frequency, the population to be served, and the procedure or technology to be used for breast cancer screenings covered under the health service. section 3 of three, legislation states and i quote, the commissioners shall specify the benefits to be made available under the exchange, participating health plans. in plain english mr. chairman what this means is new health

choices commissioner will determine what preventive services, including mammography, are covered under the health insurance based that is then this bill. now, we also knoet=v;aåb>ne⌞9 consequence of breast cancer. i have a sister who was diagnosed with breast cancer in her 30's.

luckily, receive proper treatment, had a mastectomy, and so far in the last ten years is cancer free. i have a wife, a beautiful wife who was under the age of 50 and she has annual mammograms every year. i have a good friend, who was just diagnosed with breast cancer who is in her mid-40s. again, she is undergoing treatment. hopefully she is going to have a good outcome. to have a task force make the recommendations that have been made into have in this bill the authority that is given to various unelected bureaucrats to make health care decisions including coverage and frequency in my opinion is wrong. it is wrong.

now, on a bipartisan basis, this subcommittee and the full committee repeatedly has passed bills increasing and supporting their early detection of breast cancer, the prevention, the research. we do it almost every congress. so, we are starting down a path in my opinion of socialization of medicine in this country with the passage of this bill out of this committee with its passage on the house floor. it is awaiting approval in the senate. this is an excellent time to hold this hearing and i appreciate the chairman and the full chairman of the subcommittee in full committee chairman's personal attendance but let's don't talk about fairytales. let's talk about the facts, the plain english of these bills, and if we continue to agreed

rhetorically, then we need to begin to make substantial changes in the legislation to prevent what we all say we oppose. we don't want rationing of health care in america. we don't want to intervene between the doctor patient relationship. we don't want young women or for that matter more mature women over the age of 74 developing breast cancer because they are not allowed a mammogram. my good friend to my right, mr. rogers, had an amendment passed in committee that explicitly prevented the rationing of care and it mysteriously disappeared in the bill that got reported out of the rules committee in the dark of the night. some staffer on the majority side or may be a member, i don't no, decided it was the will of the committee and it didn't mean

anything. it disappeared. maybe we need to put that back in. i don't know. so, i have great respect for this committee and i have great respect for the leadership on the committee. but let's don't talk about fairytales when we can read these bills. now i am not saying the bill is a fairytale but i will say the bill is not reflective of the policy that members on both sides of the aisle say they support. with that mr. chairman i yield back. >> thank you. next is, mr. green. >> thank you mr. chairman and i appreciate the opportunity you have been in so quickly dealing with this. first of all i want to thank the chairman emeritus for his offer, chairman dingell willing to

conduct a class on remedial health care comprehension and my only question is that it be mandatory or permissive, and hearing my colleagues on the other side talk about unelected bureaucrats, unelected insurance companies do this every day right now and i will give you an example. when i moved to be a member of congress, my wife had been getting annual mammograms and yet our new insurance in congress refused it after the first year. and she was a survivor. her mom was a 40 year survivor of breast cancer. sushi fit the exception and it took me as a member of congress saying i can't practice law but believe me i will file suit against our carrier it they don't continue to pay for those mammograms. you have to fight for the care that you want and to say that the house bill that passed would set up this unelected group to do it, it all rests on their

shoulders and i think that decision ought to be made by elected officials. this group will take recommendations from everyone but ultimately it is going to be our decision and we will continue to provide legislation. the statement i have, in 2000 to the task force change their breast cancer screenings to a mammograms every one to two years for women 40 to 75. that was only seven years ago and yet now the task force is making a change. a few weeks ago they revised it and made it a great c. and that is the issue i think that my colleagues are talking about. that women at the age of 40 would not be automatic but should not be denied. again it does go back to the doctor and patient's decision. i have dr. some bull's-eye dent i have doctors tell me all the time that they have battles with

insurance companies saying we need to do this than the insurance company won't allow it and they are the ones that are practicing medicine and that is the battle every day no matter what happens, if we pass the national health care bill. to use this opportunity to pick of the national health care bill i think it's interesting because the task force will be given an opportunity to clarify their statements and i am glad we had the testimony here today. >> adverse reaction in the wording of the recommendation obviously is not going unnoticed by our committee and the members of the committee and in fact i contacted and had been contacted by a number of constituents in my district including the cancer center in houston about the recommendations and they were very public that they were opposed to the task force's recommendations. along with many other groups unlikely the state of texas has a mandate that all private insurers must cover annual

breast cancer screenings beginning of the a40 but this new screening recommendation will cause some access problems barriers for women. it is especially sensitive because the reform bill 3962 states the u.s. preventative task force recommendations anpr mandating benefits in the bill also including report language saying a and b recommendations for the floor for benefits not a ceiling. the a and b r.a. floors of the task force recommendation would be considered that the decision should be made still whether, no matter what the task force says cell that is what we are here today to talk about. i have concerns about jeopardize in access to preventative screenings for women especially since i represent a majority latino underserved and i worked for years to expand the coverage of mammograms and our communities and for primary and preventative care services. it is designed to keep politics

out of medical recommendations because i can be an expert for 30 seconds on anything but i do depend on the experts to make those decisions and again i look forward to the testimony mr. chairman and i ask unanimous consent my full statement be placed into the record. >> without objection, so ordered. thank you mr. green. next is the gentlewoman from north carolina. >> thank you mr. chairman. thank you for holding the hearing today. i understand that scientific and statistically this information is not new in nidel that mammography is not perfect by any stretch of the imagination but i want to talk to this full report from a preventive side. because coming to me it is sending the wrong message to women. aidid saying you don't have to be vigilant, and you don't have to take care of yourself, you don't have to do preventive care and the reason that concerns me if i am a ten year breast cancer

survivor. i am one of those who persevered literally to find my own cancer because i knew something was wrong with my body. and i had good doctors who helped me. but, because of that i am here today and we all know that earlier detection means longer survival. i mean, that is a no-brainer. many women really say to me i don't want to get a mammogram, it hurts or whatever, i just don't want to do it. i have heard that over and over again ever since i started to get active on this issue and a lot of women have told me, i don't want to no, i really don't want to know if i have cancer. my whole point is you had better find else sooner rather than later because of what i said before. so i am very concerned that we are saying hey you don't have to take care of yourself. women let for an excuse not to

do this anyway and not to do self-exams and especially under women today. there are so many women in my areas that are in their 20's and '30's that have their own support group and that never used to happen. so when we talk about what we need to do, i hope that we will very seriously consider, and i'm glad the panel is going to be here to explain why they did what they did but i know that some of the groups are going to continue to recommend they do the same thing and with digital mammography now things have changed especially with younger women so mr. chairman i appreciate this opportunity very much and look forward to hearing their recommendations from the panel. >> thank you. the gentlewoman from wisconsin, ms. baldwin. >> thank you mr. chairman. i appreciate your calling this hearing of the house subcommittee to discuss whether it is both a deeply personal and deeply political issue for

myself and as you have heard many of our colleagues in this room. >> hanna preventative services task force was authorized by congress to deliver recommendations regarding the clinical preventive services. ideally these recommendations will be used to inform primary medical care. on november 16th the task force delivered new recommendations regarding breast cancer screenings incorporating the most extensive scientific evidence available. among the more controversial findings were the great c recommendation for mammography in women over 40 which means that because defines does not point to any significant harm for tremendous benefit that the provision of the services should be a decision between individual and a doctor. and independent rigorous examination of the science behind clinical preventive services is an essential part of

delivering effective health care. the task force was doing its job. and as they may admit today they could have done much more around such a sensitive topic by educating and explaining their recommendations to women across the country. they could engage community and advocacy groups to be messengers of this information rather than combatant. moving forward with additional recommendation in sensitive areas i would encourage them to do just that. i came away from this report in the surrounding controversy with two additional thought that i would like to quickly share. first we clearly need better screening and diagnostic tools. mammography is not a precise enough tool. we need advancements in technology that can help us understand what conditions require further tests, which requires treatment and how we can best help women to live long and healthy lives. some of these advancements in technology are being developed

in my state of wisconsin, >>host: selves said that five types of tissue with more precision improving the efficacy of an x-ray screening for breast cancer. my second point is that we urgently and desperately need health care reform. we must ensure that every woman and every american has access to regular source of care. if the best approach is to discuss the option of mammography or other screening with your doctor you have to have a doctor. the villain is the lack of coverage and access to care. otherwise women who are shut out of the health care system whether by stigma or lack of resources or even abusive been discriminatory insurance industry practices, these women have the potential of dying of breast cancer or other conditions before we even have a chance to intervene. again mr. chairman thank you for allowing us this then you to discuss and clarify this critical topic.

it has bearing not only on the health of women but the health of all americans. >> thank you. the gentlewomen from colorado, ms. degette. ..@@@ @ @ @ @ @ @ @ @ @ @ @ @ @

rather than a population by a recommendation for routine screening. that makes sense to me. number two, by any mammography for women age 50 to 74 years. number three, insufficient evidence to assess the additional benefits and screening of women over -- at 75 years or older and then the others. so we leave you back to look at the recommendations they probably do make sense from a scientific standpoint. but i've got to say it is no wonder why the women of america are are on believably confused as to what these recommendations are saying because what they are saying is most women need to

talk to their care provider and figure out for themselves based on their health and family history what is appropriate for them. it's not a one-size-fits-all testing that makes sense to me. but if you look at the 24-hour news cycle that's not what is being said to people. they are scared, confused, and when you add them misinformation we hear from some of my friends on the of the site they are confused and scared because they think now when we have the health care plan that applies to everybody suddenly they are going to be told they don't need -- that they can't have tests they need and that is simply not the case. so, mr. chairman, that is why i came down and sat through the opening statements and in looking forward to the testimony because i think we need to clear it up. but is it that we are seeing should be done with mammography and testing for women, and what

is it women need to be talking to their physicians about the? ultimately it is going to be the decision of the physician and the woman what the need and the need to figure that out and then they need to feel secure they are getting the level of testing the need. thank you, mr. chairman. >> i thank the gentleman. next is the gentleman from ohio, mr. speakes. >> thank you, mr. chairman for taking the time to hold this hearing on this important issue. cancer is a terrifying specter for all americans and almost all of us have had a loved one or friend who has been affected by it. it certainly is a disease that strikes fear in the heart of all of us, and i want to preface my remarks by saying i have heard some things from the other side of the aisle but have made a lot of sense and i specifically

point to congresswoman am i rex comments and if i find them three consistent with those just provided by my colleague from colorado, congresswoman degette. but we have heard things from the other side of the ogle today that i think cause us, certainly me considerable concern. i think that it's wrong to use that fear that we all share of cancer to intimidate the people of this country into fear of comprehensive legislation that has some of our witnesses will testify today is good for people with cancer to read in following up with some of the remarks made by chairman dingell some things built are not do that need to be clarified. these task force recommendations will not lead to rationing care.

that is simply not true. i think it is tactics like these but we can defeat of the american people not in any of one particular party but in the institution of congress. nothing in this legislation prohibits insurers from covering mammograms in fact the legislation gives the secretary leeway to add to the minimum benefits package as needed. i think it is disingenuous to the one hand defend the status quo which sees the insurance industry every day making decisions about the lives of insured based on financial -- strictly financial considerations. and then on the other hand condemn the system because you speculate that these kind of recommendations will lead to the rationing of care. second with this bill does do is provide some benefit insurance to the millions of americans

that don't have it and falling on with what dr. christiansen engender earlier it's not just those americans that don't have insurance that benefit from this bill when it comes to preventive care and access to mammograms it's those who have insurance but can't afford the co-payment specifically those who are in the middle class americans that makes a difference for them. this bill makes preventive care a basic and fundamental right for every american. that means again my constituents 65,000 of them have no access to coverage right now and tens of thousands more who can't afford co-pays will now have access to things like mammograms when they wouldn't have otherwise had that. these are questions we all should be asking. what is the net benefit of this legislation to our constituents. rather than jumping to the

irrational conclusions adding confusion to the public in politicizing an issue which should transcend politics we should be asking these rational questions again as my colleague from maryland indicates based on reason and science. with that i thank you once again for calling this hearing and keeled back. >> thank you. the gentleman from ohio, ms. sutton. >> thank you for holding this hearing on the u.s. preventive service task force on mammograms for women in their 40's. as we have all heard and as has been described the task force is no longer recommending 14 mammograms for women in their 40's, and as someone who cares deeply about women's health i, like others, was surprised by this change. breast cancer is to say the least a terrible disease.

it's the leading cause of death for the women between the ages of 40 and 59. we all know people have been touched by breast cancer. people that we love and care about. and we all know people who have benefited from early detection. so this is such an important hearing and i look forward to hearing the discussion of the panel. and with the recommendations basically are in stat a woman should talk to her doctor and make decisions accordingly for their care. but many women house has been pointed out don't have doctors and many women don't have access to health care and women and should get mammograms either under the old recommendations or the new recommendations do not get the mammograms. and 2007 only 70% of the women in the country to should have been screened for breast cancer

were screened for breast cancer and part of the reason when whether they are 40 or 60 arnall screen this because they did not have insurance. and because they don't have insurance they don't have access to the care that the needy and when they needed including preventive care. so let's be clear providing access to health insurance means providing access to preventive care which means saving lives. so what's important is patients and doctors are able to consult and access to care that patient needs and when they needed and that the patients and doctors together will decide the best course of care whether that includes a mammogram, but in order to do that people have to have access to doctors. women of all ages under the health care bill that has been passed by the house will have improved access to coverage.

that should not be lost and it certainly should not discussions of their wives and presentations otherwise should not be used as we debate and discuss this very important issue to the real -- de real efforts to access women need in this country. i don't think that serves wim in a while and i don't think that serves our country well and frankly >> thank you. the gentleman from iowa, mr. braley. -- before, mr. chairman and thank you for allowing this hearing. i also want to commend my colleague the gentleman from north carolina for her eloquent and thoughtful statement on a very important topic. and yy disagreed with what some of my colleagues from georgia said i have great respect for his real world experience on women's health issues and appreciate the concern he

brought to this hearing. but i also want to talk about the comments made by the chairman emeritus and others on this committee. if people don't believe rationing takes place right now in our private insurance system every day and every state and every congressional district they are sorely misguided. it does happen every day under the current system which is failing to meet the needs of the american people. give you a good example of a friend of mine who was diagnosed with prostate cancer and conferred with his physician of treatment options and agreed proton beam therapy was the best choice of treatment for him and he went to his private insurance company, which also is the medicare administrator in my city of iowa and his treatment was denied on the basis that it was experimental. well, guess what, under the medicare plan that same private insurance company had been

mastered it was considered on an experimental and even though he was eligible for medicare because of his age she was still covered by a private plan for his employer and was denied coverage for the same treatment he would have gotten if he had been a member of medicare. that is what is wrong with our work broken health care delivery system, and that is why comparative effectiveness research is such a critical part of a rational discussion about health care policy making. in an earlier hearing in the same subcommittee i talk about a hearing that took place in this very room years ago when a researcher advocating high dose chemotherapy with bone marrow transplant for metastatic breast cancer patients was the only path to cure for those women even though it had not been tested by rigorous academic research, than his years after that we came to the realization

many women were actually harmed and died because of being subjected to that treatment. and that is why by the way it is so important that the plan language amendment i put in the health care bill be implemented and people dealing with health care issues. i think that in its position paper the u.s. preventive service task force highlights with edison important. they indicate on one page of the statement that the problem was a matter of communications because the ausley with the task force meant to say, that the communication of the mammography screening recommendations was poor. i agree with that and all you have to look is the next two sentences to find out why. this is what to of the sentence is say. what we said is screening started at age 40 should not be automatic nor should it be denied. that does not make sense. the next sentence says what we

are saying is that a decision to have a mammogram for women in their forties should be based on a discussion between a, women, her doctor. if you don't communicate for your intended audience in language that they can capri and easily these barriers of communication between highly technical scientific and medical information will be a problem. but the debate we are having is a healthy debate about what the most effective use and treatment for breast cancer treatment is and that is what we need to focus on going forward and i >> i thank the gentleman. next is the gentleman from utah, mr. matheson. >> thank you, mr. chairman i will be pre-because i am looking forward to hearing from our two panels on this topic. and my state of utah the incident of breast cancer is lower than most dates. however our mortality rate is high as women and utah are diagnosed in cancers later stages. as a witness on our panel notes

in his toast with what the recent recommendations provided by the u.s. preventive services passport november 16 among providers, patients, families has most part a public discourse has led to further confusion and anxiety. as we can see from the testimony before the committee there is not consensus on screening protocols but there does seem to be consensus that any screening and discussion is an individual one between a provider and a patient. i hope today's hearing can provide concrete information on evidence-based on decision-making processes of the task force. i'm also interested to hear from the cancer community and medical providers on their next up for outreach and patient education on the benefits and limitations of mammography screening. thank you, mr. chairman. i yield back my time. >> thank you. i believe that concludes the opening statements by members of the subcommittee. so we will now turn to our witnesses, and if our first panel would come forward i would appreciate it.

thank you. we have to witnesses, both from the u.s. preventive services task force, to my left. dr. ned calonge, i hope i'm pronouncing it properly. who is chair of the u.s. preventative services task force. and next to him is doctor diana petitti. petitti? petitti. who is vice chair of the u.s. preventive services passport. i will just mention as i think you know we have five minute opening statements from you. they become part of the record in each of you may submit additional statement in writing for inclusion in the record. i would have recognized first doctor colón. >> good morning, mr. chairman and establishments of the committed on behalf of our fellow task force numbers, we

thank you for the opportunity to discuss the task force and our work. are recently published recordation on breast cancer screening have done a remarkable amount of attention. we recognize the communication of what the recommendations they was poor him and the timing of the release was unfortunate. we wish to explain the process and timeline for grading the fragmentation and to clarify what we intended to say to clinicians and women. the health care clinician scientist on the task force fully understand most personal express the impact of breast cancer on the lives of women and their families. our job is to rigorously review scientific evidence. politics played no part in our processes. costs were never considered in our considerations. we voted on these recommendations long before the last presidential election. the timing of the release of the findings last month was determined not by us, but by the publication schedule of the medical research journal which you reviewed our work. the current task force was created by congressional mandate

as an independent body with the mission of reviewing the scientific evidence, clinical preventive services, and developing evidence-based recommendations for the health care community. our primary audience for recommendations remains primary care clinicians that the task force has 16 volunteer termed members representing a diverse array of expertise in primary care and preventive health related disciplines, including a dolt, child preventive and behavioral medicine, women's health, nursing and research methods. the ahr to director appoints members from the chair's recommendations developed from a public nomination process. given the scope of topics covered subspecialists who consult on or care for those identified through string by primary care clinicians may not necessarily be recruited as members, but instead are consulted to review and comment on our work at critical points in the process. our core portfolio includes a broad array of 105 services that

are listed on the website. we strive to update topics every five years which is what prompted the new breast cancer screening recommendations. to address a topic, designated task force workgroup members and scientists at an evidence-based practice center collaboratively develop an analytic framework and pertinent key questions. a structured systematic review of evidence for each key question is conducted and a draft evidence report is created with a support group consultation. based on evidence review and explicit methodology, the workgroup draft a recommendation statement and an in person meeting the evidence of the drastic and are presented and discussed in the task force vote on the recommendation. there is a careful attention to conflict of interest, as members of potential conflict are refused from discussion, and vote, or otherwise restricted and participation. representatives of 24 partner organizations including all primary care specialties, key federal agencies, and other key

stakeholders, specified in a written test on and on our website are invited to participate in the discussion. added three key points in the process, work products are simple review and comment by the partner organizations, by subspecialty experts and consultants from the relevant disease area, such as oncologists, and by other stakeholders such as subspecialty professional organizations and advocacy groups. these parts including analytic framework and key question, evidence review, and the draft recommendation statement as noted on. all comments are considered in creating the final products. final recommendation statement and evidence reviews are published in peer-reviewed medical journals. recommendations are expressed as letter grades based upon two factors only. the madness dude of net benefit or balance of benefits and harms of providing the service, and the scientific certainty about whether the service works. costs and cost effectiveness are

not addressed in our deliberations and making a recommendation. over the pastoral years, we have discussed with costs should ever influence a recommendation, and we have repeatedly said, no. for recommendations there significant net health benefits such as primary care clinicians are recommended to provide the services for all appropriate patients. if there is no net benefit or there is net harm, we signed a deal recommendation indicating to not provide the service. the gaps in evidence provide net benefit from being determined, we assign and i statement reflecting insufficient evidence indicating that more research is needed. finally, a c recommendation is assigned when there is a small net benefit. for c replications we recommend the patient informed about the potential benefits and harms, and then be supported in making his or her own informed choice about being tested. the specific c which i would recommend against routine

provision was intended for consideration by primary care clinicians. but unfortunately, as played out in unintended ways, and a publix interpretation of the breast cancer recommendation. conquers through section to address our mission. the role of h.r. in the process and support our opportunity but the staffing director of aar to did not vote or otherwise influence our decisions. i will have to admit to the committee that breast cancers of particular concern to me that i lost both my mother-in-law to breast cancer and my sister is currently undergoing therapy. i fully understand this issue and have to rely on science as we provide our recommendations. with that, i would like to turn testimony over to dr. petitti to testify specifically about the breast cancer screening recommendation. >> i -- >> i'm sorry. i just wanted to thank dr.

calonge. i will now ask dr. petitti to begin. >> well, i am diana petit are kind of vice chair of the u.s. preventative services task force that i'm a physician and epidemiologist. i present my entire 30 year your career as a scientist working on issues of women's health. i publish on the topic of mammography screening. i served as vice chair of the national cancer policy board and i have expertise and evidence of this and systematic review and meta-analysis. i participate in this process from the very beginning. i would not sign off on any recommendation that i did not believe reflected the best possible use of evidence for the benefit of women. i appreciate the opportunity to clarify for members of the subcommittee come the task force recommendations and evidence in weighing of the evidence that led to these recommendations. in specific, the task force recommends the following.

women age 50 through 74 should have mammography every other year. that decision to start regular by annual screening mammography before the age of 50 should be an individual one and take patient context into account, including the patient's values regarding specific benefits and harms. that is, the task force is saying that screening starting at 40 should not automatic shouldn't be denied. many doctors and many women perhaps even most women will have mammography screen start at 840. the task force supports those decisions. the task force acknowledges that the language used to describe its recommendation about breast cancer screening for women, 40 to 49 did not say what the task force meant to say. the task force communication was poor. the task force was committed to improving its communication. the task force first addressed screening mammography topic in

1989. at that time the task force recommended screening women 40 to through 75 everyone to two years. with regard to screening younger women, the task force stated it may be prudent to begin screening at an earlier age for women at high risk of breast cancer. in his 1996 guide, the task force recognition was in favor of screening women 50 to 59 every one to two years to commodity screen for women 49 was given a c great. at the time a c recommendation that insufficient evidence that in 2002, the task force recommended screening women 40 to 69 every one to two years, stating that the benefits were small and don't longer to emerge for women who are first screened in the '40s. on november 16, as this commandos come the task force that it's updated recommendations, on breast cancer services here i wish first to clarify that the timing of issuance of these recommendations in late 2006, discussion of a plan for updating recommendation began. the breast cancer topic came up

for review at the regularly scheduled time. work on the topic started in 2007. when the recommendation statement came up for a vote, in november 2007, the members could not come to agreement about what to recommend, because agreement about what to say about the balance of benefits and harms. in this context the task force ask for additional evidence from its evidence-based practice. the task force considered this evidence in its july 14 and 15th 2000-meter in making his final recommendation to the task force considered evidence identified in a systematic review of evidence for six key questions that the results of an announces of the breast cancer screening consortium and the results of a study commissioned by the task force and conducted by the cancer intervention in surveillance bottling network. the systematic review identified almost 3000 studies and 5000 -- 50 of these were used to make a recommendation to the final

recommendations were made based on a weighing of the benefits and harms. the task force concluded some evidence screening mammography for women 40 to 64 has benefit in reducing death due to breast cancer. that benefit is larger and older women than in younger women. i would like to speak specifically to the issue of harms in the net benefit equation. preventive services are provided to asymptomatic individuals for the sole purpose of preventing or delaying morbidity, delay and functional decline or decline to. it is net benefit. benefit minus harms. the benefits of mammography have been eating to communicate. the harms and potential harms having difficulty keeping a. the easily identifiable and commonly used definition of harm is physical injury. these physical injury to wreck arms are very, very small. but the task force considers this arm of the screening test

not just physical harm, but psychological harm. a great deal of disagreement -- the controversy has centered on the task force use of consideration of anxiety and psychological distress as a harm of a false positive test. in particular, the psychological distress has been ridiculed. to understand the consequences of false positive test, it is necessary to consider how women into the screening cycle, what happens and what might happen to a woman who has positive test. no matter how hard a concept of screening is it's become a positive mammogram screening test means cancer until cancers proven not to exist there for some women who have a positive test, the tie between a positive test and he stated, there is no cancer is mercifully shorter for

other women the follow-up involves more than one additional test. perhaps a clinical breast examination of a trip to a surgeon. over a period of time that is not always short, and over a period of time that is unpredictable and not within the control of the woman. some women eventually need a biopsy. cancer is a terrifying process, it carries emotional weight because the consequences of the diagnosis have in the past involved not only that but the prospect of mutilating surgery. anxiety and psychological distress in women with a positive screening screening test is amply documented any evidence that the task force wants only to screening mammograms be done with full knowledge of these potential harms. the frequency of the heart and what is to be gained by being screened at an earlier compared with a later age of false positive test are more frequent and younger than in older women. other harms of mammography include ones that are less well doctor. is some women are diagnosed in

their 40s with cancer that could have been treated as with diagnosed later later. eliminate unnecessary been exposed to the harms of treatment, including surgery, chemotherapy -- >> doctor, i did want to stop you. it is so important, but there is two minutes over. keep going. >> i'm only going to say that my final statement, and mammography starting at 40 should not be automatic. the task force recommends that women in their 40s aside on an age to begin screening that is the son a conversation with the doctor and as an individual that i apologize for going over. >> i'm going to apologize for trying to stop you, because it's so important you clarify a lot of these things. and i appreciate that. our procedure now that we have questions from the members of the panel. i mean, from the members of congress. and i will start with myself. let me say that you've actually

clarified some of the questions i was going to ask very well, but i still want to kind of refuses, if i could in my own mind. and if i say anything you disagree with, tell me. but i do want to ask you some questions as well. look, there is a lot of information out there that has been spread, both today and certainly in the last few weeks ceja came out with your recommendation. and the way i understand it, the current task force uses these abc ratings. these are the same kind of ratings that would be used under a different task force that's in the legislation, the larger health care reform legislation that would pass. in other words, you are the u.s. preventative services task force, the new task force and the bill that would pass has a different name, clinical preventive services, that the abc ratings are the same. or similar. but right now, these abc ratings have no force.

they are just recommendations. what some of my colleagues have said is that these insurance companies now don't have to cover a beat or see. don't have to cover anything. and at that, what we're getting is that a lot of insurance coverage right now don't cover the prefer to cover any screens because if you do a screen and they have to pay for treatment, it cost them money which they try to avoid. so what i see right now is that in some cases states have required certain screening, like my own state, but on the other hand we've heard the gentleman from utah talk about utah where my understanding is they don't require any screenings. so the point of trying to make is that the biggest advantage of the health care reform bill that we passed is that h.r. 3962 will for the first time create minimum standards for required preventative benefits. so private insurers would be required under that bill to cover services with a grade a or

b. recommendation. right now they don't have to cover anything. what we are doing in the bill is basically saying that at a minimum, if you or your successor task force, says that this is an eight or be it has to be required, which is not that. the other thing that we do in the bill is that we say the secretary could require a.c. green also be covered. under both a public option or a private insurance plan. in fact, my understanding is the new task force -- the secretary under the bill could even require a c rating under the basic benefit package. now that's contrary to what some of my colleagues have been saying on the other side of the aisle. my whole point here is to say that the truth is that if enacted into law, h.r. 3962 would result in a lot of people who are not getting mammograms, pap smears, colonoscopies, a lot

of people don't get that at all that because insurance companies basically don't have to do it in less the state requires it. now under this bill, they would have to do anything that you made as a a or b in the senator could even require the c either in the public option or in the private plan under the basic benefit package. now i've mentioned this because the bottom line is that women's ability to continue to obtain mammograms increases in these house and senate bills that are being passed and are moved. when i look at the republican bill on the other side, it sets no floor whatsoever. there would be no minimum required benefits for insurance to provide under the republican bill. a century it will be just like the status quo. that we have now. so i don't -- i listen to the debate we've had today. and the bottom line is that the bill that we pass in this house provides a lot more coverage and a lot more guarantees. the status quo doesn't provide any guarantees at the federal

level, know or would the republican alternative that we have been given on the other side. , question is, again, you mentioned that when you recommended c, it says it has a small net benefit and women are supposed to make their own decisions. so you made it quite clear today that even if it is a c, there is some net benefit and the secretary could decide under the result is that okay, that's going to be required as well. so you're not in any way with this c recommendation, saying that this screening is not a good thing. in fact, you are saying there is a net benefit. but you would like individual women to make that decision with their doctor because it's only a small net benefit. is that accurate? >> mr. chairman, i'm going to speak to the science. >> absolutely spirit and the size is that a c recommendation does mean a small net benefit.

and we met that c. recommendation to advice that women make the decision with their doctors about whether or not to undergo. i think this committee is dealing with incredibly complicated issues about health reform and coverage, but the task force is not a coverage and health care reform and policy committee. >> but the bottom line is, and i will end with his. even when you recommend a c, you're saying there is a small net benefit. so again, let's not talk about today but let's talk about the bill that we passed in the house and may become law. even then, you know, the secretary can say okay, is a small net benefit and so we do want to require this as a basic benefit. or basically leave it up to the injured counties to decide the way they do today. but the misinformation out there i think is that even under the bill we passed, for once, there

is going to be a requirement that some of these screens of kirkuk if you rate it as an a in has to be done to give you rate it as a beat, it has to begin but if he rated as a c the secretary did they has to be done. right now there is nothing. nothing at all. and republicans and their alternatives would continue the status quo that say you don't have to cover anything. and i just appreciate because i think you have helped me clarify. i yield down an now to the gentn from illinois. >> thank you, mr. chairman. what we need in this country is a continued debate on the failed health care bill that would pass on the floor of the house. that's what really need to do and that's what we are doing today. and we are using obviously what happened through your process to make a claim, the short-term concerns of a public option,

which many of my colleagues on the other side has said is the gateway to a one payer system. so when the government controls all the health care decisions in this country, they will eventually default to control the cost through ration care. now the process of scientific process that you have just admitted to, says there's a small net benefit. when there is increased -- decreased revenue available, the default will be based upon 3962 just what you say on your website. your website recommends against routine screening mammography in women age 40 to 49. do you think that this statement would be perceived by younger, women younger than 50 that they should not get a mammogram on your website? >> we have communicated very poorly about the c

recommendation that it is clear that many women, many physicians and survey the media, interpreted that language as if we are recommending against women in their 40s ever having a mammogram. that was not our intention to. >> i understand, but we are concerned of commissions that we are concerned of bureaucracies. we are concerned of rationed care. we are concerned about eurocrats saying there is no real net benefit. and then -- yeah, it is right. that's exactly what we are concerned about and that's why we're having this debate. in the bill, and chairman pallone i think pretty adequately talked about the differences. we know that services with a rating of a and b. must include an essential benefit package. in this case come with the highest rating, women would not receive currently, if this were law, as is today, women in the c

category would not receive this other covered benefit. under 3962. and that is part of our concern. and this does say, into the health care debate. i don't have the whole 2000 pages. i just pulled out excerpts. the commissioner shall specify the benefits to be made available under exchange produced and health benefit plan during each year. and then you can go further on. basic, enhanced and premium. and then the premium plus, a., approved by the commissioner. and then you can go to the c section which is again highlighted. and we can continue to have prevented it serves services including those services recommend with a grade a or b. by the tassels on the clinical preventive services.

so this is again for a lot of us an important debate. to any of you know an individual who has been diagnosed for cancer between the ages of 40 and 49? personally. >> i know many individuals who have been diagnosed with cancer. >> dr. calonge? >> just. >> and any other question, what about over the age of 74? anyone who has been diagnosed? >> thies. >> although we are focusing on 40 to 49 annual report, over 74 has the i category. and we don't even know if it is. so what are we saying to those over the age of 74? >> i speak to the evidence and the mapping of the evidence to the task force recommendations. >> and i appreciate that and i

will have 38 seconds and i'm going to be partial on my time. par this concern with h.r. 3962, is as we said the public option, the gateway to a one payer system could eventually rationed care. and then a decision made based upon the financial ability of the country to fund care across the spectrum, but also our seniors in our country. and again, this incomplete aspect for 74 b. speaks to the concern that if you're elderly in this country and we get to it one payer system, there will be decisions made not based upon health care, but on cost. i yield back my time. >> thank you. mr. waxman. chairman waxman? >> thank you, mr. chairman. the health care bill that the republicans are complaining about is not law. yet, your agency prevented task force, is in operation.

this is set up under -- is it set up under law? >> yes. >> your job isn't to make recommendations to insurance companies is at? >> that is correct. >> your job is to make recommendations on preventive services so that the latest science and information about the science is communicated to clinical practitioners, isn't that your job? >> that is correct. >> and this is very useful information. now, we are focused on the breast cancer issue, but that's not the only area where you make recommendations, isn't that the truth is? >> that is correct. >> how many other areas has the task forces made recommendations over the last couple of years? >> our first portal is remlinger five and we take up around 13 new topics and you. >> you recommend that teenagers be screened for mental illness. >> yes, that was a new

recommendations this year, congressman, that we just came out. this is new services that had not been recommended by. >> and there is a breast feeding behavior intervention recommendation. >> that is correct. >> and you had a recommendation to ask for the prevention of cardiovascular disease, a way to prevent the disease? >> right. smacks of you have a whole range, comedies to come 130? >> one hundred five total. >> 105 to. >> i am assuming not others have been as controversial as this particular one? >> that is correct. >> we have a controversial issue, because it challenges the accepted notion about the frequency of breast cancer screening. and we're going to hear a lot more about that with the next panel. but i want to have a look at the challenges as raised by the republicans. which i think is all political. they are acting as if your recommendations, based on bring the scientist had the expertise,

which are directed at clinical people, will be used to ration care. that's their argument that we're going to ration care. and they didn't say, well, that's because there will be a health care bill that will provide the requirement for minimum benefits. there will be minimal and if it's been that they should have access to hospitals, access to doctors. we should have access to pharmaceuticals. your areas in the preventive area. and nothing could be more important, to me, then having the latest science on how to prevent diseases. because if we can prevent illnesses, we won't pay to treat them later. your task force will continue an operation. you will convene a scientist or expert in different areas of prevention. now, i guess the question, not raising this to you, but the question is how will your

recommendations affect the minimum benefits that will be required for health care insurers? health care insurers could be a public insurance, if that survives in this legislative process but it certainly we would be private intricate private interest doesn't have to abide by your recommendations, isn't that true? >> that is correct. >> and some of them cover the preventive services and some of them don't, isn't that true? >> that is to. >> it is their decision. but if we're going to provide subsidies for people to get insurance and we will try to get a market where insurance companies compete against each other, based on price and quality, we are to make sure that all of them provide at least a minimum set of benefits. one of the star issues for public and if you have a lot of insurance plans that don't provide any minimum benefit at all. they can be cheaper if they don't provide minimum benefits.

well, i find that troubling. but let's say we're going to have minimum benefits that you make a recommendation. is your recommendation under the proposed bill automatically going to be in effect for all insurance? do you know whether that to be the case? >> congressman, i'm not well-versed specular not an expert on the bill, but let me explain what the new bill will do. the new bill will take your recommendations. they will go to the secretary. the secretary will review them. the secretary will have a notice of rule and comment, and a public process. and then decide whether there's a minimum benefit. now, a minimum benefit is a minimum benefit. it's not a maximum benefit. so if there is a recommendation, as you have proposed on breast cancer screening, that would be not a requirement of an insurance to do no more than that. it will be a recommendation that

will be required that will require insurance companies to do that as a floor. not a ceiling. i just wanted to set this up because i think some people watching this hearing may get confused when they hear stories about bureaucrats or rationing care, or the health care bill being a gateway to single-payer. we expect to deal with competition and people to make choices between insurance plans, but we don't want the choices between insurance plans to be those that cover breast cancer screening and those who don't. that those will at least with a minimum preventive services that we could hope will prevent diseases and the need for paying for care for those diseases. thank you, mr. chairman. >> thank you, chairman waxman. next is the gentleman from texas, mr. burgess. >> thank you, mr. chairman. let me ask you a question.

i thought the clinical guidelines, i guess this is a reprint from the annals of the internal medicine. the last page of which is an appendix which lists the members of the u.s. preventative tasks services. there's a number of individuals are listed there. their specialties are not. is anyone on the list there a board-certified ob/gyn? >> yes. there are two port certified ob/gyn's on the task force. and that is a usual -- we usually have two. >> which are those two that are on the list that i have in front of a? >> kimberly gregory and wanda nicholson. >> and they both participated in this decision? >> kimberly gregory was on the task force when this decision was voted. wanda was not.

there was another ob/gyn on the task force when this topic was voted. that was george, who is a professor of ob/gyn at university of california san francisco. >> were the unanimous vote? >> know, the votes were not unanimous. >> do we know how the individuals voted? >> i can't recall. that is in the record, and we could make that information available to the committee if that is important. >> i would like to see. i don't know if the committee looking at import but i would certainly appreciate the opportunity to see. now, is a radiologist in this group? >> know. no, there is no radiologist in this group. >> is that a problem? >> the expertise for the spam has been called in question. the experts are individuals who have experienced in screening science and prevention. radiologists were consulted and reviewed the documents and the

recommendations and provide input. >> let's wait until that finishes. it bothers me to. on this task force, the majority of these invisible primary care doctors. was a general surgeon on the board, or on the task force? >> well, there again, the experts are experts in primary care and prevention and yes, there were. and i would have to count the. for primary care physician on the passport card and four at the time of the. >> was there a general surgeon who specializes in localization of breast biopsy? >> know, there was a. he was consulted. >> they were consulted, all right. and i apologize for being in and out, but we are doing like nine simultaneous hearings today, and the financial services makeover

requires some attention and thought as well. on the issue though of talking about, you said you factored in the psychological events surrounding of a callback on a positive mammogram. you factored in the psychological cost, if you will, to the patient in that exchange. do i understand that correctly? >> the issue was a qualitative assessment. anxiety, psychological distress, inconvenience are all considered to be harm's and potential harms. again, it is part of the net benefit equation. >> when i was in school back in the 1970s, i realized a long time ago, but mammogram screening was not at least an area where i went to school, that was not something that was done. uses him for a mammogram. it was kind of a bigger because you felt something, but it wasn't done as fast as part of

routine screening. in fact, i don't think, as i recall, looking back it was probably the mid '80s when it became a standardized screening test. in fact, in texas i don't know whether this is too nationwide, but in texas i know women can self convert for mammography. when it all happened, that psychological cost was one of the arguments that was used by people who felt that routine screening would not be a good idea. so how is it that we have come to the point now where we have rejected it back to the 1980s, but now in 2009, this is a factor against that is worthy of our consideration? >> again, this is not determent information that we want women to know about. we want them to know how common it is. again, the false positive rate is much lower as women get older.

and that's part of the net risk-benefit equation that we would not want women to be afraid of having a mammography. this is again one piece of information that women and their physicians should discuss when deciding when to start screening. >> and does that seem rationale apply to self-examination? >> the task force recommended against clinicians teaching women breast self-examination. they did not recommend that women not pay attention to their bodies, that they ignore lumps, or that they ignore problems that might come up when they find a lump. again, the task force recommendation was against doctors teaching women breast self-examination. >> well, how are women supposed to get that knowledge? if they can't just get by

intuition, somewhere along the line have got to provide them some guidelines on proper time to do the exam and how to do it and what to be concerned about and what not to be concerned about. as i recall, i maybe wrong on this, but i don't ever recall coding and being compensated for teaching self breast exam. i was a cost center for your. i wasn't a cost driver. my own inference from that could be that you're worried that people will find things that leaned lead to procedure and we're better off if we don't ask, don't tell. >> again, the evidence, there have been two very well conducted randomized clinical trials in which women were taught how to do breast self-examinations here than both of those trials found no overall benefit in terms of reducing mortality from breast cancer. again, we go to the evidence

spector gentlest time has expired. >> as i said in my opening statement -- >> mr. burgess, you are over two minutes. >> it does strike me -- >> mr. burgess. >> again, as a young doctor -- >> mr. burgess, your time has expired. >> i will be interested with some of the other clinicians tell us when they get the time. >> doctor burgess, you almost three-minute over and we're about to vote. we have time for one of the set of questions and they would have to vote. we have five votes. we will take one more set of questions and then we will adjourn and come back after the five boat pick our next is chairman dingell, did you want to proceed now? >> i think i would proceed rather quickly, mr. chairman, yes, please. i would like to welcome you both to the committee and to help helpful it is to have you here. from the things i've heard said on the other side of the aisle about you folks at the agency, i

was afraid you would appear with horns, tail, things, and in a red suit breathing fire demanding that we immediately terminate all health benefits through the unfortunate sick, weak, poor and especially with regard to mammograms and pap smears. so i am very much comforted. i want to welcome you to the committee this morning. i just have really one question that i think is important. i find it curious that the task force has repeatedly, over the years, voted to leave costs out of its deliberations on whether to provide or not a proved preventive service. why? >> thank you. congressman, i think this is a key question. the task force believes its major charge from congress and responsibility to primary care clinicians and patients is that

we set the evidence-based stake in the ground in new and from how much it costs to achieve the benefits associated with a given effective preventive service. smacks of your short answer is, that you are recommending the needed services, the needed tests, the needed treatments as opposed to looking at the cost, is that it's? >> that is correct. >> to assist my colleagues on the other side of the hour, and i do this out of great affection and respect. you address this question in your statement. you say here and i read this for the benefit of my college on the other side, you say task force recommendations are based on consideration, the health benefits and health harm's in providing the preventive service and on the scientific certainty of whether the preventive service works. costs and cost effectiveness of

specific prevention services are not addressed by the task force in its deliberations. then you say this. the task force only, and that is underlined, considers scientific evidence of health benefits and health harm's. the task force had specifically discussed whether costs should influence the a recommendation, and has repeatedly voted to leave costs out of deliberations on whether or not to provide a preventive service. is that right? >> that is correct. >> now, when your recommendations are made, are they used to put a ceiling on benefits, or are they used to describe a minimum level of benefits that people should get? >> congressman, i must admit that that is outside the scope of our recommendations, how they

are used by other entities. >> okay. your recommendations are not expected to be substituted for the need of the patient, or the concerns and expertise of the doctor. and they are not intended to intrude into the doctor-patient relationship. am i correct in that interpretation, or am i wrong? >> that is correct. in fact, if you read our statement as published in the annals, it says the task force recognizes that clinical or policy decisions involve more considerations than this body of evidence alone. clinicians should understand the evidence and individualized making to the specific patient or situation. this actually precedes all recommendation that is a recommendation statement that we expect clinicians to do what they are trying to do in order to address the needs of the individual patient for his or

her best interest. >> now, you do permit as a task force goes about its business to have different agencies and persons of concern present at the deliberations, is that not so? >> that is correct. >> and your deliberations are public? >> at this point, the deliberations of a task force vote are by invitation only. >> but by invitation. you don't gag the people who come in to listen to they can go say what is going on. and they are also permitted to make comments to you on the task force, is that not so? >> we actually invite comments from our partners to help us do our job better and to take into consideration different viewpoints and different issues. >> and you allow citizen input? >> the task force is currently moving towards increased private citizen input with the resources we have available to consider

and identify those. we have, prior to this time, done more with input through specific groups that we invite to comment because we think they are important stakeholders. this is an issue that the task force believes that in the interest of enhanced transparency and responsibility to the american public and the patients whose positions may consider our recommendation needs to be improved. >> thank you, mr. chairman. thank you. >> thank you, chairman dingell. we have five votes. i would say about an hour, but when they are done we'll come back and reconvene. the committee stands in recess. [inaudible conversations] [inaudible conversations]

>> the committee will reconvene. >> mr. chairman, thank you. [inaudible] >> i wanted to specifically ask you, how many serve as a member of task force.

[inaudible] >> let me read to you from testimony. in fact, she states in her testimony we want to know that the attacks against the makeup of the task force are misplaced. screening is an issue of primary care. it is a health and a vision for a healthy population. the experts in this area, those with a scientific training and objectivity to do the necessary analyses are primary care health professionals, and methodologists, epidemiologist, and biostatisticians. not radiologists or medical oncologists. and i'm quoting directly from her, her statement.

what is your opinion on that? >> the task force expertise in this area was sufficient to weigh the evidence that led to his recommendations. the recommendations are made either task force with the input of a variety of other specialty groups. they are not made in a vacuum. in this case, they were submitted to -- i can't remember the number of partner organizations, but at least than. each of these partner organizations have experts pick those experts provided -- >> and some of those experts then would be cancer specialists? >> yes. >> so by that response, i guess you would take exception to the comment by ms. frisco. but we'll hear from her later. let me ask you another question. on your website, and either you

or dr. calonge. on the uspstf website, it clearly states that united states preventive services task force recommends against routine screening mammography in women aged 40 to 49 years. do you think this statement could be perceived by women younger than 50 that they should not get a mammogram? >> we need to immediately figure out how to get that statement off the website. i think it could be misconstrued. it has been misconstrued, and we need to fix our website. >> dr. petitti, i thank you for that response and i hope that you would do that. i think it is very important. i agree with you. i want to thank you, dr. calonge, are you aware that the senate version of health care reform, specifically section 4004, i think on page 1150, it requires the secretary of hhs to create a national prevention awareness campaign based on all

of your task force recommendations, both those that you favor, the a or b's and those that do recommend against the c and these. you think this national campaign could be perceived by women younger than 50 that they should not get a mammogram or perform a breast self-examination? >> i want to -- congress and, could you restate your question because the first part of that and the second part i didn't -- >> what i'm saying is in the senate bill, if it becomes law, if that prevails, the senate language and becomes law, and it specifically says and i name the page and section, but secretary would require the creation of a national prevention awareness campaign. television ads, tv spots. based on all the task force recommendations, both of those that you are in favor of and those that you recommend against. don't you think or do you think

this national awareness campaign could be perceived by women younger than 50 that they should not get a mammogram, nor should they perform self breast examination? >> thank you for the clarification, congressman. so i can't speak specifically to the bill or to the policy. i will speak to the communication of the recommendation, which we believe needs to focus on the decision to start regular biannual screening mammography before the age of 50 should be a individual and to take patient contact and account, including the patient's eyes regarding specific benefits and harms. and so that message which i realize is preceded by the recommends again statement one would go to medication needs to be improved, and a clear message of what the task force intended needs to be that, not all. >> thank you, doctor. mr. chairman, if you'll bear with me for maybe just 15 seconds. i have one other point i wanted to make.

the united states committed of service task force concludes that the current evidence is insufficient to assess the additional benefits and harms of clinical breast examination beyond screening mammography in women 40 years or older. that is saying that you don't recommend that clinicians, a physician, primary care physician, ob/gyn specialists should routinely be a breast examination as part of a complete physical in his or her patients, that that has no value to? >> the evidence does not provide support for a clinician doing a clinical breast examination of. >> i thank you for that response and your honesty. mr. chairman, i know i've got me on my target i appreciate your patience that i think that is terrible and something needs to be done about that. >> next is our vice chair, the gentlewoman from california, ms. castor. >> thank you, mr. chairman.

i did want to say thank you to both of you for being here, for your excellent testimony, and for being among the few on capitol hill. i will apologize occasionally and it's not a habit that we do very well. so the fact that you, i wouldn't call it an apology as much as acknowledging the communication glitches that occurred perhaps, and for me, i think was -- it is timing. but i don't take it as a negative thing. i think we are seeing a very positive overall experience happening in our country. not to minimize the confusion as many women experience. but i think we can use it as a moment. but that would. the timing of the report and the debate on health care reform has been seized by many who want to detract really from the health care legislation to use your

testimony and widely misconstrued way. and i want to take a minute of my time to mention one very important distinction, but it is also an important point of what the health care reform bill is. which actually will be augmenting a lot of the preventive work that you are doing, because women will be able to have occasion to understand more about cancer prevention in its wider forms and their behaviors and their body changed, which are all essential. but the essential benefits package in the exchange consist of the 11 benefit categories, including inpatient hospital services as an example, outpatient services, prescription drugs, as was preventive services. but with regard to preventive services, the bills is the recommended items and services with a great of a or b. from u.s. preventative services task force shall be covered as part of the essential benefits

package or a rifle designation of the importance of your studies and your recommendations, but not a conclusive piece of it. that this be something which we highly recommend, that there be no cost-sharing for the grade tranforty and other recommendation. the benefits advisory committee, part of health reform come with the able to recommend through its public standards process that additional preventive services such as mammograms for women under 40 are between 40 and 49 be covered without cost-sharing. i mean, there is an additional recommendation that can come as part of the health care bill. the secretary may also affect coverage. the essential thing here is that the benefits package, essential benefits package is a floor, not exceeding. and that really is important. i want to record to state that very clearly that employer, once the exchange was into effect and there is real competition

between private insurance plans, they may wish to offer more attractive packages to win more, you know, more coverage is. so it may well be understood more fully as we go along. i just want to make sure that's in the record. but i wanted to give you even more opportunity, both of you, or one of you, to talk about what the future could hold. you see, i think this is an opportunity, a wild moment as one of the advocate groups put it. and i want to commend all of the breast cancer advocacy groups who have brought us to a level in this country where, when a recommendation, set of recommendations like yours comes out, that there is a more intelligent audience receiving it, able to understand it, and able to use it as to advocate even more. in a wide range of ways, which i think is very healthy for our

country to be a part of. i want, i'm only giving you about a minute, but i would like you to elaborate further on ways that your task force can communicate in a future in ways that maybe we can access and use more efficiently. >> well, what i thought would happen with these recommendations is that it would move the discussion more towards the notion of individualized decision-making. what i thought it might initiate a dialogue where we decided to work harder at finding out who really is at high risk so we could make more tailored recommendations for screening, and among those groups that we really have ignored our african-american women who are and women of jewish background, some of them have a very high risk, basically on the mentorship in this group. again, what i thought would happen would be a move towards individualized tailored to risk

stratified decision-making and not sort of rehashing a bunch of old data. . . >> mr. calonge would you like to add anything to that and i know i am squeezing a few more seconds. i think this is really important. >> i want to echo the issue about individualized decisionmaking. we hear a lot about personalize medicine and i think the basis of personalized medicine can be and should be individualize based decision-making and it is really what we were hoping the language for the younger age group would start engendering, this issue about we as consumers of health care should kind of understand and that every test we have and every treatment we have has both the inherent risks and benefits and we should make our decisions based on understanding those and what is important to us. >> that underscores the value of the work you do in this topic and in every other topic and the

importance of having educated in the areas of health population that can seized the material as well as primary care providers and other doctors who use your information every single day to make the kinds of informed decisions that they and their patients need to have before them so i hope this can be the beginning. i again want to thank our chairman. this is the kind of setting, this hearing setting that is so important for us to take it been a judge then use your expertise and your research and have this kind of the bate if you will, the discussion so i thank you again for your being here. >> thank you. mr. rogers. >> thank you for being here and i have some quick yes or no questions. were you familiar with the references to your task force in the bill introduced in july?

>> no. >> so, you knew nothing about the over a dozen references to your task force in this bill? >> you know, i hate to say but i was busy preparing the course and biostatistics and the answer is honestly, no. >> is that consistent to the whole task force or any of its representatives or administration there of? >> i hesitate to >> but it wasn't part of your discussion? >> in july, absolutely not. >> are you aware in this particular bill, and i think maybe the chairman was mistaken, this is not necessarily a new committee. they may create a new name. and i'll read right from the bill. the preventive services task force convened under section 750a and the task force on

preventive services, they were in existence, the day before the enactment of this act shall be transferred to the task force on clinical preventive services respectfully established under these section. and it goes on to say whatever your recommendation were prior to to enactment are in effect. are you aware of that? >> well, certainly -- >> are you aware of it? >> were you aware of that during your deliberations? >> would that have changed your deliberations at all? >> i can't speculate on what might have happened. >> interesting. so what you are saying is according to the law of which the committee is going to enact, you are taken age 40 to 49 and made them category c, which

means they won't be paid for. is every appendix is something that is reviewed by the individuals of determination. is that something of value? >> yes, all of the material and evidence is germane. >> perfect. thank you very much. are you familiar with appendix c1? what is the cost effectiveness of the screening? are you familiar with this? this clearly is a cost effectiveness portion of your study. clearly, you cannot in good conscious tell me you didn't considered cost. this is a dollar value per quality of life. and it's done on mammography screening. >> the committee -- >> will you remove this from your task force study as well as your recommendation? >> i'm sorry. but i'm trying to see what you're pointing at. >> it's appendix c1 of your own

task force recommendation that clearly considered cost just by your own testimony. again, you can see why women of america and those of us who are very concerned about bureaucracies interacting, you say that you recommend against routine screening. you may we're going to take that off. gee, we didn't consider cost. but on your own report, it says you considered cost. you can see why after 118 new commissions like your, all of your authority will be enacted into law according to the own bill. that's pretty serious. let me ask you another question. as of part of this, it says, and i'm going to read this from the bill, because i think some of my members on the other side haven't read the bill or misunderstand their own language. this is the indian health care section.

the secretary shall ensure that screening provided for under this paragraph complied, meaning you have to do it, with respect to a, frequency, b, the population to be served, and c, the procedure or technology to be used. all of which is referenced in your report. imagine that when this passes, your report now becomes a matter of law according to the language in this bill right here. would that change your consideration as a scientist knowing as by your own testimony it did not pass unanimously. you say science and evidence, but clearly people equally as learned as both of you believe this is the wrong answer. this is something that you should reconsider. >> mr. rodgers, -- >> no. i would like an answer. >> yeah. you used your five minutes. you take what's necessary to

respond. i'm not sure you know what the questions are. >> there were a number of different questions. i'm not sure which want to respond to. what i'd like to say, when we voted mammography screening a, b, c, we voted them without regard to cost effectiveness analysis. the word cost was not in the room. it was not mentioned. it was not uttered, and it did not in any way determine -- >> but it was part of your study. you just told me that everything in your study was considered, appendix c1 considers cost. >> look, mr. rogers time is up. >> i have nothing more to say. >> i'm just trying to make sure she is able to respond. we're a minute over now. she doesn't want to say anything

else. >> my only caution -- >> and i understand. >> no, i do believe the intention of the other side is real. but the language of the bill which i believe moat members of congress has not said. >> she has said she didn't know what was in the bill. they deliberations were done under the previous administration. >> the point is that the cost wasn't part of your voting. but it certainly was part of their report. that's very important knowledge when you raise questions about adding. >> you made your statement. she responded to it. let's move on. i can't help but repeat that their deliberations, as they said, even preceded the current administration. but, whatever, let's move on. next on the democratic side is the gentlewoman from the virgin

islands, ms. christiansen. is your mic not working there? >> it's on now; right? thank you. thank you for your presentation and your answers thus far. i want to go back to the issues of african-american woman. some years ago, many of us worked so that mammograms would be covered for african-american under age 40. given that even though we may have lower breast cancer, we are more than likely to be diagnosed

at later stages and have a higher mortality rate. we find the younger are more likely to be diagnosed with breast cancer. in the recommendation, why wouldn't the task force single out this particular group and maybe give them a different recommendation, rather than lumping all women between 40 and 49 or younger under c or i? >> you make an excellent point. and i think again what i expected to happen with these recommendation is that we would begin to focus on how to make more stratified and nuanced recommendation that would identify those groups who are unrecognized at being at higher risk when diagnosed at a high age. >> so even know the bill says in the health certification that

your recommendation would be applied, you might look at the native american population as a group and decide maybe a different grade for different age groups and that particular age group and make that recommendation. might that not happen? >> i think the accompanying editorial pointed in the direction that we thought we would be going. >> okay. >> you know, not congress trying to defend them. but moving to the point where we have more individualized risk. and i would say that based on my understanding of the science, which i follow very closely, that breast cancer in young african-american is a topic which is not widely appreciated as being one which perhaps needs a different kind of recommendation. again, we need to do better at the risk and individualized risk. i can't say the task forces will

immediately be able to go back. >> i understand. but you recognize it. this is not the final answer. >> this is definitely not the final answer. people would have wished that we not ever open this topic again after 2002. >> especially not right now. >> that was an accident. >> but given what occurred in response to the article and the press taking it up and how it has been interrupted, have you looked at other ways of presenting recommendation that might be controversial? i've never really liked the fact that the press really gets these advance notices. they start to tell us what is coming up in the next medical journal, because they don't really understand it. >> we communicated very poorly. we should have spent more time talking with the stakeholder groups, we should have had a former plan both to consumers and physicians. >> right.

i agree. >> can you explain how the overdiagnosis is a bit confusing. can you explain how overdiagnosis occurs when dcis especially in younger individual that is diagnosed and treated. because my understanding under dcis is likely precursor to invasive cancer. is the task force saying that it might be better to not diagnosis it or if you think it's there to leave it alone and not do further investigation or remove it? because i was thinking anxiety is one of the issues that you raise. i would think it would be more anxiety to think that i had a ca or early stage cancer and sit and wait on it rather than to have it bioopied and removed. >> here we are getting out of my

range of expertise. this is a topic that i would want to have addressed by a medical oncology. and those who are now working so hard to understand how we separate and differentiate how to progress rapidly. this is outside my area of expertise. >> speaking to medical oncology -- surgical oncologist actually yesterday. they feel it's invasive, but it's one of those things that we're overdiagnosing or overtreating. but i think my time is up. >> chairman. >> thank you, mr. chairman. i have to say you stepped into the controversy that's going forward. i think to a certain degree you've been socked into a mark

larger battle than your recommendation. as i understand, you based it on science. here's what we have concluded, it shouldn't be automatic. it should be something you think through. here's our recommendation. that makes a a lot of sense. you think it should be a decision between the patient and her doctor. if a particular patient had a history of breast cancer or cancer, then you might get screening at a younger age or some of the categories where you didn't feel it should be automatic, but under those circumstances it should occur, correct? >> yes, that is correct. >> okay. you would agree with me if the government were to prohibit an insurance plan from providing coverage for someone after consulting with their doctor or looking at the family history

thought they needed it, that would make it uninsurable event; correct? >> i am not here to get involved in the health insurance coverage issue. >> fair enough. in my view, the government should never prohibit someone and the government should never be able to prohibit someone from offering mammogram coverage or as an insurance company or public plan, nor should it be able to prohibit an individual women or her family from deciding they want to purchase mammogram coverage. i am deeply troubled that this bill which seems to be the larger context into which your work has been reported does precisely that. i do want to say that it is important, mr. chairman, that facts be a abided by. unfortunately in a piece of legislation this size, it's subject to the interpretation, and subject to quick review

without people being very precise. i want to make it very clear, i mean no personal office, but there are have been things stated in this room today that has been flat untrue. if a c option of your a and b and now a c. if a c option is determined by the secretary to be covered, it will be covered. the only way a c option can be covered under the language of the bill is for two things to happen. first, the health care benefit advisory has to say we think it should be covered. so it's not a single decision. second, the chairman of the full committee came and made an added argument that the bill prescribes minimum. minimum benefits, and therefore to say that coverage of mammograms is not prohibited is

untrue. all the bill does is prescribe minimum. that also is flat not true. if you go to page 169 of the bill passed by the congress, you will discover as i mentioned earlier that there are four levels of plan. this is a basic plans, an enhanced plan, a premium plan, and a premium plus plan. the basic plan can only cover as and bs, the thing you recommend, b and a are a b. it could cover a c if the two exceptions were to occur. but those two things happening does not cover anything but as and bs. but more important than that, the definition of enhanced plan and the definition of premium plan both prohibit any additional benefits. they say you can have an enhanced plan. and you can have lower cost sharing. you can have a premium plan, and

it can have lower cost sharing. but it can only cover the basic services. so all three of the first levels are prohibited from covering any service other than an a or a b. only until you get the definition of a premium plus plan. and i would point the chairman of the full committee to page 169 lines 20 through 25. it says a premium plus plan is a premium plan that also provides additional benefits. that's the only plan that can provide a benefit beyond the basic plan. and therefore the first three levels of plans are prohibited from covered mammograms by law, whether they are offered by the government or offered by a private insurance company in public or private, they are prohibited. that may not be the intent as the ranking member mr. barton made very clear, we need to deal with what the bill says.

if it does not reflect our intent, and i would hope in this case it doesn't. i don't think the government should be in the business of saying you cannot buy coverage for mammograms, we need to fix the language of the bill. the chairman of the committee was wrong when he said that this sets only minimums. there are words at the beginning of the bill which refer. but the words of the bill specifically say it can only cover those items with the exception of when both the secretary and the health benefits advisory committee decide to cover a c. and i appreciate the opportunity to put that into the record. thank you, mr. chairman. >> thank you. i just -- i don't want to keep belaboring the point. the reason i respond to your statement and said there were situations where the secretary and now you're saying the

advisory committee, when you made your opening statement you suggested they couldn't include it. i don't want to belabor the point. i don't disagree with you, but you are disagreeing with yourself. you said they couldn't add it. now you are saying they can. >> if the gentleman would yield. >> i didn't say they didn't add it. i said the basic plan cannot offer it. and it cannot offer it at extraordinary circumstances. >> i think the problem is we're saying the same thing. but i'm not going to get into it. i don't think there's any difference between what you said and i said. >> let's agree on that. someone cannot choose to buy a plan. let's allow people who get a public plan to get mammogram coverage. >> i'm not going to continue to belabor it. we're not disagreeing on whether

it could or could not be included. the next person is a gentlewoman from florida. >> thank you very much. i believe the larger issue is the lack of access to any screening or health service for millions of american women of all ages. and i'd like you to come upon the implications of your latest recommendations on the millions of women who are not being screened at all. what do you say to them? no matter their age? >> you know, again, the task force can't fix the problem. i'm here as a member of the task force speaking to mammography guidelines and speaking to the evidence used to make them. they are clearly huge issues facing this country about health

care and health insurance and health policy. but i'm not an expert in that area. >> if i could just add to the point that it's clear that the provision of the mammography and screening for breast cancer extents life. and so that's the service that we recommend. and i think everyone in the room knows that. and need to keep in mind that if the idea is to maximize health and extend life then the services that are recommended should be considered for revision. >> i mean your recommendations talk about how, for example, the age 40 to 49 how it is important for women and their doctors to have these personalized plan with their trusted physician. but there are many, many woman

out there who don't have a trusted physician. they don't have -- they are not receiving their checkups. certainly, y'all have something to say to women all across america no matter their age on being as proactive as they can, taking personal responsibility, finding -- you must have something to say on higher risk groups to help us communicate in a better way. you've already acknowledged that duh not do a good job in communication. here's your chance today to bring all of your expertise in to provide a message to women on the importance of taking personal responsibility. they may not have access to care. but there are wonderful nonprofit groups where they provide some services in communities. can you at least go that far and

provide a proactive message to women in this country on the importance of taking care of themselves and seeking out the screenings. >> well, again, i feel uncomfortable in being asked to put on a personal hat, rather than my task force hat. i would be remised if i didn't encourage women to be interested in their health, to take care of themselves, but i'm here as a member of the task force to speak to the mammography guideline recommendation, and not to go beyond my expertise. i have friends who have no insurance, my daughter is uninsured, i know women who are uninsured and can't get surgeries they need. but that is not my role here. my role here is to speak to the mammography guideline. >> you're familiar with the huge

disparities in screening diagnosis and treatment among various income levels and if your an african-american, latina ; correct? >> we -- there are disparities in health care throughout all services. >> the -- if you could go back or will you go back and review your recommendation along the lines of higher risk groups? what we know in disparities of screening and diagnosis and treatment, don't you think you could have done a better job in some of those recommendation? >> i think on many levels we know we can do a better job than among them is the communication. we need to -- we have tried for a number of years to make our

recommendation more risk stratified. for breast cancer, this has been perhaps a little more difficult than for some other topics. what i thought would happen with these recommendation is we would start having exactly this kind of discussion. how do we find women who are extremely high risk. how do we communicate with them effectively. how do we make screening mammography something that is more individualized and tailored. >> thank you. >> i would only add to that a plea for consideration of research of preventive services in the specific populations who are underrepresented in screening and other prevention studies. we often fail in this area. and i will inform the committee that we have a discussion about health disparities associated with nearly every recommend vote

and the frustration on our point is the lack of evidence of efficacy in a specific trial aimed at high-risk populations. so i think this is a consideration of the task force, and as we are evidence-based, this is a real plea on our part for researchers and funders of research to consider adequate studies that include different groups, but where we are on concerned there may be differents and require different recommendations. >> the gentlewoman, complete? all right.

thanks. the gentlewoman from tennessee. >> thank you, mr. chairman. i guess you are not used to women speaking a little more quickly and be p more sustained. that's why we have time left many times. i want to thank you all for your patient and your endurance today. i really want to thank you for being here. this is an issue that is of tremendous concern to you. as we look at what your findings were, and as we look at the language of the bill that is are before us, i think what we want to make certain if there is language in the bill, we want to get it out. of course we want to make person of clear understanding of what you brought forward in your intent. i'm going to try to be quick on this. dr. burgess asked that you

submit the vote from your committee as you arrived at your findings and guidance. as you submit that vote, who voted and how. one thing i would like you to do for the record is also submit to us your science or evidence upon which you based your recommendations? what was reviewed? what studies, what findings, what group? if we can have that as part of the record, i think that would be very instructive to us as we decide how to best move forward. i would like to ask y'all to do that. i'd also like to know what period of time, how long did you spend on this? how long was this up for discussion and under review? what was the thought process and the matrix that you worked from to come to this decision? let us see a little bit about

what you went through, and how you went through it. how you worked, what your process is, how you arrived at those decisions? i do honestly believe that will be helpful to us with an understanding. i will have to say i agree with some of my colleagues, you probably stepped into a bit of a quagmire that you did not expect. as you release these findings, and i'd like to ask you, were you all aware of how the hr3962, how it would affect you? how your task force would be drawn into that bill that the language of 3962 actually pulls you in, renames you, and then gives credence to these findings through statute? >> well, as unbelievable as it may seem to those who are so caught up in washington, i was writing my biostatistics

lectures, and have been actually woefully and naively oblivious of what's been going on in the health care reform arena. certainly in this point of view, the statutory language in the 2,000 page bill, i knew nothing. quite honestly when i found out that these recommendations were being released the week of the vote that was the big vote, i was sort of stunned. and then also terrified. i think my terrified was the right reaction. >> dr. calonge. >> i would like to add that it was completed prior to any sense that the role of the task force might change under upcoming health care reform.

i will say that earlier this year we became aware of language in the house bill regarding the recommendations of the task force. however, this recommendation was considered voted on with our explicit scientific methods well before that. >> okay. i appreciate that. and i do thank you y'all for your sensitivity to this. i think the linkage that exist with the language of changing your title and then giving credence and the force of law basically to the priority assignments that you would make is a concern to us and to our constituents, i thank you all. i'm only going to yield back 18 seconds, but i yield it back. >> thank you. >> i'm sorry. the gentleman from ohio, mr. spades.

-- space. >> thank you. the task force has been charged with developing a scientifically determined floor for preventive services in this bill. that your understanding of your role? >> you know, i'm realizing that i really don't understand the bill. i shouldn't speak to the bill. i've learned to say that about the bill here. >> the bill itself does invest that kind of power within the task force to develop a scientifically-determined familiar, in other words a minimum threshold under the basic coverage. those recommendations then follow to the benefits advisory committee. your recommendations will establish a floor under which the benefits advisory committee cannot go. they can go higher, however. once the benefits advisory committee, by the way, the benefits advisory committee consistents of private medical

doctors, patient, employers, a dentist, and representatives of relevant agency, it's compared by the surgeon's general. once it issues the recommendation, those recommendations are the floor. the secretary then has the discretion to increase or enhance the coverage available in the basic essential benefits package. once that has been established, private insurer have the additional option of offering more coverage. so the suggestion that because your task force has issued the recommendations that it has, no insurance policy will cover mammograms for women in these categories. even the suggestion that the essential benefits package will not cover them is preposterous. there's no truth in it. i do have a specific question

i'd like to ask you regarding the confusion that your findings have created back home in my district. there was a recent letter to the editor recording your findings. it has created some confusion. i'd ask that you try to clear this up for us. the author of this letter writes, this is a quote, what's most troubling about the recommendation is they are based main on on cost saving. they are cost-saving measures, end of quote. can you tell us today in no uncertain term what the role of cost of mammograms played in your investigation and findings? >> it's an easy question. cost played no role in our recommendation.

again, and i've said it publicly in other settings, and i'll say it again here, cost was not a consideration in the voting of our recommendations. >> thank you. and finally, the author of that same letter pointed out that the task force contains quote, no cancer specialist, end quote. this is obviously a point that would be disconcerting to many. is it true that no members of the preventive task force have any experience working with cancer? >> that -- that is incorrect. members of the task force consistent of myself, i was the vice chair of the national cancer policy board, one member is a member of the national cancer institute for the scientific counselors, another current member is a professor, let's see he's the associate

director of population sciences for the dartmouth-hitchcock comprehensive cancer center. again, the members of the task force has the expertise in that that -- that permits them to make the kinds of recommendations they made within the arena of screening and preventive services. >> thank you, doctor, i yield back my time. >> thank you, the gentleman from texas, mr. green. >> thank you, mr. chairman. i'll be as quick as i can. i want to welcome our doctors. i guess having served on the subcommittee for 12 years now. the release from the uspgf probably got more coverage than anything our subcommittee's done expect the health care bill. and there was a lot of misinformation about it. in your testimony you say that individuals representing the

views of the obstetricians weighed in and the obstetricians and gynecologist had concerns. do you believe it would have seals in the organization such as these are actual reviewer instead of commenters? >> well, i would to clarify that they were official reviewers. first of all, there were two members of the american obstetrician and gynecologist on the panel. they were official reviewers. they made a number of comments, one of their comments which was the most substive comment was about the anticipation of misperception of our c recommendation. and they were right. we should have listened more

carefully to them. i'm sure we will listen more carefully in the future. i think there's misinformation on the self-exact. from what your testimony earlier, physicians need to be able to provide the expertise on so women can do the self-examine. it's not perfect. if there's a question, they ought to talk to their physician. that's where it goes from there. that's why i don't understand the fear of the self-examine. my last question is major concern of the lack of transparency of the process for deciding whether or not to change or create new screening recommendation. depending on what happens with the health care bill, your initial decision would with make a big difference. how would the task force be more open, and what changes would you make in the future after what you've learned from this experience? >> thank you for your question.

the task force understands the criticism regarding transparency. as our profile has been increased during the discussion of health care reform, we believe it is incumbent upon us, as they asked how we get to the decisions that we get to. the task force is already working on new transparency approaches, including allowing internet-based public comment on different work products. we think that's a good step. we are cautiously trying to expand into areas of transparency to include potentially although commentary during meetings and other approaches that we believe meet the intent and requirement so that the decisions are made in such a way that we're not spending time in front of the

public trying to help people understand the processes. so we understand its criticism. we actually started working on enhancing transparency about a year and a half ago. i will only tell the congressman that our slow working has to do with understanding the resource impact of becoming more transparent. but we absolutely believe we need to do it. and we're working towards that end. >> thank you. >> thank you. and i think that concludes our questions. let me just thank both of you really. i think that you did a tremendous job today of clearing up a lot of misunderstandings. and as someone who's been in politics, i guess i could say my entire life, i think it's kind of refreshing to find out that, you know, you really were very independent and not aware at all of what we were doing.

we give ourselves too much importance. we think everybody is paying so much attention to everything we do. kind of refreshing to know that you were not. thank you, and i'll ask the next panel to come forward. [silence] >> let me welcome our second panel and introduce the panel beginning on my left. it is dr. otis webb brawley, who is chief medical for the american cancer society, next is

jennifer luray who is president of the susan g. komen for the cure advocacy alliance, and then we have dr. donna sweet, and finally fran visco who is president of the national breast cancer coalition. as some of you have been here before. thank you for being here. i won't repeat, we ask you to it keep your comments to five minutes. they become part of the record. if you want to, you can submit additional written comments later. let's start with dr. brawley, thank you. >> good afternoon, mr. chairman and distinguished members. on behalf of the 11 million patients and survivors in america today, the society thanks you for your continued leadership in your fight against cancer and your commitment to

act in legislation this year. i appreciate the opportunity to testify today about the important role that mammograms play in combating breast cancer deaths. as a medical oncologist who treats breast cancer patients, i've treated hundreds of breast cancer patient in my career indeed. i have observed first hand the heartbreak this disease has on women and the their families. over thes years, i've witnessed the advances in breast cancer. i can't help but note that in our current system, our society prohibits with a large number of women, 30 to 40% of those who should be getting mammograms from actually getting mammograms. i also have to note that my own research published and sited have uninsured women of the same

share have poor survival to insured women of the same stage. mr. chairman, as you know, the society in recent weeks have disagreed with the u.s. services task force with respect to mammography. let me say right now that i have tremendous respect for the task force. as an academic physician, i look forward to everything that the task force has published over the last 20 years regarding cancer. i also want to say that experts can look at science and disagree. there is useful screening that should be done, and useless screening that actually can be harmful. and that is something that the task force, i think, should be looking at in an objective fashion. it is generally done a very good job of doing. with respect to mammography, the scientific evidence supporting its value in reducing deaths from breast cancer is quite

strong. in looking at the evidence, the society along with other medical groups believe that screening mammography offers an identifiable and important survival benefit to women in the age group, 40-4-9d and women age 40 and above. more specifically, the society believes that the reduction in mortality associated with early detection of breast cancer continues to warrant a recommendation of annual screening for all women, beginning at the age of 40. we do agree with the task force that women should be informed of the potential risk as well as the potential benefits of the procedure. the data and literature examined by the task force in the lead up is essentially the same data reviewed by an expert panel of researchers, clinicians, and open deemologist. however, in that earlier review,

the society's panel considered the additional findings of a population-based study of modern mammography which showed much stronger with thes compared with more limited data examined by the task force. translated, we think there's a greater benefit to the mammography screening than does the task force. addition, since that time, a number of advancements that have emerged to increase the effectiveness for mammography for women with age 40 to 49. there have been improvemented resulting from the mammography standards act or mqsa. there's been a shift from individual mammograms over film mammograms, which maybe important in younger women with denser breast. the technology has also proven to be a particularly effective tool in high-risk women. let me be clear on the next

point. we understand and acknowledge that mammography screening is not a perfect test. indeed, it is an imperfect test. but we also believe that this imperfect test is the only good test own awareness of ones breast to help save lives at this time. we can, and we must invest in research to find better tools for detecting and treating breast cancer. women deserve a better test than mammography. indeed, one a great problems is there's a satisfaction with mammography. we need a better test. mammography is one of the two ways that we can use to save lives. i have to note that there's been a lot of talk about breast self-examine. as a medical oncologist and a

doctor who treats, let me say we've been talking past ourselves. i want to talk about the breast self-examine today. breast self-examine is shown and is women doing a exam once a month. it would take about 20 to 30 minutes for a women to do. what most of us have done is moved away from that regimented breast self-exam which was advocated 20 to 30 years ago toward something that is a little bit different. which is women being aware of their breast and being aware of their breast and looking for differences in their breast on an almost daily basis. this is called breast awareness. most women indeed find their breast cancer through breast self-exam. there are two randomized clinical trials that show that breast awareness and self-exam

are equivalent. but breast self-exam actually increases the number of biopsies done. so i prefer to advocate breast awareness. it is also approximately 30 to 40% of american women are not getting record mammograms. in the united states, about half of all women are are diagnosed through the breast awareness. for many of the women who cannot get mammography, this is the only way that they can have any type of early detection. in summing up, we know we can do better. we are heading in the right direction with your help. the act recently passed by the house will improve health care, and it provides a significant investment in cancer prevention and early detection be requiring

first dollar coverage in public and private plans with little or no cost to patient. the society and its affiliate, the american cancer society -- >> doctor, i think you are concluding. you are two and a half minutes over. >> i'm sorry. we strongly support the changes that you've made in the legislation that will help the task force improve the transparency and inclusiveness of its operation. let me just stop at that point and say thank you for asking me to appear here. >> thank you. ms. luray? >> thank you, mr. chairman, mr. ranking member, and members of the committee, thank you for the opportunity to testify about the recommendations of the u.s. preventive task force. my name is jennifer luray, i'm president for the susan g. komen advocacy ai -- alliance.

thank you for holding the hearing. i also want to thank the past panel for their honesty. breast cancer expert agree far more than they disagree. this is a point that we have stressed since the task force recommendations were first released. there is no debate that mammography reduces the risk from dying, only the debate over the timing and frequency of mammography. we don't want women to react as a reason not to get screened. komen in consultation with our scientific advisory board is not changing our screening recommendations at this time. we continue to recommend that women be aware of their breast health, understand their risk, and continue to following existing screening recommendation, including mammography beginning at age 40, and earlier for women with known risk of breast cancer. as you can imagine, komen

affiliated have been concerned about mammography. many comments have come from breast cancer survivor who are diagnosed before the age of 50. this is a very typical one. i was 46 years old when i went in for my annual. i was stage two. if not for the mammogram, i would have had much more advance cancer. we know it's not perfect. but instead of stepping aa way way -- away from it, we must close the technology gaps and come up with better method. we must work together, government, private industry, doctors, and patient advocates, to deliver technology that is more predictive, and personalized, but less expensive. next year, komen will host the national technology summit. we ask nih to help us with the

advancement they've made on screening technology. let us also double our efforts on behalf of 1/3 of women who are not being screened due to lack of access, education, or awareness. we partner closely with the cdc early detection program to fund free clinics and mobile vans. half of eligible women for this program do not receive screening. that's a disturbing finding that underscores the need for affordable insurance to eliminate the health disparities. it would prevent insurance companies from denying coverage, protect patients from high out-of-pocket cost. and in light of the new task force recommendations, however, we must ensure that women ages

40 to 49 will have access to same coverage and cost-sharing benefits. even a relatively small copayment reduces mammography rates. we do understand that hr3962 willeeuate a new entity which would not be bound by the task forces guidelines, and that the bill does not exclude services that are not rated a and b. we understand the task force recommend are a floor not a ceiling. women in the 40-49 age choose after consulting with their doctor choose to forego, but those who go choose to have one, must have access on the same terms as women 50 and older. it's pleased that hr3962 includes patient representative advisers to the task force on clinical preventive services. we believe patients can help to

develop and deliver effective messages about prevention and screening. we hope that the past few weeks of confusion will ultimately result in women taking more interest in their breast health. that many more underserved women will be screened, and that. in intensive efforts will begin anew. thank you, mr. chairman. >> thank you. mr.dr. sweet? >> good afternoon, and thank you, chairman, for this opportunity. i'm donna sweet, i'm pleased to present the testimony. i'm a member of the apc subcommittee which oversaw sees the development of acp's government-based guidelines. and i provide comprehensive medical care to hundreds of patients in the state of kansas. because acp does not comment, i am unable to express an acp opinion of the task force

recommendation. but i can speak to the college's own guideline on screening women ages 40 to 49 which was published in 2007. we recommend they should inform individualized assessment to help guide decisions. inform women about the potential benefits and harms of mammography, and base screening mammography decisions on benefits and harms of screening, as well as a women's preferences and her own breast cancer risk profile. the purpose of acp is to facilitate an informed between the patient and her clinician, so together they can decide on a personalized plan of screening, diagnosis, and treatment. not all women have the same risk for breast cancer. factor that increase include older age, older age at the time of first birth, and history of biopsy.

in my own practice, i engaged my female patient in a discussion. i explained although a valuable tool is an imperfect one. for some patient it will detect cancer at a more treatable trade. it can also lead to false positives. it can lead to false negatives. this is it does miss cancers. just in the past three days i've had three different patients comes to see me who has been extremely confused over this whole issue. i was able to speak to each women's risk profile and discuss with them the benefits and harms. one was a 66 year old patient enrolled in medicare who have come in for hypertension, and clearly misunderstood most of the debate. she has a history of a sister. we have been doing yearly