Medicaid
Source of Screening Affects Women's Eligibility for Coverage of Breast and Cervical Cancer Treatment in Some States Gao ID: GAO-09-384 May 22, 2009Tens of thousands of women die each year from breast or cervical cancer. While screening and early detection through mammograms and Pap tests--followed by treatment--can improve survival, low-income, uninsured women are often not screened. In 1990, Congress authorized the Centers for Disease Control and Prevention (CDC) to fund screening and diagnostic services for such women, which led CDC to establish the National Breast and Cervical Cancer Early Detection Program. The Breast and Cervical Cancer Prevention and Treatment Act of 2000 was also enacted to allow states to extend Medicaid eligibility to women screened under the Early Detection Program and who need breast or cervical cancer treatment. Screened under the program is defined, at a minimum, as screening paid for with CDC funds. GAO examined the Early Detection Program's screening of eligible women, states' implementation of the Treatment Act, Medicaid enrollment and spending under the Treatment Act, and alternatives available to women ineligible for Medicaid under the Treatment Act. To do this, GAO compared CDC data on women screened by the Early Detection Program from 2002 to 2006 with federal estimates of the eligible population, surveyed program directors on the 51 states' (including the District of Columbia) implementation of the Treatment Act, analyzed Medicaid enrollment and spending data, and conducted case studies in selected states.
The CDC's Early Detection Program providers screen more than half a million low-income, uninsured women a year for breast and cervical cancer, but many eligible women are screened by other providers or not screened at all. Comparing CDC screening data with federal estimates of low-income, uninsured women, GAO estimated that from 2005 through 2006, 15 percent of eligible women received a mammogram from the Early Detection Program, while 26 percent were screened by other providers and 60 percent were not screened. For Pap tests, GAO estimated that from 2004 through 2006, 9 percent were screened by the program, 59 percent by other providers, and 33 percent were not screened. Most states extend Medicaid eligibility under the Treatment Act to more women than is minimally required. As of October 2008, 17 states met the minimum requirement to offer Medicaid eligibility to women whose screening or diagnostic services were paid for with CDC funds; 15 extended eligibility to women screened or diagnosed by a CDC-funded provider, whether CDC funds paid specifically for these services or not; and 19 states further extended eligibility to women who were screened or diagnosed by a non-CDC-funded provider. In most of the states that offer Medicaid eligibility only to women served with CDC funds or by a CDC-funded provider, if a woman is screened and diagnosed with cancer outside the Early Detection Program, she cannot access Medicaid coverage under the Treatment Act. Medicaid enrollment and average spending under the Treatment Act vary across states. In 2006, state enrollment ranged from fewer than 100 women to more than 9,300. Median enrollment was 395 among the 39 states reporting data, with most experiencing enrollment growth from 2004 to 2006. Among the 39 states, average monthly spending per enrollee was $1,067, ranging from $584 to $2,304. Spending may vary due to several factors, including differences in state eligibility policies and practices and Medicaid benefit plan design. Few statewide alternatives to Medicaid coverage are available to low-income, uninsured women who need breast or cervical cancer treatment but are ineligible for Medicaid under the Treatment Act. Early Detection Program directors in only four of the states with more limited eligibility standards reported having a statewide program that pays for cancer treatment or provides broader health insurance or free or reduced-fee care. And while several sources identified possible local resources as alternatives--donated care, funding from local charity organizations, and county assistance--the availability and applicability of these resources varies by area. For example, an Early Detection Program official in Indiana told us that densely populated areas of the state had multiple treatment resources, but women living in rural areas had limited access to them.
GAO-09-384, Medicaid: Source of Screening Affects Women's Eligibility for Coverage of Breast and Cervical Cancer Treatment in Some States
This is the accessible text file for GAO report number GAO-09-384
entitled 'Medicaid: Source of Screening Affects Women's Eligibility for
Coverage of Breast and Cervical Cancer Treatment in Some States' which
was released on June 22, 2009.
This text file was formatted by the U.S. Government Accountability
Office (GAO) to be accessible to users with visual impairments, as part
of a longer term project to improve GAO products' accessibility. Every
attempt has been made to maintain the structural and data integrity of
the original printed product. Accessibility features, such as text
descriptions of tables, consecutively numbered footnotes placed at the
end of the file, and the text of agency comment letters, are provided
but may not exactly duplicate the presentation or format of the printed
version. The portable document format (PDF) file is an exact electronic
replica of the printed version. We welcome your feedback. Please E-mail
your comments regarding the contents or accessibility features of this
document to Webmaster@gao.gov.
This is a work of the U.S. government and is not subject to copyright
protection in the United States. It may be reproduced and distributed
in its entirety without further permission from GAO. Because this work
may contain copyrighted images or other material, permission from the
copyright holder may be necessary if you wish to reproduce this
material separately.
Report to Congressional Requesters:
United States Government Accountability Office:
GAO:
May 2009:
Medicaid:
Source of Screening Affects Women's Eligibility for Coverage of Breast
and Cervical Cancer Treatment in Some States:
GAO-09-384:
GAO Highlights:
Highlights of GAO-09-384, a report to congressional requesters.
Why GAO Did This Study:
Tens of thousands of women die each year from breast or cervical
cancer. While screening and early detection through mammograms and Pap
tests”followed by treatment”can improve survival, low-income, uninsured
women are often not screened. In 1990, Congress authorized the Centers
for Disease Control and Prevention (CDC) to fund screening and
diagnostic services for such women, which led CDC to establish the
National Breast and Cervical Cancer Early Detection Program. The Breast
and Cervical Cancer Prevention and Treatment Act of 2000 was also
enacted to allow states to extend Medicaid eligibility to women
screened under the Early Detection Program and who need breast or
cervical cancer treatment. Screened under the program is defined, at a
minimum, as screening paid for with CDC funds.
GAO examined the Early Detection Program‘s screening of eligible women,
states‘ implementation of the Treatment Act, Medicaid enrollment and
spending under the Treatment Act, and alternatives available to women
ineligible for Medicaid under the Treatment Act.
To do this, GAO compared CDC data on women screened by the Early
Detection Program from 2002 to 2006 with federal estimates of the
eligible population, surveyed program directors on the 51 states‘
(including the District of Columbia) implementation of the Treatment
Act, analyzed Medicaid enrollment and spending data, and conducted case
studies in selected states.
What GAO Found:
The CDC‘s Early Detection Program providers screen more than half a
million low-income, uninsured women a year for breast and cervical
cancer, but many eligible women are screened by other providers or not
screened at all. Comparing CDC screening data with federal estimates of
low-income, uninsured women, GAO estimated that from 2005 through 2006,
15 percent of eligible women received a mammogram from the Early
Detection Program, while 26 percent were screened by other providers
and 60 percent were not screened. For Pap tests, GAO estimated that
from 2004 through 2006, 9 percent were screened by the program, 59
percent by other providers, and 33 percent were not screened.
Most states extend Medicaid eligibility under the Treatment Act to more
women than is minimally required. As of October 2008, 17 states met the
minimum requirement to offer Medicaid eligibility to women whose
screening or diagnostic services were paid for with CDC funds; 15
extended eligibility to women screened or diagnosed by a CDC-funded
provider, whether CDC funds paid specifically for these services or
not; and 19 states further extended eligibility to women who were
screened or diagnosed by a non-CDC-funded provider. In most of the
states that offer Medicaid eligibility only to women served with CDC
funds or by a CDC-funded provider, if a woman is screened and diagnosed
with cancer outside the Early Detection Program, she cannot access
Medicaid coverage under the Treatment Act.
Medicaid enrollment and average spending under the Treatment Act vary
across states. In 2006, state enrollment ranged from fewer than 100
women to more than 9,300. Median enrollment was 395 among the 39 states
reporting data, with most experiencing enrollment growth from 2004 to
2006. Among the 39 states, average monthly spending per enrollee was
$1,067, ranging from $584 to $2,304. Spending may vary due to several
factors, including differences in state eligibility policies and
practices and Medicaid benefit plan design.
Few statewide alternatives to Medicaid coverage are available to low-
income, uninsured women who need breast or cervical cancer treatment
but are ineligible for Medicaid under the Treatment Act. Early
Detection Program directors in only four of the states with more
limited eligibility standards reported having a statewide program that
pays for cancer treatment or provides broader health insurance or free
or reduced-fee care. And while several sources identified possible
local resources as alternatives”donated care, funding from local
charity organizations, and county assistance”the availability and
applicability of these resources varies by area. For example, an Early
Detection Program official in Indiana told us that densely populated
areas of the state had multiple treatment resources, but women living
in rural areas had limited access to them.
Commenting on a draft of this report, the Department of Health and
Human Services concurred with GAO‘s findings.
To view the full product, including the scope and methodology, click on
[hyperlink, http://www.gao.gov/products/GAO-09-384]. For more
information, contact James Cosgrove at (202) 512-7114 or
cosgrovej@gao.gov.
[End of section]
Contents:
Letter:
Background:
CDC's Early Detection Program Screens More Than Half a Million Women
Annually, but Many Eligible Women Are Not Screened:
Most States Extend Medicaid Eligibility to More Women Than the Minimum
Required, but Some Women Are Still Excluded Based on Screening Source:
Medicaid Enrollment and Spending under the Treatment Act Vary across
States:
Few Statewide Alternatives to Medicaid Coverage for Treatment Are
Available to Low-Income, Uninsured Women; Local Resources Offer
Assistance in Some Areas:
Agency Comments:
Appendix I: Scope and Methodology:
Appendix II: Number of Women Screened by National Breast and Cervical
Cancer Early Detection Program Grantees, 2002-2006:
Appendix III: Medicaid Breast and Cervical Cancer Prevention and
Treatment Act Enrollment and Spending, 2006:
Appendix IV: Comments from the Department of Health and Human Services:
Appendix V: GAO Contact and Staff Acknowledgments:
Table:
Table 1: Medicaid Enrollment under the Treatment Act by State, Ranked
by 2006 Enrollment:
Figures:
Figure 1: Age of Women Receiving Mammograms or Pap Tests from the Early
Detection Program, 2002 through 2006:
Figure 2: Race and Ethnicity of Women Receiving a Screening from the
Early Detection Program, 2002 through 2006:
Figure 3: Percentage of Eligible Women 40 to 64 Years Old Who Received
a Mammogram, 2005 through 2006:
Figure 4: Percentage of Eligible Women 18 to 64 Years Old Who Received
a Pap Test, 2004 through 2006:
Figure 5: State Definitions of "Screened under the Program" for
Purposes of Medicaid Eligibility, October 2008:
Figure 6: Average Monthly Medicaid Spending per Treatment Act Enrollee
by State, 2006:
Abbreviations:
CDC: Centers for Disease Control and Prevention:
CMS: Centers for Medicare & Medicaid Services:
FPL: federal poverty level:
HHS: Department of Health and Human Services:
MDE: Minimum Data Elements:
MEPS: Medical Expenditure Panel Survey:
MSIS: Medicaid Statistical Information System:
[End of section]
United States Government Accountability Office:
Washington, DC 20548:
May 22, 2009:
The Honorable Max Baucus:
Chairman:
Committee on Finance:
United States Senate:
The Honorable Barbara A. Mikulski:
United States Senate:
The Honorable Debbie Stabenow:
United States Senate:
In 2008, an estimated 182,000 women were diagnosed with breast cancer
and 40,000 women died from the disease. In addition, an estimated
11,000 women were diagnosed with and 4,000 women died from cervical
cancer. Screening and early detection through mammography and Pap tests
to detect breast and cervical cancer--followed by treatment--can
improve survival. But among low-income, uninsured women, such screening
is underused and access to treatment is sometimes difficult. To improve
access to screening, in 1990 Congress authorized the Centers for
Disease Control and Prevention (CDC) to make grants to states[Footnote
1] for breast and cervical cancer screening services, which led the CDC
to establish the National Breast and Cervical Cancer Early Detection
Program (the Early Detection Program).[Footnote 2],[Footnote 3]
Subsequently, the Breast and Cervical Cancer Prevention and Treatment
Act of 2000 (the Treatment Act) was enacted, which allowed states to
offer Medicaid coverage to uninsured women under the age of 65 who were
screened under the Early Detection Program and who need treatment for
breast or cervical cancer.[Footnote 4] The CDC and the Centers for
Medicare & Medicaid Services (CMS), which administers the Medicaid
program, define what it means to be screened under the Early Detection
Program. States electing to provide Medicaid coverage under the
Treatment Act must, at a minimum, offer eligibility to women who
received screening services paid for, at least in part, with CDC funds.
But states have additional flexibility. For example, a state may extend
eligibility to women screened by providers such as community health
centers or family planning clinics, regardless of whether the providers
receive CDC funds.
Because of concerns that low-income, uninsured women living in certain
states may still have difficulty accessing and paying for treatment
services, you asked us to report on the impact of the Early Detection
Program and the implementation of the Treatment Act. In this report, we
examine (1) how many eligible women have been screened by the Early
Detection Program; (2) how states have implemented the Treatment Act;
(3) how many women have enrolled in Medicaid under the Treatment Act
and the average spending by state for this coverage; and (4)
alternatives available to low-income, uninsured women who need
treatment for breast or cervical cancer, but are not covered under the
Treatment Act.
To determine how many eligible women have been screened by the Early
Detection Program,[Footnote 5] we analyzed information from the CDC's
Minimum Data Elements (MDE)[Footnote 6] on the number of women screened
by the program from 2002 through 2006. We then compared this
information with estimates from the Medical Expenditure Panel Survey
(MEPS)[Footnote 7] on the number of low-income, uninsured
women[Footnote 8] who would likely be eligible for screening by the
Early Detection Program, and with the overall number of women who
received a mammogram or a Pap test within the recommended screening
interval (2 years for a mammogram, 3 years for a Pap test).
To determine how states have implemented the Treatment Act, we
conducted a Web-based survey of Early Detection Program directors in
the 51 states. We determined that the Early Detection Program directors
were knowledgeable about their states' Medicaid eligibility policies
and practices regarding the Treatment Act based on preliminary
interviews and discussions with the CDC.
To determine how many women have enrolled in Medicaid under the
Treatment Act, we analyzed data from CMS's Medicaid Statistical
Information System (MSIS).[Footnote 9] Data on Treatment Act enrollment
were not available for all states and all years. Data are presented for
2004 (38 states) and 2006 (39 states). To determine the average
spending by state for providing coverage under the Treatment Act, we
analyzed CMS's MSIS data on Medicaid spending for women under the
Treatment Act. As with enrollment data, these data were not available
for all states and all years. Spending data are presented for 39 states
reporting data for 2006.
To identify alternatives available to low-income, uninsured women who
need treatment for breast or cervical cancer, but who are not covered
under the Treatment Act, we obtained general information from our Web-
based survey of Early Detection Program directors. For a more in-depth
understanding of these alternatives, we conducted case studies of three
states: Florida, Indiana, and Virginia. These states were selected
because they are among the states that do not extend Medicaid
eligibility under the Treatment Act beyond the minimum, women whose
screening services were paid for with CDC funds. These states also have
low rates of low-income, uninsured women screened for breast and
cervical cancer by the Early Detection Program when compared to the
national average. In each state, we interviewed Early Detection Program
directors and other officials,[Footnote 10] representatives of cancer
advocacy groups such the American Cancer Society and Susan G. Komen for
the Cure (Komen for the Cure),[Footnote 11] and other relevant
organizations and providers. For more information on our methodology,
see appendix I.
We conducted our work from May 2008 to May 2009 in accordance with all
sections of GAO's Quality Assurance Framework that are relevant to our
objectives. The framework requires that we plan and perform the
engagement to obtain sufficient and appropriate evidence to meet our
stated objectives and to discuss any limitations in our work. We
believe that the information and data obtained, and the analysis
conducted, provide a reasonable basis for any findings and conclusions.
Background:
The Early Detection Program is implemented through cooperative
agreements between the CDC and 68 grantees--health departments in the
50 states, the District of Columbia, and the 5 U.S. territories, as
well as 12 American Indian/Alaska Native tribal organizations. The
program funds breast and cervical cancer screening services for women
who are uninsured or underinsured, have an income equal to or less than
250 percent of the federal poverty level (FPL),[Footnote 12] and are
aged 40 through 64 for breast cancer screenings or aged 18 through 64
for cervical cancer screenings. Within these eligibility criteria, CDC
prioritizes certain groups for screening and individual program
grantees may target certain groups or broaden eligibility.[Footnote 13]
Breast cancer screening consists of clinical breast exams and
mammograms. Cervical cancer screening consists of pelvic exams and the
Pap test.[Footnote 14],[Footnote 15] While screening services represent
the core of the Early Detection Program, program providers must also
provide diagnostic testing and follow-up services for women whose
screening tests are abnormal. The CDC funds cannot be used to pay for
treatment; however, for women diagnosed with breast or cervical cancer,
program providers must provide referrals for appropriate treatment
services and case management services, if determined necessary.
The Early Detection Program, which was reauthorized by Congress in
2007, is funded through annual appropriations to the CDC. According to
CDC officials, in fiscal year 2008, total funding for the program was
approximately $182 million. To implement the program, the CDC solicits
applications to select Early Detection Program grantees every 5 years.
All grantees must submit an annual request for funding to CDC.
According to CDC officials, annual budgets are awarded based on
performance and other factors. By law, grantees must match every $3 in
federal contribution with at least $1 in non-federal contribution.
[Footnote 16] Grantee matching funds may support the screening or non-
screening components of the program. At least 60 percent of the awarded
funds must be used for direct clinical services;[Footnote 17] the
remainder may be used for other program functions including program
management, education, outreach, quality assurance, surveillance, data
management, and evaluation. Some grantees have also acquired additional
state or local resources for their programs. Early Detection Program
grantees typically have a network of local providers such as community
health centers and private providers that deliver the screening and
diagnostic services to women.
Under the Treatment Act states may extend Medicaid eligibility to women
who are under age 65, uninsured,[Footnote 18] otherwise not eligible
for Medicaid, and who have been (1) screened under the CDC-funded Early
Detection Program and (2) found to be in need of treatment for breast
or cervical cancer including precancerous conditions.[Footnote 19] All
51 states chose to implement this optional Medicaid eligibility
category.[Footnote 20] In doing so they were required to provide full
Medicaid coverage to eligible women screened under the Early Detection
Program and found in need of treatment for breast or cervical cancer.
States must provide Medicaid coverage for the period when the woman
needs treatment for breast or cervical cancer.[Footnote 21] In guidance
provided to states, CMS and CDC define "screened under the program" as,
at a minimum, offering Medicaid eligibility to women whose clinical
services under the Early Detection Program were provided all or in part
with CDC funds. Accordingly, CDC officials stated that any state
offering Medicaid coverage under the Treatment Act would be required,
at a minimum, to offer coverage to women screened with CDC funds,
provided the women met all other eligibility requirements. The guidance
also allows states to use a broader definition of "screened under the
program," which includes extending Medicaid eligibility to (1) women
screened by a CDC-funded provider within the scope of the state's Early
Detection Program, even if CDC funds did not pay for the particular
service, or (2) women screened by a non-CDC-funded provider whom the
state has elected to include as part of its Early Detection Program.
[Footnote 22]
CDC's Early Detection Program Screens More Than Half a Million Women
Annually, but Many Eligible Women Are Not Screened:
The CDC's Early Detection Program screened about half a million or more
women for breast and cervical cancer annually from 2002 through 2006.
[Footnote 23] In 2006, the program screened 579,665 women. There were
331,672 women screened with mammography and 4,026 breast cancers
detected. There were 350,202 women screened with a Pap test and 5,110
cervical cancers and precursor lesions detected. Almost half of all
women screened by the Early Detection Program in 2006 were screened by
grantees in 10 states.[Footnote 24] (See appendix II for information by
grantee.) A number of factors determined how many women were screened
by a grantee, including the CDC funding awarded, the availability of
other resources, and clinical costs (for example, the use of more
costly screening technologies such as digital mammography).
Over the 5-year period from 2002 through 2006, the Early Detection
Program screened 1.8 million low-income, uninsured women. About 1.1
million women were screened for breast cancer, and 18,937 breast
cancers were detected. Similarly, about 1.1 million women were screened
for cervical cancer, and 22,377 cervical cancers and precursor lesions
were detected. The age and race of women screened reflect the Early
Detection Program's policies that prioritize breast cancer screening
for women 50 to 64 years old[Footnote 25] and cervical cancer screening
for women 40 to 64 years old.[Footnote 26] Thus, women who received a
mammogram tended to be older, with 71 percent age 50 or older. Women
who received a Pap test tended to be younger, with 55 percent under age
50. (See figure 1.) The program also targets racial and ethnic
minorities, who tend to have lower screening rates for breast and
cervical cancer, so more than half the women screened were racial or
ethnic minorities. (See figure 2.)[Footnote 27]
Figure 1: Age of Women Receiving Mammograms or Pap Tests from the Early
Detection Program, 2002 through 2006:
[Refer to PDF for image; two pie-charts]
Mammograms:
Age: under 40: 2%;
Age: 40-49: 28%;
Age: 50-59: 51%;
Age: 60-54: 17%;
Age: 65 and over: 3%.
Pap tests:
Age: under 40: 18%;
Age: 40-49: 37%;
Age: 50-59: 33%;
Age: 60-54: 10%;
Age: 65 and over: 1%.
Source: GAO analysis of CDC MDE data.
Notes: Women aged 40-64 are eligible for breast cancer screening and
women aged 18-64 are eligible for cervical cancer screening by the
Early Detection Program. Some grantees screened women under age 18
years if they were symptomatic or women aged 65 or older if they lacked
resources to obtain a screening elsewhere. Percentages do not add to
100 due to rounding.
[End of figure]
Figure 2: Race and Ethnicity of Women Receiving a Screening from the
Early Detection Program, 2002 through 2006:
[Refer to PDF for image: pie-chart]
American Indian/Alaskan Native: 4%;
Asian/Pacific Islander: 6%;
Unknown/Multiracial: 3%;
Hispanic: 33%;
White: 41%;
Black: 14%.
Source: GAO analysis of CDC MDE data.
Notes: Race and ethnicity are self-reported by participants.
Percentages do not add to 100 due to rounding.
[End of figure]
The Early Detection Program screened a small share of all eligible, low-
income, uninsured women, but some eligible women sought screenings from
other providers and many were not screened at all.[Footnote 28] From
2005 through 2006, we estimated that the Early Detection Program
provided mammograms to about 15 percent of eligible women 40 to 64
years old in the recommended 2-year period. About 26 percent received a
mammogram from other providers, such as free clinics and mobile vans.
The remaining 60 percent of eligible women did not receive a mammogram
from any provider. (See figure 3.) According to CDC officials, women do
not receive mammograms for a variety of reasons, including a lack of
insurance, high personal costs such as deductibles and co-pays, fear of
painful procedure, fear of having cancer, lack of knowledge about need
for screening or recommended screening intervals, inadequate provider
capacity, and a lack of accessibility to services in geographically
isolated areas.
Figure 3: Percentage of Eligible Women 40 to 64 Years Old Who Received
a Mammogram, 2005 through 2006:
[Refer to PDF for image: pie-chart]
Screened by Early Detection Program: 15%;
Screened by other providers: 26%;
Not screened: 60%.
Source: GAO analysis of CDC MDE data.
Notes: Eligible is defined as low income (at or below 250 percent of
the FPL) and uninsured. Since MEPS does not include women living in the
tribes or territories, the percentage of women screened with a
mammogram by the Early Detection Program represents those women
screened by the 51 state program grantees. Percentages do not add to
100 due to rounding.
[End of figure]
From 2004 through 2006, we estimated that the Early Detection Program
provided Pap tests to about 9 percent of eligible low-income, uninsured
women 18 to 64 years old in the recommended 3-year period. About 59
percent were screened by other providers, such as family planning
clinics. (See figure 4.) The remaining 33 percent of eligible women did
not receive a Pap test from any provider. Women do not receive Pap
tests for reasons similar to those for not receiving a mammogram.
Figure 4: Percentage of Eligible Women 18 to 64 Years Old Who Received
a Pap Test, 2004 through 2006:
[Refer to PDF for image: pie-chart]
Screened by Early Detection Program: 9%;
Screened by other providers: 59%;
Not screened: 33%.
Notes: Eligible is defined as low income (at or below 250 percent of
the FPL) and uninsured. Since MEPS does not include women living in the
tribes or territories, the percentage of women screened with a Pap test
by the Early Detection Program represents those women screened by the
51 state program grantees. Percentages do not add to 100 due to
rounding.
[End of figure]
Most States Extend Medicaid Eligibility to More Women Than the Minimum
Required, but Some Women Are Still Excluded Based on Screening Source:
Most states extend Medicaid eligibility under the Treatment Act to more
women than is minimally required--those whose screening or diagnostic
services were paid for with CDC funds. As of October 2008, 17 states
reported applying only this minimum definition in determining Medicaid
eligibility under the Treatment Act. Of the states that extend
eligibility, 15 states extend Medicaid eligibility to women served by a
CDC-funded provider, whether or not CDC funds were used to pay for
services. The remaining 19 states further extend eligibility to women
who were screened and diagnosed by non-CDC-funded providers. (See
figure 5.)
Figure 5: State Definitions of "Screened under the Program" for
Purposes of Medicaid Eligibility, October 2008:
[Refer to PDF for image: map of the United States]
Offer eligibility to women screened and diagnosed with CDC funds only
(17 states):
Colorado:
Connecticut:
District of Columbia:
Florida:
Hawaii:
Idaho:
Indiana:
Minnesota:
Missouri:
Montana:
Nevada:
New Mexico:
North Carolina:
Oregon:
South Dakota:
Virginia:
Wyoming:
Extend eligibility to women screened or diagnosed by a CDC-funded
provider (15 states):
Alabama:
Alaska:
Arizona:
Delaware:
Kansas:
Kentucky:
Louisiana:
Maine:
Maryland:
Mississippi:
New Hampshire:
New Jersey:
North Dakota:
Ohio:
Vermont:
Extend eligibility to women screened or diagnosed by a CDC-funded or
non-CDC-funded provider (19 states):
Arkansas:
California:
Georgia:
Illinois:
Iowa:
Massachusetts:
Michigan:
Nebraska:
New York:
Oklahoma:
Pennsylvania:
Rhode Island:
South Carolina:
Tennessee:
Texas:
Utah:
Washington:
West Virginia:
Wisconsin:
Source: Copyright: Corel Copr. All rights reserved (map); GAO survey of
state Early Detection Program directors, October 2008.
[End of figure]
* Seventeen states offer Medicaid eligibility only to women screened or
diagnosed with CDC funds. Fifteen of these states require a woman to
have received at least one CDC-funded screening or diagnostic service
to be considered "screened under the program." Two states, Florida and
the District of Columbia, require that both the screening and
diagnostic services be paid for with CDC funds for women to be eligible
for Medicaid.
* Fifteen states extend Medicaid eligibility to women screened or
diagnosed by a CDC-funded provider. In these states, women whose
services were paid for with state or other funds, but delivered by a
provider receiving some CDC grant funds, are considered eligible for
Medicaid if they need treatment. This allows states that fund their
Early Detection Programs above the contribution required to receive the
CDC grant to extend eligibility to women screened by a program provider
but with other funds.[Footnote 29]
* Nineteen states further extend Medicaid eligibility to women screened
or diagnosed by a non-CDC-funded provider. Some of these states
designate specific providers. For example, Iowa extends eligibility to
women whose services were provided by Komen-funded providers. Other
states consider women eligible for Medicaid under the Treatment Act if
they were screened by any qualified provider.
Among the states that limit Medicaid eligibility to women served only
with CDC funds (17 states) or that extend eligibility to women served
by a CDC-funded provider (15 states), some have alternate pathways to
Medicaid eligibility for women initially screened or screened and
diagnosed outside the Early Detection Program. In most of these states,
women initially screened outside the program can qualify for Medicaid
if they later receive their diagnostic services with CDC funds. Only
four states reported they do not allow women who have been screened
outside the program to receive diagnostic services under the program to
qualify for Medicaid.[Footnote 30]
In most of the states that limit Medicaid eligibility to women served
with CDC funds or that extend eligibility to women served by a CDC-
funded provider, once a woman who received her screening and diagnostic
services outside the Early Detection Program is diagnosed with cancer,
she cannot access Medicaid coverage under the Treatment Act. However,
Early Detection Program directors in 6 of these states reported that
women diagnosed outside the program can be rescreened under the program
to qualify for Medicaid, and in 11 states women can qualify for
Medicaid by receiving additional diagnostic services from a program
provider. Although rescreening or providing additional diagnostic
services is inefficient and may be medically unnecessary, program rules
in some states require a woman to have received at least one CDC-funded
service to qualify for Medicaid. Whether a woman can access Medicaid
through one of these alternate pathways depends on her obtaining a
referral and on the availability of funds and providers to deliver the
additional screening and diagnostic services.[Footnote 31]
In implementing the Treatment Act, most states reported they require a
confirmed diagnosis of breast cancer, cervical cancer, or precancerous
lesions to meet the requirement that women be in need of cancer
treatment services.[Footnote 32] Two states, Missouri and New
Hampshire, indicated that a woman may be enrolled in Medicaid in order
to receive certain diagnostic procedures, such as a biopsy or magnetic
resonance imaging. A third state, Oklahoma, indicated that an abnormal
screening test alone met the standard of needing treatment and
qualified a woman for Medicaid coverage. In Oklahoma, women with an
abnormal mammogram or Pap test are enrolled in Medicaid for their
diagnostic services, and Medicaid coverage ends if they are found to
not have a cancer diagnosis.
As of October 2008, 20 states had adopted presumptive eligibility--an
option allowed by the Treatment Act--to help women get treatment sooner
by provisionally enrolling them in Medicaid while their full
application is being processed.[Footnote 33] Among the states that do
not have presumptive eligibility, Early Detection Program directors
reported that the average length of time it takes a woman to be
enrolled once their application has been submitted did not exceed 30
days, with an overall state average of 9 days.[Footnote 34] In most
states, whether or not they have adopted presumptive eligibility, a
separate visit to the Medicaid office is not required for a woman to be
enrolled in Medicaid under the Treatment Act. Early Detection Program
staff receive application materials and then forward applications to
the Medicaid agency for approval.
Medicaid Enrollment and Spending under the Treatment Act Vary across
States:
Medicaid enrollment under the Treatment Act varied widely in 2006,
ranging from fewer than 100 women in each of South Dakota, Delaware,
and Hawaii to more than 9,300 women in California. (See table 1.)
Enrollment was concentrated in a few states, with California, Oklahoma,
and Georgia accounting for more than half of all Treatment Act
enrollees in 2006. However, Treatment Act enrollees are a small share
of Medicaid enrollees overall--less than 0.5 percent--with a median
enrollment of 395 across 39 states reporting data for 2006.
Table 1: Medicaid Enrollment under the Treatment Act by State, Ranked
by 2006 Enrollment:
State: California;
2006 Enrollment: 9,333;
Enrollment per 100,000 women ages 40-64: 169.
State: Oklahoma;
2006 Enrollment: 6,550;
Enrollment per 100,000 women ages 40-64: 1,233.
State: Georgia;
2006 Enrollment: 4,142;
Enrollment per 100,000 women ages 40-64: 290.
State: Tennessee;
2006 Enrollment: 2,903;
Enrollment per 100,000 women ages 40-64: 289.
State: Texas;
2006 Enrollment: 1,580;
Enrollment per 100,000 women ages 40-64: 47.
State: Pennsylvania;
2006 Enrollment: 1,521;
Enrollment per 100,000 women ages 40-64: 73.
State: Michigan;
2006 Enrollment: 1,345;
Enrollment per 100,000 women ages 40-64: 80.
State: Louisiana;
2006 Enrollment: 1,078;
Enrollment per 100,000 women ages 40-64: 156.
State: New York;
2006 Enrollment: 897;
Enrollment per 100,000 women ages 40-64: 28.
State: Illinois;
2006 Enrollment: 639;
Enrollment per 100,000 women ages 40-64: 32.
State: South Carolina;
2006 Enrollment: 614;
Enrollment per 100,000 women ages 40-64: 88.
State: Missouri;
2006 Enrollment: 606;
Enrollment per 100,000 women ages 40-64: 65.
State: Arkansas;
2006 Enrollment: 580;
Enrollment per 100,000 women ages 40-64: 127.
State: Minnesota;
2006 Enrollment: 477;
Enrollment per 100,000 women ages 40-64: 54.
State: Washington;
2006 Enrollment: 466;
Enrollment per 100,000 women ages 40-64: 44.
State: Virginia;
2006 Enrollment: 442;
Enrollment per 100,000 women ages 40-64: 34.
State: Maryland;
2006 Enrollment: 432;
Enrollment per 100,000 women ages 40-64: 45.
State: Rhode Island;
2006 Enrollment: 409;
Enrollment per 100,000 women ages 40-64: 217.
State: Alabama;
2006 Enrollment: 398;
Enrollment per 100,000 women ages 40-64: 50.
State: Wisconsin;
2006 Enrollment: 395;
Enrollment per 100,000 women ages 40-64: 43.
State: Oregon;
2006 Enrollment: 394;
Enrollment per 100,000 women ages 40-64: 65.
State: Nebraska;
2006 Enrollment: 356;
Enrollment per 100,000 women ages 40-64: 125.
State: New Mexico;
2006 Enrollment: 319;
Enrollment per 100,000 women ages 40-64: 102.
State: New Jersey;
2006 Enrollment: 318;
Enrollment per 100,000 women ages 40-64: 21.
State: Florida;
2006 Enrollment: 292;
Enrollment per 100,000 women ages 40-64: 10.
State: Utah;
2006 Enrollment: 277;
Enrollment per 100,000 women ages 40-64: 88.
State: Indiana;
2006 Enrollment: 269;
Enrollment per 100,000 women ages 40-64: 25.
State: Connecticut;
2006 Enrollment: 260;
Enrollment per 100,000 women ages 40-64: 41.
State: Colorado;
2006 Enrollment: 248;
Enrollment per 100,000 women ages 40-64: 33.
State: West Virginia;
2006 Enrollment: 247;
Enrollment per 100,000 women ages 40-64: 77.
State: Mississippi;
2006 Enrollment: 226;
Enrollment per 100,000 women ages 40-64: 48.
State: Montana;
2006 Enrollment: 197;
Enrollment per 100,000 women ages 40-64: 119.
State: Wyoming;
2006 Enrollment: 188;
Enrollment per 100,000 women ages 40-64: 215.
State: Kansas;
2006 Enrollment: 188;
Enrollment per 100,000 women ages 40-64: 44.
State: Alaska;
2006 Enrollment: 169;
Enrollment per 100,000 women ages 40-64: 156.
State: Vermont;
2006 Enrollment: 125;
Enrollment per 100,000 women ages 40-64: 109.
State: South Dakota;
2006 Enrollment: 67;
Enrollment per 100,000 women ages 40-64: 56.
State: Delaware;
2006 Enrollment: 66;
Enrollment per 100,000 women ages 40-64: 45.
State: Hawaii;
2006 Enrollment: 42;
Enrollment per 100,000 women ages 40-64: 20.
Source: GAO analysis of CMS MSIS data and U.S. Census Bureau Population
Estimates.
Note: Enrollment data from the following states were not available:
Arizona, District of Columbia, Idaho, Iowa, Kentucky, Maine,
Massachusetts, North Carolina, North Dakota, Nevada, New Hampshire, and
Ohio.
[End of table]
Enrollment may be affected by state policies and practices for initial
and ongoing eligibility under the Treatment Act. In general, states
with the highest enrollment and highest enrollment as a share of
population adopted the broadest definition of "screened under the
program" by extending Medicaid eligibility to women served by non-CDC
funded providers. In 2006, median enrollment was 639 in these states,
or an average of 124 enrollees per 100,000 women 40 to 64 years old. In
contrast, median enrollment was 265 in states that limit eligibility to
women served with CDC funds or by a CDC-funded provider. In these
states an average of 44 women were enrolled for every 100,000 women 40
to 64 years old.
Medicaid enrollment of women covered under the Treatment Act has grown
in most states. Seven states experienced growth greater than 70
percent, while one state reported a significant decline from 2004 to
2006. (See appendix III.) From 2004 to 2006, the median rate of
enrollment growth was 40 percent among the 35 states reporting data for
both years. States that shifted to broader definitions of "screened
under the program" generally experienced higher than average growth.
[Footnote 35] Among states that initially applied the minimum
definition of screened under the program, but later broadened
eligibility to include women screened by non-CDC-funded providers,
enrollment growth averaged 67 percent from 2004 to 2006.[Footnote 36]
For example, in 2004 South Carolina limited Medicaid eligibility to
women served with CDC funds, but in July 2005 it extended coverage to
women served by any qualified provider in the state. Its enrollment
grew from 162 women in 2004 to 614 women in 2006.[Footnote 37]
Enrollment in Medicaid under the Treatment Act can also be affected by
state policies and practices for periodic redetermination of Medicaid
eligibility.[Footnote 38] Practices for redetermining eligibility can
range from a statement by the beneficiary that she continues to need
treatment to a verbal or signed statement by the health provider of the
beneficiary's treatment status. For example, in West Virginia, Medicaid
enrollment declined from 709 in 2004 to 247 in 2006 after the state
imposed stricter redetermination requirements in 2004.
As with enrollment, average per capita Medicaid spending under the
Treatment Act also varies widely across states (see figure 6). Among
the 39 states reporting Medicaid enrollment and spending data for 2006,
total monthly spending per Treatment Act enrollee averaged $1,067,
ranging from $584 in Oklahoma to $2,304 in Colorado.[Footnote 39]
Federal funds accounted for more than two-thirds of this spending. The
average monthly state share per enrollee was $307, ranging from $131 in
Oklahoma to $806 in Colorado.[Footnote 40]
Figure 6: Average Monthly Medicaid Spending per Treatment Act Enrollee
by State, 2006:
[Refer to PDF for image: multiple vertical bar graph]
State: Alaska;
State: $682;
Federal: $1,274
Total: $1,976.
State: Alabama;
State: $279;
Federal: $1,029;
Total: $1,298.
State: Arkansas;
State: $345;
Federal: $1,534;
Total: $1,879.
State: Arizona;
State: No data;
Federal: No data;
Total: No data.
State: California;
State: $270;
Federal: $502;
Total: $772.
State: Colorado;
State: $806;
Federal: $1,497;
Total: $2,303.
State: Connecticut;
State: $489;
Federal: $908;
Total: $1,397.
State: District of Columbia;
State: No data;
Federal: No data;
Total: No data.
State: Delaware;
State: $304;
Federal: $566;
Total: $870.
State: Florida;
State: $431;
Federal: $1,066;
Total: $1,497.
State: Georgia;
State: $295;
Federal: $775;
Total: $1,070.
State: Hawaii;
State: $268;
Federal: $661;
Total: $929.
State: Iowa;
State: No data;
Federal: No data;
Total: No data.
State: Idaho;
State: No data;
Federal: No data;
Total: No data.
State: Illinois;
State: $550;
Federal: $1,021;
Total: $1,571.
State: Indiana;
State: $404;
Federal: $1,156;
Total: $1,560.
State: Kansas;
State: $327;
Federal: $853;
Total: $1,180.
State: Kentucky;
State: No data;
Federal: No data;
Total: No data.
State: Louisiana;
State: $368;
Federal: $1,371;
Total: $1,739.
State: Massachusetts;
State: No data;
Federal: No data;
Total: No data.
State: Maryland;
State: $434;
Federal: $806;
Total: $1,240.
State: Maine;
State: No data;
Federal: No data;
Total: No data.
State: Michigan;
State: $337;
Federal: $771;
Total: $1,108.
State: Minnesota;
State: $308;
Federal: $571;
Total: $879.
State: Missouri;
State: $440;
Federal: $1,211;
Total: $1,651.
State: Mississippi;
State: $266;
Federal: $1,319;
Total: $1,585.
State: Montana;
State: $308;
Federal: $1,185;
Total: $1,493.
State: North Carolina;
State: No data;
Federal: No data;
Total: No data.
State: North Dakota;
State: No data;
Federal: No data;
Total: No data.
State: Nebraska;
State: $366;
Federal: $931;
Total: $1,297.
State: New Hampshire;
State: No data;
Federal: No data;
Total: No data.
State: New Jersey;
State: $774;
Federal: $1,437;
Total: $2,211.
State: New Mexico;
State: $424;
Federal: $1,678;
Total: $2,102.
State: Nevada;
State: No data;
Federal: No data;
Total: No data.
State: New York;
State: $359;
Federal: $667;
Total: $1,062.
State: Ohio;
State: No data;
Federal: No data;
Total: No data.
State: Oklahoma;
State: $131;
Federal: $453;
Total: $584.
State: Oregon;
State: $437;
Federal: $1,189;
Total: $1,626.
State: Pennsylvania;
State: $326;
Federal: $711;
Total: $1,037.
State: Rhode Island;
State: $381;
Federal: $815;
Total: $1,196.
State: South Carolina;
State: $393;
Federal: $1,437;
Total: $1,830.
State: South Dakota;
State: $455;
Federal: $1,405;
Total: $1,860.
State: Tennessee;
State: $276;
Federal: $818;
Total: $1,094.
State: Texas;
State: $326;
Federal: $857;
Total: $1,183.
State: Utah;
State: $325;
Federal: $1,262;
Total: $1,587.
State: Virginia;
State: $462;
Federal: $857;
Total: $1,319.
State: Vermont;
State: $269;
Federal: $656;
Total: $925.
State: Washington;
State: $598;
Federal: $1,111;
Total: $1,709.
State: Wisconsin;
State: $271;
Federal: $642;
Total: $913.
State: West Virginia;
State: $308;
Federal: $757;
Total: $865.
State: Wyoming;
State: $320;
Federal: $680;
Total: $1,000.
Average monthly spending per enrollee: $1,067.
Notes: Enrollment and spending data for the following states were not
available: Arizona, District of Columbia, Idaho, Iowa, Kentucky, Maine,
Massachusetts, North Carolina, North Dakota, Nevada, New Hampshire, and
Ohio. Spending may vary across states due to several factors such as
differences in Medicaid benefit plan design and reimbursement and
differences in eligibility policies and practices.
[End of figure]
Some of the variation in average total spending per Treatment Act
enrollee may be accounted for by differences in state Medicaid
reimbursement rates and variation in states' Medicaid benefit packages.
[Footnote 41] It may also be affected by the relative proportion of
breast and cervical cancer patients. For example, a 2007 study using
state Medicaid claims data from 2003 in Georgia found that spending for
breast cancer patients averaged more than twice that for cervical
cancer patients. In 2003, annual Medicaid spending was $20,285 for each
woman with breast cancer, but $9,845 for each woman with cervical
cancer.[Footnote 42]
State eligibility policies and practices can also affect average
spending. For example, Oklahoma, the state with the lowest monthly per
person spending under the Treatment Act, enrolls women in Medicaid
based on the results of an abnormal screening test alone. Thus,
according to an Oklahoma official, many women in Oklahoma are enrolled
in Medicaid only for diagnostic services and do not subsequently incur
costs for cancer treatment. At $584 per month in 2006, average Medicaid
spending per Treatment Act enrollee in Oklahoma is the lowest of the 39
states for which we have data. West Virginia has reduced its overall
enrollment from 709 in 2004 to 247 in 2006 by taking a proactive
approach to disenrolling women if they have completed their cancer
treatment, and cannot otherwise qualify for Medicaid. The state
requires more than just a woman's self-certification of her continued
need for treatment; case managers actively follow women receiving
treatment, and a registered nurse evaluation is required to certify
their continued need for treatment and Medicaid eligibility. While
total spending in West Virginia declined 50 percent in 2006, average
monthly per enrollee spending increased by 19 percent, from $894 to
$1,064.
Few Statewide Alternatives to Medicaid Coverage for Treatment Are
Available to Low-Income, Uninsured Women; Local Resources Offer
Assistance in Some Areas:
Among states that limit Medicaid eligibility under the Treatment Act to
women screened with CDC funds or that extend Medicaid eligibility to
women screened by a CDC-funded provider, few statewide alternatives to
Medicaid coverage for treatment are available to low-income, uninsured
women who are screened and diagnosed outside of the Early Detection
Program.[Footnote 43] Early Detection Program directors in four
states[Footnote 44] reported having state-funded programs as an
alternative to Medicaid. These programs pay specifically for breast or
cervical cancer treatment or more broadly provide health insurance
coverage or free or reduced-fee health care.
* The Maryland Breast and Cervical Cancer Diagnosis and Treatment
Program pays specifically for breast and cervical cancer diagnosis and
treatment services, according to our survey. Maryland residents who are
within 250 percent of the FPL, are uninsured or meet other health
insurance criteria, and were screened for breast or cervical cancer by
any medical provider, may be eligible for this program.
* The Delaware Cancer Treatment Program can pay for treatment of breast
or cervical cancer, according to our survey. Delaware residents who
have been diagnosed with cancer on or after July 1, 2004, have no
comprehensive health insurance coverage, and have household incomes
less than 650 percent of the FPL may be eligible for free cancer
treatment for up to 2 years under this program.
* The state charity hospital system in Louisiana--which provides free
health care services for low-income, uninsured residents below 200
percent of the FPL--can provide free breast and cervical cancer
treatment, according to our survey. The hospital system also provides
reduced-fee care to individuals with incomes above 200 percent of the
FPL.
* The Healthy Indiana Plan provides health insurance coverage for state
residents who are 19 to 64 years old, earn less than 200 percent of the
FPL, have been uninsured for the past 6 months, and do not have access
to employer-sponsored health insurance coverage, according to our case
study. A program official stated that the benefit package was similar
to that of Medicaid and included the same provider network. Since the
program's implementation in January 2008, enrollment has been higher
than expected, and needed treatment could be delayed because the
enrollment process may take 60 to 90 days.
Early Detection Program directors, advocacy groups, and providers
reported in our survey and case studies that some local resources were
available as alternatives to Medicaid to pay for treatment of breast or
cervical cancer.[Footnote 45] These include donated care, funding from
local charity organizations, and county assistance.
* Physicians may donate free health care services to low-income,
uninsured individuals. Fourteen states reported through our survey
having donated care available as a resource for breast or cervical
cancer treatment. For example, Project Access has networks of
physicians in Virginia that provide donated care to eligible residents
in local areas.[Footnote 46]
* Local charity organizations can provide resources to pay for breast
or cervical cancer treatment, and 20 states reported through our survey
having charity funds available. For example, Anthem Blue Cross Blue
Shield and Komen for the Cure affiliates in Indiana provide funding for
breast or cervical cancer treatment services for low-income, uninsured
women.
* County indigent funds, public assistance programs, and county
hospitals can cover some health care costs for low-income, uninsured
individuals in some areas. Eleven states reported having some county
indigent funds or other public assistance programs available, according
to our survey. In Florida, county hospitals provide breast and cervical
cancer screening and diagnostic services, as well as funding for
treatment costs, for low-income, uninsured women.
However, the availability of these resources varied by locality, and 21
Early Detection Program directors reported as much in our survey.
Furthermore, in our case studies, several officials and providers cited
concerns over the availability of treatment resources on a local level.
For example, an Early Detection Program official in Indiana told us
that densely populated areas of the state, such as North Central
Indiana and South Bend, had multiple treatment resources, but women
living in rural areas had limited access to them. A Komen for the Cure
official in Indiana stated there was only 1 county hospital to serve
low-income, uninsured residents in a 21-county region. We also spoke
with the executive director of a Komen affiliate in Florida who said
that some areas of the state, such as West Palm Beach and Tallahassee,
had limited treatment resources, while southern areas had more
accessible resources. Furthermore, physicians we spoke to in Virginia
stated that treatment alternatives vary by location in the state, and
some areas have problems with access to care.
Although not required, some Early Detection Program staff help women
screened outside the program and ineligible for Medicaid under the
Treatment Act find local treatment resources, as reported in two of our
case study states. Officials said they encouraged these women to
contact local or county hospitals or referred them to available local
programs. In addition, three Early Detection Program directors surveyed
reported having programs that track the treatment process for women
screened outside the Early Detection Program.
Furthermore, in some states, charity organizations have programs to
provide referrals to low-income, uninsured women for local treatment
resources. We learned from advocacy group representatives in our case
study states that Komen for the Cure and the American Cancer Society
operate cancer resource hotlines and health insurance information
hotlines women can call for information about local cancer treatment
resources. They also fund patient navigators who provide counseling and
support services, which include finding local programs for women
ineligible for Medicaid under the Treatment Act.
Agency Comments:
The Department of Health and Human Services (HHS) reviewed a draft of
this report and provided comments on our findings, which are reprinted
in appendix IV. Overall, HHS concurred with our description of the
Early Detection Program. HHS indicated that the data we provided on
states' implementation of the Treatment Act, including eligibility
options, Medicaid enrollment, and treatment cost data were useful.
Finally, HHS noted that the information contained in our report will be
used to make improvements to better serve low-income women.
HHS also provided technical comments, which we incorporated as
appropriate.
As we agreed with your offices, unless you publicly announce the
contents of this report earlier, we plan no further distribution of it
until 30 days from the date of this letter. At that time, we will send
copies of this report to the Secretary of Health and Human Services,
the Director of CDC, the Administrator of CMS, appropriate
congressional committees, and other interested parties. The report also
is available at no charge on GAO's Web site at [hyperlink,
http://www.gao.gov].
If you or your staff have any questions regarding this report, please
contact me at (202) 512-7114 or cosgrovej@gao.gov. Contact points for
our Offices of Congressional Relations and Public Affairs may be found
on the last page of this report. GAO staff who made major contributions
to this report are listed in appendix V.
Signed by:
James C. Cosgrove:
Director, Health Care:
[End of section]
Appendix I: Scope and Methodology:
To determine how many eligible women have been screened by the Early
Detection Program,[Footnote 47] we compared the number of women
screened by the Early Detection Program with the number of low-income,
uninsured women eligible to be screened, including those who were
screened by another provider or were not screened by any provider. We
analyzed data from the Centers for Disease Control and Prevention's
(CDC) Minimum Data Elements (MDE) to determine the number of women
screened by the Early Detection Program. Program grantees report these
data to the CDC twice a fiscal year (October and April).[Footnote 48]
MDE data include data for some women whose services were paid for in
part with state or other nonfederal funding. We analyzed MDE data for
calendar years 2002 through 2006, including information in total and by
grantee on the number of women screened by the Early Detection Program-
-those who had mammograms and Pap tests--and the number of breast
cancers and cervical cancers or precursor lesions detected. We also
analyzed the age, race, and ethnicity distributions of the women
screened. The Early Detection Program has policies and procedures for
standardizing and assessing the quality of the MDE data submitted by
grantees. We found the data to be sufficiently reliable for our
purposes by reviewing these policies and procedures and the results of
an MDE data validation study.
We then compared the number of women screened by the Early Detection
Program to the number of women potentially eligible for screening,
which we determined with data collected from the Medical Expenditure
Panel Survey (MEPS), administered by the Agency for Healthcare Research
and Quality.[Footnote 49] For our analysis of women receiving
mammograms, we pooled MEPS data for 2005 and 2006 because the U.S.
Preventive Services Task Force recommends that women receive a
mammogram every 1 to 2 years. We identified how many women were 40 to
64 years old--the age group generally eligible for a mammogram by the
Early Detection Program--as well as low income and uninsured. We
defined low income as at or below 250 percent of the federal poverty
level (FPL) because federal guidelines allow the Early Detection
Program to pay for services to women whose income is at or below this
level. According to MEPS, women are considered uninsured if they
indicated for each of the 12 months of the year that they were not
covered under any type of health insurance for the entire month.
Although underinsured women are eligible for screenings provided by the
Early Detection Program, we were not able to identify this population
in MEPS.[Footnote 50] Next, we determined how many of these potentially
eligible low-income, uninsured women 40 to 64 years old received a
mammogram in 2005 to 2006. We then compared this number with the number
of women that the Early Detection Program screened with a mammogram in
2005 to 2006.[Footnote 51]
For our analysis of women receiving Pap tests, we pooled MEPS data for
2004, 2005, and 2006 because the U.S. Preventive Services Task Force
recommends that women receive a Pap test at least every 3 years. We
identified how many women were 18 to 64 years old--the age group
generally eligible for a Pap test by the Early Detection Program--as
well as low-income and uninsured, using the above criteria. We
determined how many women meeting these criteria received a Pap test in
2004 to 2006. We compared this number with the number of women that the
Early Detection Program screened with a Pap test in 2004 to 2006.
[Footnote 52] In our analyses of women receiving mammograms and Pap
tests, we did not examine why women did not receive either of these
screening tests, because it was beyond the scope of this report.
We determined that the MEPS data were sufficiently reliable for our
purposes by speaking with knowledgeable agency officials at the Agency
for Healthcare Research and Quality, reviewing related documentation,
and comparing our results with CDC and U.S. Census data.
To determine how states have implemented the Treatment Act, we
conducted a Web-based survey of Early Detection Program directors in
the 51 states. We reviewed federal guidelines for implementing the
Treatment Act, and interviewed Early Detection Program directors and
other officials in selected states to gather information to design the
survey questions. We reviewed previous studies of the Treatment Act
conducted by George Washington University in 2004 under contract with
the CDC and by Susan G. Komen for the Cure (Komen for the Cure) in
2007. We determined that the Early Detection Program directors were
knowledgeable about their states' Medicaid eligibility policies and
practices for the Treatment Act based on this review and discussions
with CDC and Centers for Medicare and Medicaid Services (CMS)
officials.
The survey included both closed-ended and open-ended questions on
characteristics of the Early Detection Program, implementation of the
Treatment Act, Medicaid eligibility criteria, and the Medicaid
enrollment process. We pretested the survey at CDC's national meeting
of Early Detection Program directors in Atlanta, Georgia, on September
9, 2008. The survey was fielded during October 2008, and we obtained a
100 percent response rate from all 50 states and the District of
Columbia. Survey responses were edited for logic and appropriate skip
patterns. We reviewed survey responses for outliers and followed up
with officials in selected states to verify the accuracy of responses.
To determine the number of women enrolled in state Medicaid programs
under the Treatment Act and average state spending for this coverage,
we analyzed enrollment and spending data from CMS's Medicaid
Statistical Information System (MSIS) as presented in the MSIS State
Summary Datamart.[Footnote 53] The MSIS contains state-submitted
Medicaid enrollment and claims data, including each person's basis of
eligibility, use of services, basic demographic characteristics, and
payments made to providers. We used MSIS data on the number of women
enrolled in Medicaid with the Treatment Act as their basis of
eligibility by state for fiscal years 2004 and 2006. We then calculated
the average per person monthly spending by state for fiscal year 2006
using MSIS data on total spending for Medicaid enrollees under the
Treatment Act and the total number of months of eligibility accounted
for by all enrollees during the year. Our analysis was limited to 38
states for 2004 and 39 states for 2006 because MSIS data on enrollment
and spending were not available for all states or for all years.
According to CMS, data from the remaining states either were not
reported separately for Treatment Act eligibility or had not yet passed
CMS's data quality control process. In addition, we could not
separately determine both the number of women enrolled in Medicaid and
Medicaid costs for women by diagnosis (breast cancer, cervical cancer,
or precancerous conditions) because enrollment data reported in the
MSIS State Summary Datamart are not broken down by diagnostic category.
We worked with CMS officials to establish the reliability of the data
used in our analysis. States submit their MSIS data quarterly to CMS.
The data are submitted to a system of quality control edit checks. Data
files that exceed prescribed error tolerance limits are rejected and
must be resubmitted by states until they are determined acceptable by
CMS. Following the quality review process, data are then posted to
CMS's public Web site.[Footnote 54] We also reviewed MSIS documentation
including user manuals, design specifications, a data dictionary, and
known MSIS data anomalies. We also interviewed knowledgeable CMS
officials and followed up with states whose reported enrollment and per
capita spending data appeared as outliers when we arrayed the data for
all states. We determined that the data were sufficiently reliable for
our purposes based on our review.
To identify alternatives available to low-income, uninsured women who
need treatment for breast or cervical cancer, but who are not covered
under the Treatment Act, we obtained general information from our Web-
based survey of Early Detection Program directors (described above). We
targeted the relevant survey questions to states that limited Medicaid
eligibility under the Treatment Act to women screened or diagnosed with
CDC funds or that extend Medicaid eligibility to women screened by a
CDC-funded provider. Our findings were limited by responses to a
narrowly-worded survey question on statewide programs for breast and
cervical cancer diagnosis and treatment and may not necessarily account
for all available statewide or state-funded programs.
We also conducted case studies of three states that limited Medicaid
eligibility under the Treatment Act to women screened or diagnosed with
CDC funds only: Florida, Indiana, and Virginia. We chose these states
because their rate of screening eligible women was lower than the
national average. In each state, we interviewed: Early Detection
Program directors and other officials;[Footnote 55] representatives
from Komen for the Cure,[Footnote 56] American Cancer Society local
chapters, and other state or local organizations; and health care
providers. We developed a protocol for each interview with semi-
structured interview questions and obtained detailed examples of
available alternatives to Medicaid under the Treatment Act. Our
findings are illustrative examples and thus are not generalizable,
because the officials we surveyed and interviewed may not have had
complete knowledge of all available local resources, and because
available resources may vary by state.
We conducted our work from May 2008 to May 2009 in accordance with all
sections of GAO's Quality Assurance Framework that are relevant to our
objectives. The framework requires that we plan and perform the
engagement to obtain sufficient and appropriate evidence to meet our
stated objectives and to discuss any limitations in our work. We
believe that the information and data obtained, and the analysis
conducted, provide a reasonable basis for any findings and conclusions.
[End of section]
Appendix II: Number of Women Screened by National Breast and Cervical
Cancer Early Detection Program Grantees, 2002-2006:
Program: Alabama;
Women screened[A]: 37,987;
Women screened with mammogram: 19,928;
Breast cancers detected: 481;
Women screened with Pap Test: 21,526;
Cervical cancers and precursor lesions detected (CIN2[B] or worse):
245.
Program: Alaska;
Women screened[A]: 21,979;
Women screened with mammogram: 4,538;
Breast cancers detected: 85;
Women screened with Pap Test: 19,812;
Cervical cancers and precursor lesions detected (CIN2[B] or worse):
435.
Program: Arizona;
Women screened[A]: 17,521;
Women screened with mammogram: 11,502;
Breast cancers detected: 267;
Women screened with Pap Test: 9,021;
Cervical cancers and precursor lesions detected (CIN2[B] or worse): 96.
Program: Arkansas;
Women screened[A]: 17,889;
Women screened with mammogram: 15,879;
Breast cancers detected: 288;
Women screened with Pap Test: 8,516;
Cervical cancers and precursor lesions detected (CIN2[B] or worse): 65.
Program: California;
Women screened[A]: 394,564;
Women screened with mammogram: 322,523;
Breast cancers detected: 2,454;
Women screened with Pap Test: 112,471;
Cervical cancers and precursor lesions detected (CIN2[B] or worse):
498.
Program: Colorado;
Women screened[A]: 35,674;
Women screened with mammogram: 20,465;
Breast cancers detected: 410;
Women screened with Pap Test: 23,975;
Cervical cancers and precursor lesions detected (CIN2[B] or worse):
157.
Program: Connecticut;
Women screened[A]: 12,330;
Women screened with mammogram: 10,784;
Breast cancers detected: 137;
Women screened with Pap Test: 6,946;
Cervical cancers and precursor lesions detected (CIN2[B] or worse): 35.
Program: Delaware;
Women screened[A]: 9,360;
Women screened with mammogram: 2,112;
Breast cancers detected: 52;
Women screened with Pap Test: 8,190;
Cervical cancers and precursor lesions detected (CIN2[B] or worse):
220.
Program: District of Columbia;
Women screened[A]: 5,832;
Women screened with mammogram: 3,831;
Breast cancers detected: 32;
Women screened with Pap Test: 3,653;
Cervical cancers and precursor lesions detected (CIN2[B] or worse): 12.
Program: Florida;
Women screened[A]: 36,989;
Women screened with mammogram: 33,082;
Breast cancers detected: 606;
Women screened with Pap Test: 21,606;
Cervical cancers and precursor lesions detected (CIN2[B] or worse):
107.
Program: Georgia;
Women screened[A]: 37,937;
Women screened with mammogram: 34,074;
Breast cancers detected: 577;
Women screened with Pap Test: 19,124;
Cervical cancers and precursor lesions detected (CIN2[B] or worse):
456.
Program: Hawaii;
Women screened[A]: 3,277;
Women screened with mammogram: 2,924;
Breast cancers detected: 81;
Women screened with Pap Test: 2,717;
Cervical cancers and precursor lesions detected (CIN2[B] or worse): 24.
Program: Idaho;
Women screened[A]: 8,888;
Women screened with mammogram: 7,551;
Breast cancers detected: 187;
Women screened with Pap Test: 5,183;
Cervical cancers and precursor lesions detected (CIN2[B] or worse):
159.
Program: Illinois;
Women screened[A]: 44,013;
Women screened with mammogram: 30,029;
Breast cancers detected: 689;
Women screened with Pap Test: 27,038;
Cervical cancers and precursor lesions detected (CIN2[B] or worse):
1,017.
Program: Indiana;
Women screened[A]: 25,685;
Women screened with mammogram: 10,365;
Breast cancers detected: 292;
Women screened with Pap Test: 20,087;
Cervical cancers and precursor lesions detected (CIN2[B] or worse):
249.
Program: Iowa;
Women screened[A]: 18,870;
Women screened with mammogram: 12,955;
Breast cancers detected: 285;
Women screened with Pap Test: 13,476;
Cervical cancers and precursor lesions detected (CIN2[B] or worse):
171.
Program: Kansas;
Women screened[A]: 16,243;
Women screened with mammogram: 9,490;
Breast cancers detected: 164;
Women screened with Pap Test: 12,284;
Cervical cancers and precursor lesions detected (CIN2[B] or worse):
344.
Program: Kentucky;
Women screened[A]: 34,928;
Women screened with mammogram: 18,136;
Breast cancers detected: 207;
Women screened with Pap Test: 31,301;
Cervical cancers and precursor lesions detected (CIN2[B] or worse):
146.
Program: Louisiana;
Women screened[A]: 18,967;
Women screened with mammogram: 12,532;
Breast cancers detected: 181;
Women screened with Pap Test: 10,429;
Cervical cancers and precursor lesions detected (CIN2[B] or worse): 60.
Program: Maine;
Women screened[A]: 10,845;
Women screened with mammogram: 9,305;
Breast cancers detected: 122;
Women screened with Pap Test: 8,181;
Cervical cancers and precursor lesions detected (CIN2[B] or worse): 64.
Program: Maryland;
Women screened[A]: 27,059;
Women screened with mammogram: 19,267;
Breast cancers detected: 294;
Women screened with Pap Test: 21,852;
Cervical cancers and precursor lesions detected (CIN2[B] or worse):
174.
Program: Massachusetts;
Women screened[A]: 33,652;
Women screened with mammogram: 19,578;
Breast cancers detected: 275;
Women screened with Pap Test: 21,598;
Cervical cancers and precursor lesions detected (CIN2[B] or worse):
684.
Program: Michigan;
Women screened[A]: 66,507;
Women screened with mammogram: 26,263;
Breast cancers detected: 355;
Women screened with Pap Test: 53,993;
Cervical cancers and precursor lesions detected (CIN2[B] or worse):
1,450.
Program: Minnesota;
Women screened[A]: 29,107;
Women screened with mammogram: 18,412;
Breast cancers detected: 292;
Women screened with Pap Test: 21,964;
Cervical cancers and precursor lesions detected (CIN2[B] or worse):
1,056.
Program: Mississippi;
Women screened[A]: 16,496;
Women screened with mammogram: 8,454;
Breast cancers detected: 245;
Women screened with Pap Test: 10,362;
Cervical cancers and precursor lesions detected (CIN2[B] or worse):
181.
Program: Missouri;
Women screened[A]: 22,102;
Women screened with mammogram: 13,875;
Breast cancers detected: 552;
Women screened with Pap Test: 16,621;
Cervical cancers and precursor lesions detected (CIN2[B] or worse):
503.
Program: Montana;
Women screened[A]: 9,112;
Women screened with mammogram: 8,110;
Breast cancers detected: 238;
Women screened with Pap Test: 6,423;
Cervical cancers and precursor lesions detected (CIN2[B] or worse):
220.
Program: Nebraska;
Women screened[A]: 25,142;
Women screened with mammogram: 13,609;
Breast cancers detected: 276;
Women screened with Pap Test: 20,503;
Cervical cancers and precursor lesions detected (CIN2[B] or worse):
852.
Program: Nevada;
Women screened[A]: 20,702;
Women screened with mammogram: 9,366;
Breast cancers detected: 217;
Women screened with Pap Test: 18,220;
Cervical cancers and precursor lesions detected (CIN2[B] or worse):
167.
Program: New Hampshire;
Women screened[A]: 10,748;
Women screened with mammogram: 4,894;
Breast cancers detected: 99;
Women screened with Pap Test: 8,932;
Cervical cancers and precursor lesions detected (CIN2[B] or worse):
335.
Program: New Jersey;
Women screened[A]: 40,525;
Women screened with mammogram: 18,444;
Breast cancers detected: 324;
Women screened with Pap Test: 35,023;
Cervical cancers and precursor lesions detected (CIN2[B] or worse):
327.
Program: New Mexico;
Women screened[A]: 32,434;
Women screened with mammogram: 19,910;
Breast cancers detected: 355;
Women screened with Pap Test: 24,237;
Cervical cancers and precursor lesions detected (CIN2[B] or worse):
517.
Program: New York;
Women screened[A]: 160,282;
Women screened with mammogram: 57,236;
Breast cancers detected: 1,288;
Women screened with Pap Test: 103,105;
Cervical cancers and precursor lesions detected (CIN2[B] or worse):
3,477.
Program: North Carolina;
Women screened[A]: 43,340;
Women screened with mammogram: 32,189;
Breast cancers detected: 511;
Women screened with Pap Test: 29,159;
Cervical cancers and precursor lesions detected (CIN2[B] or worse):
426.
Program: North Dakota;
Women screened[A]: 6,489;
Women screened with mammogram: 3,831;
Breast cancers detected: 83;
Women screened with Pap Test: 5,639;
Cervical cancers and precursor lesions detected (CIN2[B] or worse):
121.
Program: Ohio;
Women screened[A]: 28,512;
Women screened with mammogram: 20,815;
Breast cancers detected: 532;
Women screened with Pap Test: 20,260;
Cervical cancers and precursor lesions detected (CIN2[B] or worse):
189.
Program: Oklahoma;
Women screened[A]: 31,708;
Women screened with mammogram: 10,343;
Breast cancers detected: 248;
Women screened with Pap Test: 26,214;
Cervical cancers and precursor lesions detected (CIN2[B] or worse):
141.
Program: Oregon;
Women screened[A]: 20,935;
Women screened with mammogram: 11,236;
Breast cancers detected: 334;
Women screened with Pap Test: 15,248;
Cervical cancers and precursor lesions detected (CIN2[B] or worse):
278.
Program: Pennsylvania;
Women screened[A]: 23,897;
Women screened with mammogram: 18,754;
Breast cancers detected: 383;
Women screened with Pap Test: 14,539;
Cervical cancers and precursor lesions detected (CIN2[B] or worse):
308.
Program: Rhode Island;
Women screened[A]: 10,873;
Women screened with mammogram: 5,011;
Breast cancers detected: 107;
Women screened with Pap Test: 8,224;
Cervical cancers and precursor lesions detected (CIN2[B] or worse):
280.
Program: South Carolina;
Women screened[A]: 22,954;
Women screened with mammogram: 20,545;
Breast cancers detected: 276;
Women screened with Pap Test: 19,353;
Cervical cancers and precursor lesions detected (CIN2[B] or worse): 93.
Program: South Dakota;
Women screened[A]: 9,024;
Women screened with mammogram: 3,191;
Breast cancers detected: 65;
Women screened with Pap Test: 7,258;
Cervical cancers and precursor lesions detected (CIN2[B] or worse):
144.
Program: Tennessee;
Women screened[A]: 20,951;
Women screened with mammogram: 12,220;
Breast cancers detected: 333;
Women screened with Pap Test: 12,400;
Cervical cancers and precursor lesions detected (CIN2[B] or worse):
514.
Program: Texas;
Women screened[A]: 65,923;
Women screened with mammogram: 45,178;
Breast cancers detected: 1,304;
Women screened with Pap Test: 35,036;
Cervical cancers and precursor lesions detected (CIN2[B] or worse):
2,498.
Program: Utah;
Women screened[A]: 14,517;
Women screened with mammogram: 12,206;
Breast cancers detected: 198;
Women screened with Pap Test: 8,839;
Cervical cancers and precursor lesions detected (CIN2[B] or worse): 63.
Program: Vermont;
Women screened[A]: 6,660;
Women screened with mammogram: 3,200;
Breast cancers detected: 65;
Women screened with Pap Test: 5,014;
Cervical cancers and precursor lesions detected (CIN2[B] or worse):
167.
Program: Virginia;
Women screened[A]: 15,418;
Women screened with mammogram: 14,412;
Breast cancers detected: 392;
Women screened with Pap Test: 10,719;
Cervical cancers and precursor lesions detected (CIN2[B] or worse): 78.
Program: Washington;
Women screened[A]: 39,480;
Women screened with mammogram: 19,470;
Breast cancers detected: 547;
Women screened with Pap Test: 30,712;
Cervical cancers and precursor lesions detected (CIN2[B] or worse):
238.
Program: West Virginia;
Women screened[A]: 43,789;
Women screened with mammogram: 24,897;
Breast cancers detected: 392;
Women screened with Pap Test: 34,714;
Cervical cancers and precursor lesions detected (CIN2[B] or worse):
1,337.
Program: Wisconsin;
Women screened[A]: 28,716;
Women screened with mammogram: 22,331;
Breast cancers detected: 397;
Women screened with Pap Test: 21,416;
Cervical cancers and precursor lesions detected (CIN2[B] or worse):
220.
Program: Wyoming;
Women screened[A]: 3,011;
Women screened with mammogram: 2,277;
Breast cancers detected: 83;
Women screened with Pap Test: 2,277;
Cervical cancers and precursor lesions detected (CIN2[B] or worse):
223.
Program: American Samoa;
Women screened[A]: 2,055;
Women screened with mammogram: 742;
Breast cancers detected: 23;
Women screened with Pap Test: 1,682;
Cervical cancers and precursor lesions detected (CIN2[B] or worse): 7.
Program: Guam;
Women screened[A]: 1,019;
Women screened with mammogram: 847;
Breast cancers detected: 7;
Women screened with Pap Test: 876;
Cervical cancers and precursor lesions detected (CIN2[B] or worse): 8.
Program: Commonwealth of Northern Mariana Islands;
Women screened[A]: 833;
Women screened with mammogram: 155;
Breast cancers detected:
