Medicaid: Source of Screening Affects Women's Eligibility for Coverage of Breast and Cervical Cancer Treatment in Some States
Published: 2009-05-22T00:00:00

Fast Facts:

Highlights:
section_title: Why GAO Did This Study
paragraphs: 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.
section_title: What GAO Found
paragraphs: 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.

section_title: Letter
paragraphs: 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 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).
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. 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, we analyzed information from the CDC’s Minimum  Data Elements (MDE) 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) on the  number of low-income, uninsured women 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). 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, representatives of cancer advocacy groups such the American  Cancer Society and Susan G. Komen for the Cure (Komen for the Cure),  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.
subsections: section_title: Background
paragraphs: 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), 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. Breast cancer screening consists of clinical breast  exams and mammograms. Cervical cancer screening consists of pelvic  exams and the Pap test. 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. 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; 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, 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. All 51 states chose to  implement this optional Medicaid eligibility category. 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. 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.
section_title: CDC’s Early Detection Program Screens More Than Half a Million Women Annually, but Many Eligible Women Are Not Screened
paragraphs: The CDC’s Early Detection Program screened about half a million or more  women for breast and cervical cancer annually from 2002 through 2006.  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.  (See app. 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 and cervical cancer screening for women 40 to  64 years old. 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 fig. 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 fig. 2.)
section_title: Most States Extend Medicaid Eligibility to More Women Than the Minimum Required, but Some Women Are Still Excluded Based on Screening Source
paragraphs: 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 fig. 5.)
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.
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.
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.
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. 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. 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. 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.
section_title: Medicaid Enrollment and Spending under the Treatment Act Vary across States
paragraphs: 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.
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 app. 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. 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. 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.
Enrollment in Medicaid under the Treatment Act can also be affected by  state policies and practices for periodic redetermination of Medicaid  eligibility. 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 fig. 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. Federal funds accounted  for more than two-thirds of this spending. The average monthly state share  in  per enrollee was $307, ranging from $131 in Oklahoma to $806 in  Colorado.  Colorado.
States receive an enhanced federal matching assistance percentage, which is the amount  the federal government reimburses states for expenditures incurred in providing services  to women enrolled in Medicaid under the Treatment Act. In 2006, these percentages, for  expenditures for women enrolled in Medicaid under the Treatment Act, ranged from   65 percent to 83 percent.
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. 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.
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.
section_title: Few Statewide Alternatives to Medicaid Coverage for Treatment Are Available to Low- Income, Uninsured Women; Local Resources Offer Assistance in Some Areas
paragraphs: 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. Early Detection Program directors in four states 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. 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.
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.
section_title: Agency Comments
paragraphs: 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 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.
section_title: Appendix I: Scope and Methodology
paragraphs: To determine how many eligible women have been screened by the Early  Detection Program, 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). 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. 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. 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.
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. 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. 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. 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; representatives from Komen for the Cure, American  Cancer Society local chapters, and other state or local organizations; and  health care providers. We developed a protocol for each interview with  semistructured 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.
section_title: Appendix II: Number of Women Screened by National Breast and Cervical Cancer Early Detection Program Grantees, 2002–2006
subsections: section_title: Women screened
section_title: Appendix III: Medicaid Breast and Cervical Cancer Prevention and Treatment Act Enrollment and Spending, 2006
section_title: Appendix IV: Comments from the Department of Health and Human Services
section_title: Appendix V: GAO Contact and Staff Acknowledgments
subsections: section_title: Acknowledgments
paragraphs: In addition to the contact named above, Jennifer Grover, Assistant  Director; Anne Dievler; Eric Anderson; Seta Hovagimian; Dan Ries; Hemi  Tewarson; Timothy J. Walker; and Suzanne Worth made key contributions  to this report.