Private Health Insurance: Coverage of Key Colorectal Cancer Screening Tests is Common but Not Universal
Published: 2004-06-17T00:00:00

Fast Facts:

Highlights:
section_title: Why GAO Did This Study
paragraphs: Colorectal cancer is the second leading cause of cancer deaths in the United States. Its mortality can be reduced through early detection and treatment. Four key tests are used to detect the cancer--fecal occult blood test (FOBT), flexible sigmoidoscopy, double-contrast barium enema (DCBE), and colonoscopy. Private health insurance plans generally cover these tests to diagnose cancer; however, the extent to which plans cover the tests for screening purposes--where no symptoms are evident--is less clear. Congress is considering legislation that would require coverage of the tests for screening purposes among all private health insurance plans. GAO was asked to (1) identify the state laws that require private health insurance coverage of these screening tests; and (2) determine the extent to which the tests are covered among small employer, individual, large employer, and federal employee health plans. GAO summarized state laws that require coverage of the tests. GAO examined test coverage among a sample of the largest 19 small employer and 14 individual plans in 10 states without laws requiring the coverage, and among 35 large employer plans nationally. The findings cannot be generalized beyond these plans. GAO also reviewed brochures for 143 federal employee health plans.
section_title: What GAO Found
paragraphs: Twenty states had laws in place as of May 2004 requiring private insurance coverage of colorectal cancer tests for screening purposes. In 19 of these states, the laws generally applied to insurance sold to small employers and individuals, and required coverage of all four tests--FOBT, flexible sigmoidoscopy, DCBE, and colonoscopy. The law in 1 of the states was more limited in scope, applying to group and managed care plans and not explicitly requiring coverage of each of the four screening tests according to American Cancer Society (ACS) guidelines. Most, but not all, health plans offered by the insurers and employers GAO reviewed covered all four colorectal cancer tests for screening purposes. Over four-fifths of the small employer plans (16 of 19) covered all of the tests, whereas 1 plan covered only FOBT and flexible sigmoidoscopy and 2 plans covered only FOBT. Almost three-quarters of the individual plans (10 of 14), covered all of the tests, and the remaining 4 plans covered none of the tests. Approximately two-thirds of the large employer plans (24 of 35) covered all four of the tests. Among the remaining 11 plans, 5 covered only FOBT, 2 covered only flexible sigmoidoscopy, and 4 covered none of the tests. Over half of the plans offered to federal employees covered each of the four tests. Finally, among all plans that covered at least one but fewer than four tests, DCBE and colonoscopy were least likely to be covered. In commenting on a draft of this report, ACS suggested that the report overstated the extent of coverage and did not sufficiently highlight the methodological limitations of the study. In contrast, America's Health Insurance Plans (AHIP) commented that the report overstated the lack of coverage. Moreover, AHIP commented that the report did not address the low rate at which Americans actually receive colorectal cancer screening tests regardless of insurance coverage, suggesting that factors other than health insurance coverage are responsible for low screening rates. Recognizing that the findings are subject to varying interpretations, GAO attempted to report them neutrally. Although the draft report disclosed the methodological limitations of the study, in response to ACS comments, GAO more prominently highlighted certain of the limitations. Finally, whereas the draft report noted the screening utilization rates, assessing the factors responsible for them was beyond the scope of this study.

section_title: Letter
paragraphs: Colorectal cancer is the second leading cause of cancer deaths in the United States. Over 146,000 new cases of colorectal cancer will be  diagnosed and almost 57,000 people will die from the disease in 2004,  according to the American Cancer Society (ACS). The mortality associated  with colorectal cancer can be reduced through early diagnosis and  treatment. Four key tests—fecal occult blood test (FOBT), flexible sigmoidoscopy, double-contrast barium enema (DCBE), and  colonoscopy—are commonly used to detect colorectal cancer or its  symptoms. ACS recommends that individuals at high risk for developing  the disease and all individuals who reach age 50 receive one or more of these tests on a regular basis for screening purposes, regardless of whether they exhibit symptoms of the disease. Private health insurance  plans generally cover these four tests to diagnose suspected cases of  cancer when symptoms are present; however, the extent to which plans  cover the tests for screening purposes is less clear.
Private health insurance plans are offered through different market segments—such as the small employer, individual, or large employer  segments, or the health plans offered to federal employees. Some  previous surveys of the extent of colorectal cancer screening coverage  among private health insurance plans have been limited to only certain  health plans or market segments. Moreover, laws that may require  coverage of the screening tests among health plans sold by insurers vary  from state to state. Congress is considering legislation that would require  coverage of colorectal cancer screening tests among all private health  insurance plans. At your request we have examined the extent to which  private health insurance plans cover colorectal cancer screening tests.  Specifically, we determined  1. 	 the extent to which state laws require private health insurance plans to  cover the four colorectal cancer tests for screening purposes; and  2. 	 the extent to which private health insurance plans cover the four  colorectal cancer tests for screening purposes, specifically health  plans sold by insurers to small employers and individuals in states that do not offered by large employers across the United States, and offered through the Federal Employees Health Benefits Program  (FEHBP).
To identify states that had laws that require private health insurance plans  to cover colorectal cancer screening tests, we reviewed the laws in each  state and the District of Columbia as of May 2004, and consulted with state  officials to clarify the laws as necessary. To examine the extent to which  health insurance plans sold to small employers and individuals by insurers  in the states without laws requiring coverage of the tests actually covered  the tests, we contacted the largest health insurers in 10 states without  such laws. From these insurers we obtained information from plan  representatives about their coverage policies for their health plan with the  most members. We received responses to our questions from 95 percent  (18 of 19) of the small employer insurers we contacted and 82 percent (14  of 17) of the individual insurers we contacted. To examine the extent to  which health plans offered by large employers covered the tests for  screening purposes, we randomly selected 50 large employers from  Fortune 500 companies throughout the United States and received  responses from 71 percent (35 of 49) of the employers we contacted. We  relied on self-reported information from officials of the health plans  reviewed and did not independently verify their responses. Further,  although we achieved relatively high response rates, we may nonetheless  have encountered selection bias. That is, insurers and large employers  with more colorectal cancer screening benefits could have been more  likely to participate in our survey than those with fewer colorectal cancer  screening test benefits. In addition, we surveyed a small number of health  plans, precluding our ability to generalize the findings beyond these plans.  Finally, to examine the extent to which health plans offered through  FEHBP covered the four tests for screening purposes, we reviewed  coverage brochures for 143 plans maintained on the Office of Personnel  Management’s (OPM) Web site.We identified the extent to which each  brochure explicitly indicated coverage of each of the four tests for  screening purposes. In addition, we clarified our understanding of the  brochures with OPM staff and confirmed our interpretations of selected  brochures with plan representatives.
We conducted our work from October 2003 through June 2004 according  to generally accepted government auditing standards. Appendix I provides  additional details about our scope and methodology.
subsections: section_title: Background
paragraphs: Surviving colorectal cancer is greatly enhanced when the disease is  detected and treated early; however, only 38 percent of colorectal cancer  cases are diagnosed at an early stage, according to ACS. To facilitate  early diagnosis, ACS recommends regular colorectal cancer screening for  certain individuals using at least one of four key tests: FOBT, flexible  sigmoidoscopy, DCBE, and colonoscopy. These tests are used to find  potential signs of colorectal cancer, including polyps—abnormal growths  in a person’s colon—or blood in a person’s stool. FOBT is a laboratory test  used to detect blood (that is otherwise not visible) in stool samples that  are collected by patients at home. Using a flexible sigmoidoscopy, a  physician can find and take samples of polyps in a patient’s lower colon  and rectum. DCBE detects polyps by providing x-ray images of a patient’s  entire rectum and colon. Finally, a colonoscopy allows a physician to find  and take samples of polyps in a patient’s rectum and entire colon as well  as remove most polyps found during the test.
ACS, medical providers, and others have developed medical guidelines  that outline the frequency at which colorectal cancer screening tests  should be administered depending on an individual’s age and risk for  developing the disease. For example, ACS guidelines recommend that,  beginning at age 50, all average-risk individuals be screened annually using  an FOBT; every 5 years using a flexible sigmoidoscopy or DCBE; or every  10 years using a colonoscopy. ACS guidelines also state that a combination  of both FOBT and flexible sigmoidoscopy at the intervals indicated is the  preferred screening method over either test alone, and that individuals at  high or increased risk for developing the disease should be screened more  frequently. Furthermore, ACS believes that patients and providers should  jointly choose the appropriate tests and testing strategy based on patient  risk factors and the varying accuracy, cost, and discomfort of the tests,  among other factors. ACS’s colorectal cancer screening guidelines are also  similar to those endorsed by the American Gastroenterological  Association and the American Medical Association. The Medicare program  covers all four screening tests following guidelines similar to those  developed by ACS. The United States Preventive Services Task Force  (USPSTF) also strongly recommends that clinicians screen men and  women 50 years of age or older for colorectal cancer. However, it specifies  the frequency with which tests should be administered only for FOBT, for  which annual testing is suggested. Similar to ACS, USPSTF recommends  that the choice of tests and testing strategy be based on a variety of factors  including patient preferences and medical contraindications.
Fewer than half of individuals age 50 and over surveyed in a 2002 national  study reported receiving a colorectal cancer test for screening or  diagnostic purposes. FOBT was used by approximately 45 percent of  respondents age 50 and over, with less than half of these respondents  having had their last test within the past year. The survey also found that a  sigmoidoscopy or colonoscopy test was used by just under 50 percent of  respondents age 50 and over at some point in their lives. Reasons that  individuals do not obtain a colorectal cancer screening test may include a  lack of patient education, a general reluctance to be tested, or a  physician’s lack of time to discuss or educate patients about screening.
Private health insurance is offered in two primary markets—the group and  individual markets. The group market includes health plans offered by  employers to employees. An employer may provide coverage for its  employees either by purchasing the coverage from a health insurer (fully  insured coverage) or by funding its own health plan (self-funded  coverage). Within the group market, small employers typically purchase  coverage from insurers, while larger employers are more likely to self-fund  their coverage. Although the federal government is a large employer—  with over 2.7 million employees in 2002—it provides health coverage for  its employees through health insurance carriers that participate in  FEHBP. About 161 million individuals received health coverage from the  group market in 2002. The individual market includes health plans sold  by insurers to individuals who do not receive coverage through an  employer. About 16.8 million Americans received health coverage from the  individual market in 2002.
Private health plans are subject to various state and federal requirements,  depending upon the market segments in which they are offered and the  manner in which the plans are funded. The fully insured health coverage  offered by small employers is subject to state insurance requirements,  which can include mandated coverage for preventive health services and  other benefits. Individual market coverage purchased by individuals from  insurers is also subject to state insurance requirements. The self-funded  coverage typically offered by larger employers is generally not subject to  state insurance regulation, but only to federal requirements, none of which  are related to preventive health services.
OPM is responsible for regulating, and contracting with, private health  insurers to offer health benefit plans to federal employees, pursuant to the  Federal Employees Health Benefits Act. While private health insurers are  generally subject to the applicable laws in their respective states, by  federal law, the terms of any FEHBP contract negotiated by OPM, which  relate to coverage or benefits, preempt any inconsistent state or local law  or regulation. To assure a consistent set of benefits among the national  plans, OPM routinely preempts state regulation, but generally does not do  so for the local plans, according to an OPM official.
section_title: Twenty States Had Laws That Require Private Health Insurance Plans to Cover Colorectal Cancer Screening Tests
paragraphs: Twenty states had laws requiring private health insurance plans to cover  colorectal cancer screening tests as of May 2004. In 19 of these states, the  laws generally applied to group or individual health plans, and required  coverage of all four tests—FOBT, flexible sigmoidoscopy, DCBE, and  colonoscopy—typically consistent with ACS guidelines. However, the law  in Wyoming had limitations. It was more limited in scope, applying to  group and managed care plans and not explicitly requiring coverage of  each of the four screening tests according to ACS guidelines. Table 1  shows the scope of state laws and appendix II provides a detailed  summary of each of the 20 state laws.
section_title: Majority of Health Plans Reviewed Covered the Four Colorectal Cancer Screening Tests
paragraphs: The majority of health insurance plans we reviewed provided coverage for  the four key colorectal cancer screening tests. These included health plans  that were sold to small employers and individuals in states without laws  requiring colorectal cancer screening coverage, were offered by large  employers across the United States, and were offered to federal employees  through FEHBP. Among plans that covered fewer than four of the tests,  DCBE and colonoscopy were least likely to be covered.
subsections: section_title: In States Without Colorectal Cancer Screening Test Laws, Most of the Small Employer and Individual Plans Reviewed Provided Coverage for All Four Tests
paragraphs: In 10 states without laws requiring private health insurance coverage of  colorectal cancer screening tests, most of the small employer plans we  reviewed—16 of 19—covered all four colorectal cancer screening tests.  The remaining 3 plans covered FOBT or FOBT and flexible  sigmoidoscopy, but not DCBE or colonoscopy. Among the 14 individual  plans we reviewed, 10 covered all four colorectal cancer tests for  screening purposes. The remaining 4 plans did not offer screening  coverage for any of the tests. (See table 2.)
section_title: Most Large Employer Plans Reviewed Covered All Four Colorectal Cancer Screening Tests
paragraphs: Twenty-four of the 35 large employer plans we reviewed, or approximately  two-thirds of these plans, covered all four colorectal cancer tests for  screening purposes. Seven of the 35 plans covered only one of the  colorectal cancer screening tests: FOBT or flexible sigmoidoscopy.  Neither DCBE nor colonoscopy was covered by any of the large employer  plans that provided limited test coverage. Four of the health plans offered  by the large employers did not cover any of the colorectal cancer tests for  screening purposes. (See table 3.)
section_title: Over Half of FEHBP Plans Covered All Four Colorectal Cancer Screening Tests
paragraphs: Seventy-seven of the 143 FEHBP plans covered all four screening tests for  colorectal cancer in 2004. Among the 17 national FEHBP plans, 12  covered all four tests, and 5 covered FOBT, flexible sigmoidoscopy, and  colonoscopy, but not DCBE. (See table 4.) About 70 percent of the over 8 million FEHBP enrollees and their dependents were covered through the  national plans in 2003.
Among the 126 local FEHBP plans, 65 plans either provided coverage for  the four colorectal cancer screening tests as confirmed through a review  of their brochures or follow-up with selected plan officials, or were  located in states that required this coverage. The brochures for the  remaining 61 plans indicated coverage of at least FOBT and flexible  sigmoidoscopy, but did not explicitly identify whether the additional tests  were covered for screening purposes. According to an OPM official, plans  may cover tests that are not explicitly referenced in the brochures. We  contacted 8 local plans and confirmed that brochure language was not  definitive. According to the plan representatives, each of the 8 plans  covered at least one test in addition to the two specified in the brochure.
section_title: External Comments and Our Evaluation
paragraphs: Representatives of ACS and AHIP provided comments on a draft of this  report. ACS commented that the report overstates coverage, for example  by stating that coverage is common or by not placing greater emphasis on  plans that covered few or none of the colorectal cancer tests for screening  purposes. In contrast, AHIP commented that the report overstates the lack  of coverage, for example by highlighting the number of plans that covered  fewer than four tests rather than the number of plans that covered at least  one test. Recognizing that our findings are subject to varying  interpretations, we attempted to report them neutrally and to not overly  emphasize the coverage that did or did not exist. ACS and AHIP also  commented on the scope of our report and limitations to our study  methods, as discussed below, and provided technical comments, which we  incorporated as appropriate.
subsections: section_title: ACS Comments
paragraphs: ACS suggested that we did not sufficiently address several methodological  limitations in our report. In particular, ACS stated that we used small  samples, did not conduct an analysis of nonrespondents, surveyed only the  health plans with the most members where insurers or employers offered  more than one plan, and did not independently verify the responses of the  insurers and employers we contacted. We agree that our study methods  are subject to limitations, which we disclosed in our draft report. We  reviewed samples of health plans that would provide credible evidence of  coverage levels in each market segment, recognizing that the results would  not be generalizable to all health plans. While we believe our relatively  high response rates of between 71 and 95 percent diminished the need for  a detailed analysis of nonrespondents, we acknowledged the possibility of  selection bias in the draft report. Similarly, although we did not examine  every plan offered by each insurer and employer, we focused on those  plans that covered the greatest number of enrollees to best illustrate the  coverage most widely available to consumers. In terms of verifying survey  responses, we did not have ready access to the documents that could have  provided verification of employer and insurer responses to our questions.  Insurer underwriting manuals may provide such verification, but are  considered proprietary by insurers and not shared externally. Documents  readily available to us, such as plan brochures, do not indicate coverage of  every medical test or procedure under every possible circumstance, and  thus could not be used to verify insurer or employer responses to our  questions. Our draft report noted that we did not independently verify  reported responses. In response to ACS’s comments that we did not  sufficiently address our study limitations, we modified the final report to  more prominently highlight certain limitations of our methodology.
ACS further commented that we did not highlight the differences between  the higher coverage rates we found based on the self-reported data  provided by employers and insurers and the lower coverage rates we  found based on our review of FEHBP brochures, suggesting that the  differences indicate the potential for self-reported data to overstate plan  coverage. As the draft report noted, we found that FEHBP brochures did  not specify every medical test or procedure covered under every  circumstance and thus the brochures may understate coverage actually  available. This fact was confirmed by several plan and OPM officials and is  consistent with our own previous reviews of health plan brochures.  Among the 17 national plans, for which we were able to follow up with  plan officials in each instance where the brochure language was not  exhaustive, most covered tests not mentioned in their brochures.  Moreover, through our follow-up with eight local plans we determined that  each plan covered at least one test in addition to those listed in their  brochures.
ACS also commented that we did not assess the quality of prior studies of  colorectal cancer screening coverage rates and consider the study results  in our report. While our draft report acknowledged that prior studies have  been conducted, we did not elaborate on them because, as ACS noted,  each was subject to certain limitations. Evaluating the quality of prior  studies was beyond the scope of our work.
section_title: AHIP Comments
paragraphs: AHIP commented that the draft report did not sufficiently address the low  rate at which Americans actually receive colorectal cancer screening tests  in spite of relatively high coverage rates among health plans, suggesting  that factors other than insurance coverage are responsible for the low  screening rate. The draft report’s background section noted colorectal  cancer screening rates and certain factors cited by other researchers that  influence these rates. However, an assessment of the factors influencing  screening utilization rates, beyond the extent of health insurance  coverage, was outside the scope of this report.
AHIP also suggested that the report include a discussion of the factors that  drive the benefit package decisions made by employers and consumers in  selecting health plans, noting that such decisions are necessarily  influenced by cost, individual circumstances, and other factors. We agree  that many factors influence the choice of benefits consumers or employers  select when choices are available, but examining these factors was beyond  the scope of this study.
AHIP further commented that we emphasized the ACS colorectal cancer  screening guidelines, but not those set forth by USPSTF, which they  suggested are also highly regarded. We used the ACS guidelines as a  complete framework for presenting our findings because the guidelines  indicate a frequency for each test. While USPSTF guidelines include the  four tests specified by ACS, they only indicate the frequency with which  the tests should be administered for FOBT. Nevertheless, we modified the  report to add reference to the USPSTF guidelines.
As agreed with your office, unless you publicly announce its contents earlier, we plan no further distribution of this report until 30 days after its  issue date. At that time, we will send copies to interested congressional committees and members and make copies available to others upon  request. In addition, the report will be available at no charge on the GAO  Web site at http://www.gao.gov.
Please contact me at (202) 512-7118 or Randy DiRosa at (312) 220-7671 if  you or your staff have any questions. Key contributors to this report are  listed in appendix III.
section_title: Appendix I: Scope and Methodology
paragraphs: To examine the extent to which the four key colorectal cancer tests are  covered for screening purposes by private health insurance plans, we  reviewed the extent to which state laws require such coverage, and we  reviewed the extent of coverage among selected small employer and  individual plans in states without such laws, a sample of large employer  plans, and coverage within FEHBP plans. We conducted our work from  October 2003 through June 2004 according to generally accepted  government auditing standards.
subsections: section_title: State Laws Requiring Colorectal Cancer Screening Test Coverage
paragraphs: To identify states that had laws that require private health insurance plans  to cover colorectal cancer screening tests, we reviewed the laws in each  state as of May 2004, and consulted with state officials to clarify the laws  as necessary.  We did not include state regulations or policies applicable to  insurance plans in our review.
section_title: Small Employer and Individual Health Plans
paragraphs: To examine coverage of colorectal cancer screening tests in small  employer and individual health plans, we identified the largest health  insurers in 10 of the states without existing or pending colorectal cancer  screening laws by using information compiled by CDC, the National  Association of Insurance Commissioners, Blue Cross and Blue Shield  Association, and the National Conference of State Legislatures. This  assessment was completed in November 2003. We selected five states  based on their large population—Florida, Massachusetts, Michigan, New  York, and Wisconsin—and randomly chose five additional states—  Arizona, Arkansas, Colorado, Louisiana, and Maine. To identify the largest  health insurers in these states, we contacted insurance regulators in each  state and asked them to identify the two largest small employer health  insurers and the two largest individual health insurers in terms of covered  lives, premiums collected, or—in the absence of quantitative data—their  best judgment.
We contacted the insurers identified to obtain information about the  extent to which their health plan with the most members covered  colorectal cancer screening tests. We posed a series of questions related to  insurers’ coverage of four colorectal cancer tests—FOBT, flexible  sigmoidoscopy, DCBE, and colonoscopy—for screening purposes.Further, we asked insurers about their health plans’ coverage restrictions,  including those related to age, frequency, family history, personal history,  and plan authorization. We received responses to our questions from 18 of  the 19 small employer insurers we contacted (95 percent), and 14 of the 17  individual insurers we contacted (82 percent).
section_title: Large Employer Health Plans
paragraphs: To examine coverage of colorectal cancer screening tests in large  employer health plans, we randomly selected 50 companies from the 2002  Fortune 500 list.One company was subsequently removed from the  sample because it filed for bankruptcy protection after the list was  published and no longer had any U.S. employees. Thus, the final sample  included 49 companies. We contacted health plan benefits administrators  or human resources staff in each of these companies. We made at least  three attempts to obtain a response from each company in our sample,  including contacting the company’s government affairs or chief executive  office to request participation in certain instances. Similar to insurers  offering small employer and individual health plans, participating  employers answered questions related to their largest plan’s coverage of  the four key colorectal cancer tests for screening purposes and  restrictions related to this screening test coverage. We received responses  from 35, or 71 percent, of the companies we contacted.
Three plans offered by large employers reported covering one or more of  the four colorectal cancer tests for screening purposes, but also required  that a member have a family or personal history of the disease in order to  receive coverage for the screening test. Because these requirements were  inconsistent with our definition of screening test coverage, we  characterized these plans as not covering the relevant tests for screening  purposes.
section_title: FEHBP Plans
paragraphs: To identify coverage policies of health plans offered through FEHBP, we  reviewed 2004 coverage brochures maintained on the OPM website. When  a plan offered multiple benefit options, we counted each option as a  separate plan. When the same plan was offered in multiple locations but  with the same benefits, we counted it as one plan. Our review of 2004  FEHBP brochures identified 143 distinct benefit plans. We identified the  extent to which each of the four tests was explicitly listed as a covered  benefit for screening purposes for each plan. We then discussed our  interpretation of the brochure language with OPM representatives. In  addition, we contacted representatives of each of the 5 national plans and  8 of the 61 local plans whose brochures did not explicitly indicate the  coverage of each of the four tests. The local plans were selected  judgmentally from different geographic areas of the country. We discussed  with plan officials our interpretation of their brochure language, and  revised our analysis based on these discussions.
section_title: Limitations
paragraphs: We relied on self-reported information from officials of the health plans  offered to small employers, individuals, and large employers, and did not  independently verify their responses. Further, although we achieved  relatively high response rates of between 71 and 95 percent for our review  of coverage in the small employer, individual, and large employer market  segments, we may nonetheless have encountered selection bias. That is,  insurers and large employers with more colorectal cancer screening  benefits could have been more likely to participate in our survey than  those with fewer colorectal cancer screening test benefits. In addition, we  surveyed a small number of small employer, individual, and large  employer health plans, precluding our ability to generalize the findings  beyond these health plans. Nevertheless, our findings illustrate the  colorectal cancer screening test benefits of approximately 4 million  individuals covered under the small employer, individual, and large  employer plans we reviewed, and more than 8 million individuals covered  under FEHBP.
section_title: Appendix II: State Laws Requiring Private Health Insurance Coverage of Colorectal Cancer Screening Tests
paragraphs: Table 5 shows state colorectal cancer screening laws in place as of May  2004. As indicated, 20 states have laws that require private insurance  coverage of colorectal cancer screening tests.
section_title: Appendix III: GAO Contact and Staff Acknowledgments
subsections: section_title: GAO Contact
section_title: Acknowledgments
paragraphs: Susan Anthony, Christine DeMars, Iola D’Souza, Sari B. Shuman, and Behn  M. Kelly made key contributions to this report.
section_title: Related GAO Products
paragraphs: Private Health Insurance: Federal and State Requirements Affecting  Coverage Offered by Small Businesses. GAO-03-1133. Washington, D.C.:  September 30, 2003.
Medicare: Most Beneficiaries Receive Some but Not All Recommended  Preventive Services. GAO-03-958. Washington, D.C.: September 8, 2003.
Medicare: Use of Preventive Services is Growing but Varies Widely.  GAO-02-777T. Washington, D.C.: May 23, 2002.
Medicare: Beneficiary Use of Clinical Preventive Services. GAO-02-422.  Washington, D.C.: April 12, 2002.
Medicare: Few Beneficiaries Use Colorectal Cancer Screening and  Diagnostic Services. GAO/T-HEHS-00-68. Washington, D.C.: March 6, 2000.