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. 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.) 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. 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. 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. 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. 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. 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.

Summary: 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. 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.