© Oxford University Press 2007.
NEWS |
Screening Program Serves Fraction of Those Eligible
The 109th Congress adjourned without passing legislation updating the federal program for breast and cervical cancer screening last year, a program that provided access to mammography and Pap smears for hundreds of thousands of low-income women.
Since its inception in 1991, the National Breast and Cervical Cancer Early Detection Program, which is run through the Centers for Disease Control and Prevention, has screened approximately 2.5 million women. However, under current funding levels, the program can provide screening to only one of five eligible women. In some states, there is only enough money to screen one in 20, according to the American Cancer Society.
Despite modest increases over the past few years, the overall lack of federal money has hamstrung states’ efforts to extend the free screening to all eligible women, said Pama Joyner, director of the state of Washington's Breast and Cervical Health Program and president-elect of the Breast and Cervical Cancer Program Directors Council.
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With the help of new private and state funds—Washington's legislature recently allocated about $2.3 million for the program, exceeding the federal matching requirements—the program can be expected to serve one of every four eligible women.
"We went 5 years without any increase in funding, so it was really more of a catchup," she said.
However, there are 10 states with programs that get little or no direct funding from their legislatures (see box). For those programs, restrictions on how the federal grant money can be spent have affected outreach efforts, a problem that would have been corrected in the failed bill. In other states, outreach has been so successful that programs are running out of money. For example, Michigan's program began turning women away as early as August of last year because of funding shortfalls. Many programs are struggling to find the right balance.
| Screening Lacking in Some States Most states contribute funds to breast and cervical cancer screening programs for low-income women, which allows them to receive federal matching funds. But several state programs have little or no funding outside federal grants, limiting screening access for uninsured women. The states include the following:
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"You don’t want to set up an expectation you cannot fulfill, but at the same time it is hard to justify requests for more money if you don’t have people on a waiting list," Joyner said.
More Money Needed, Less Sought
By statute, the NBCCEDP is the last resort for breast and cervical cancer screening services; funds for the program cannot be used to pay for services if other coverage is available through any state fund, private health insurance, or other government program such as Medicaid or Medicare. Under the program's rules, state grantees are required to contribute $1 for every $3 of federal funds, although in-kind costs such as employee salaries, rent, equipment, or donated services can also count toward the states’ share.
The federal program received just over $200 million from Congress last year. While the president's proposed budget for fiscal year 2007 requested a $1.4 million reduction in funding, the congressional reauthorization bill called for a $48 million increase in federal appropriations, which would have raised the program's budget to close to $250 million. As of press time, Congress had not passed an appropriations bill funding most agencies, including funding for the program. Those agencies are receiving funding at 2006 levels under a continuing resolution.
In 2005, the most recent year for which data are available, the CDC reported that the program screened nearly 630,000 women. Outreach and screening costs less than $300 per patient. Increasing the program's annual budget by $50 million would allow screening an estimated 147,000 more women, according to an ACS assessment of the CDC data.
"The great thing about the program is that it's cost effective," said Meghan Evett, public policy specialist with the Susan G. Komen Breast Cancer Foundation.
The reauthorization would have also have included a waiver giving more flexibility to program grantees that operate under rules governing how the federal dollars can be spent. Under current law, the grantees must devote at least 60% of their federal funding to screening, referral, and follow-up services. The remaining 40% of funds may be allocated toward other outreach activities, including public education, professional education, quality assurance, and surveillance and evaluation efforts. The law also places an overall 10% cap on administrative expenses.
Although the 60/40 split works for most grantees, the restrictions on outreach and client recruitment spending have made it difficult to reach some eligible women in those programs that serve smaller populations, according to lawmakers who propose increasing funding. That has been especially true in rural states, where women may be harder to reach, and in states that rely almost solely on federal funds, which gives them less spending flexibility. The reauthorization measure would have allowed them to use federal funds in a way that fits their particular needs, said Wendy Selig, vice president for legislative affairs for the American Cancer Society.
"The one-size-fits-all approach has not worked," she said.
On the Horizon
The reauthorization measure did not address one potential issue: a decision by CDC officials to bar the higher payments for new technologies, such as digital and computer-assisted mammography. An expert panel convened by the agency concluded that there was not enough evidence that these methods offered an advantage over film mammography. However, in some states, finding physicians who still use conventional mammography is becoming increasingly difficult, Joyner said. No one has refused to contract with the program on the basis of the low reimbursement, but that could just be around the corner, she said.
The Komen Foundation and the American Cancer Society hope that they can build on the momentum of last year's reauthorization measure, which passed the House overwhelmingly. However, given the tight fiscal situation on the federal level, the advocacy groups will also be working diligently on the state level to gain new funding for the program, Evett said.
"While we want to increase funding on the federal level and we want to try to get systematic language to allow state programs to operate at optimum levels, we also want to work to increase funding elsewhere, such as from the private sector," she said.
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