Cervical cancer screening consists of pelvic  exams and the Pap test. 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. CDC’s Early Detection Program Screens More Than Half a Million Women Annually, but Many Eligible Women Are Not Screened

The CDC’s Early Detection Program screened about half a million or more  women for breast and cervical cancer annually from 2002 through 2006. Most States Extend Medicaid Eligibility to More Women Than the Minimum Required, but Some Women Are Still Excluded Based on Screening Source

Most states extend Medicaid eligibility under the Treatment Act to more  women than is minimally required—those whose screening or diagnostic  services were paid for with CDC funds. As of October 2008, 17 states  reported applying only this minimum definition in determining Medicaid  eligibility under the Treatment Act. The  remaining 19 states further extend eligibility to women who were screened  and diagnosed by non-CDC-funded providers. Seventeen states offer Medicaid eligibility only to women screened  or diagnosed with CDC funds. 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. Medicaid Enrollment and Spending under the Treatment Act Vary across States

Medicaid enrollment under the Treatment Act varied widely in 2006,  ranging from fewer than 100 women in each of South Dakota, Delaware,  and Hawaii to more than 9,300 women in California. From 2004 to 2006, the median rate of enrollment  growth was 40 percent among the 35 states reporting data for both years. 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. State eligibility policies and practices can also affect average spending. Few Statewide Alternatives to Medicaid Coverage for Treatment Are Available to Low- Income, Uninsured Women; Local Resources Offer Assistance in Some Areas

Among states that limit Medicaid eligibility under the Treatment Act to  women screened with CDC funds or that extend Medicaid eligibility to  women screened by a CDC-funded provider, few statewide alternatives to  Medicaid coverage for treatment are available to low-income, uninsured  women who are screened and diagnosed outside of the Early Detection  Program. 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. These include donated care, funding from local charity  organizations, and county assistance. 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. GAO staff who made major contributions to this  report are listed in appendix V.

Appendix I: Scope and Methodology

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. 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).
Why GAO Did This Study

Tens of thousands of women die each year from breast or cervical cancer. While screening and early detection through mammograms and Pap tests--followed by treatment--can improve survival, low-income, uninsured women are often not screened. In 1990, Congress authorized the Centers for Disease Control and Prevention (CDC) to fund screening and diagnostic services for such women, which led CDC to establish the National Breast and Cervical Cancer Early Detection Program. The Breast and Cervical Cancer Prevention and Treatment Act of 2000 was also enacted to allow states to extend Medicaid eligibility to women screened under the Early Detection Program and who need breast or cervical cancer treatment. Screened under the program is defined, at a minimum, as screening paid for with CDC funds. GAO examined the Early Detection Program's screening of eligible women, states' implementation of the Treatment Act, Medicaid enrollment and spending under the Treatment Act, and alternatives available to women ineligible for Medicaid under the Treatment Act. To do this, GAO compared CDC data on women screened by the Early Detection Program from 2002 to 2006 with federal estimates of the eligible population, surveyed program directors on the 51 states' (including the District of Columbia) implementation of the Treatment Act, analyzed Medicaid enrollment and spending data, and conducted case studies in selected states.

What GAO Found

The CDC's Early Detection Program providers screen more than half a million low-income, uninsured women a year for breast and cervical cancer, but many eligible women are screened by other providers or not screened at all. Comparing CDC screening data with federal estimates of low-income, uninsured women, GAO estimated that from 2005 through 2006, 15 percent of eligible women received a mammogram from the Early Detection Program, while 26 percent were screened by other providers and 60 percent were not screened. For Pap tests, GAO estimated that from 2004 through 2006, 9 percent were screened by the program, 59 percent by other providers, and 33 percent were not screened. Most states extend Medicaid eligibility under the Treatment Act to more women than is minimally required. As of October 2008, 17 states met the minimum requirement to offer Medicaid eligibility to women whose screening or diagnostic services were paid for with CDC funds; 15 extended eligibility to women screened or diagnosed by a CDC-funded provider, whether CDC funds paid specifically for these services or not; and 19 states further extended eligibility to women who were screened or diagnosed by a non-CDC-funded provider. In most of the states that offer Medicaid eligibility only to women served with CDC funds or by a CDC-funded provider, if a woman is screened and diagnosed with cancer outside the Early Detection Program, she cannot access Medicaid coverage under the Treatment Act. Medicaid enrollment and average spending under the Treatment Act vary across states. In 2006, state enrollment ranged from fewer than 100 women to more than 9,300. Median enrollment was 395 among the 39 states reporting data, with most experiencing enrollment growth from 2004 to 2006. Among the 39 states, average monthly spending per enrollee was $1,067, ranging from $584 to $2,304. Spending may vary due to several factors, including differences in state eligibility policies and practices and Medicaid benefit plan design. Few statewide alternatives to Medicaid coverage are available to low-income, uninsured women who need breast or cervical cancer treatment but are ineligible for Medicaid under the Treatment Act. Early Detection Program directors in only four of the states with more limited eligibility standards reported having a statewide program that pays for cancer treatment or provides broader health insurance or free or reduced-fee care. And while several sources identified possible local resources as alternatives--donated care, funding from local charity organizations, and county assistance--the availability and applicability of these resources varies by area. For example, an Early Detection Program official in Indiana told us that densely populated areas of the state had multiple treatment resources, but women living in rural areas had limited access to them.