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Leslie P. Boss, MPH, PhD, and Fredenck H. Guckes
Intrducion Mammography coupled with physical breast examination and the Papanicolaou smear (Pap) are accepted screening tools for breast and cervical cancer, respectively, but not all women receive these tests at recommended intervals. A substantial barrier for routine screening is cost, and poor women are less likely to receive the tests at recommended intervals than are other women.' The Medical Assistance Program, or Medicaid, mandates coverage of diagnostic and certain preventive services but not of breast and cervical cancer screening. Beyond services mandated by law, those covered by Medicaid are defined by each state based on a list of optional services. Medicare coverage, defined nationally, includes both screening mammography and Pap exams. Many elderly persons are eligible for coverage by both Medicaid and Medicare. When dual coverage exists, Medicare takes precedence. Based on the per capita income of a state, federal Medicaid funds are available to match state expenditures. In 1989, the federal share ranged from 50% to 78%.2 As benefits such as screening mammography are added to a state's Medicaid program, the state is responsible for payment and receives matching federal funds at the preassigned matching rate. Knowledge of individual state practices regarding coverage of screening tests for breast and cervical cancer is important information for health practitioners and program planners. It can also be of value in efforts to mobilize support for increasing existing benefits.
rollment for females was not readily available for all states, the age distribution of all females in states reporting to CFA was applied to the total HCFA estimate of female Medicaid recipients to obtain estimates of the number of recipient females in the age groups of interest. The estimated numbers of screening-eligible women for whom Medicaid-financed screening coverage could be provided in each state were summed to estimate the total number of screens that could occur and be covered, given current Medicaid regulations.
Results
Methods
In 1989, there were approximately 24 million Medicaid recipients, 15 million (63%) ofwhom were female. Of all female recipients, approximately 9.4 million (64%) were aged 15 to 84 years, roughly corresponding to American Cancer Society guidelines for Pap smear screening. Similarly, roughly 3.3 million female Medicaid recipients (22%) were between the ages of 45 and 84, ages appropriate for routine mammographic screening. Twenty-seven states allow coverage of Pap smears as a screening tool for all women eligible for Medicaid (Table 1). In another nine states and the District of Columbia, Pap smears are covered only with a physician's order. In five states, only the laboratory cost of the Pap smear is covered. In seven states, representing 22% of the total US population, women of childbearing age seen in family planning or maternity clinics are eligible for Medicaid coverage of Pap screening. Two states (2.8% of the US population) provide no coverage for screening for cervical cancer. It is estimated that there are 680 000 Medicaid eligible women for
A person responsible for cancer control activities in health agencies in each state (including the District of Columbia in this category) was asked about Medicaid coverage for screening for his or her state's population. When additional information was needed, the'state Medicaid office was also contacted. General Medicaid statistics were obtained from the Health Care Financing Administration (HCFA). Because age-specific en-
Leslie Boss is in the Epidemiology Program Office at the Centers for Disease Control in Atlanta; Frederick Guckes is at Eastern Virginia Medical School. Requests for reprints should be sent to Leslie P. Boss, Epidemiology Program Office, Centers for Disease Control, MS C08, 1600 Clifton Road NE, Atlanta, GA 30333. This paper was submitted to the journal January 23, 1991, and accepted with revisions August 23, 1991.
February 1992, Vol. 82, No. 2
Public Health Briefs
whom even partial payment for a Pap exam is not covered. In 23 states, coverage of screening mammography is provided for all Medicaid-eligible women; in an additional 15 states and the District of Columbia, coverage depends on a physician's order (Table 2). These 38 states represent 72% of the US population. No coverage is provided in 12 states. It is estimated that there are 570 000 Medicaid-eligible women ages 45 to 84 in these 12 states for whom mammography is not covered. Legislation requiring third-party payors to provide coverage of screening for breast and cervical cancer exists in 33 and 8 states, respectively. The availability of Medicaid coverage in these states is shown in Tables 1 and 2.
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Discussion The current interest in and awareness of early detection of breast cancer has led to increased use of mammography, changes in payment practices, and legislative and regulatory activity at both the state and national levels. Payment for diagnostic tests and appropriate follow-up care for cancer are generally covered by Medicaid, whereas screening procedures frequently are not adequately covered. However, expenditures for treatment of cancer can be decreased by cost-effective use of screening tests.3,4 It is not known how many screening procedures have been described as diagnostic tests so that costs would be covered under current regulations. Medicaid is one of many third-party payors of medical care. Third-party payment laws vary considerably in their mandate. In this assessment of coverage, we chose to include all existing legislation, given that such legislation signifies a certain level of consciousness in that legislative body concerning the importance of cancer screening.
In 1990, Congress passed Public Law 101-354, Preventive Health Measures with Respect to Breast and Cervical Cancers. A major part of its purpose is "to screen women for breast and cervical cancer as a preventive health measure," "to provide appropriate referrals for medical treatment of the women screened," and "to ensure, to the extent practicable, the provision of appropriate follow-up services."5 The law is meant to provide a pay-
February 1992, Vol. 82, No. 2
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ment of last resort; it is not to pay for a service forwhich payment can be made by any other state or federal compensation or health benefits program such as Medicaid or Medicare or under any other insurance or prepaid program. The law requires that low-income women be given priority for these services. Unfortunately, implementation of this act will be gradual, as appropriations to support the law will be incremental. Low-income women are particularly in need of opportunities for early diagnosis of cancer. Appropriate screening results in improved survival. Thus, legislators, caregivers, and public health professionals alike need to maximize the use of the benefits available to millions of American women through such government compensation programs as Medicaid. O
References 1. Dawson DA, Thompson GB. Breast cancer risk factors and screening: United States, 1987. Vital Health Statstics; Series 10, No. 172. Hyattsville, Md: National Center for Health Statistics; 1989. 2. Health Care Financing Administration. A Statistical Report on Medical Care Pro vided by Title XIXofthe Social SecwityAct. Unpublished report. 3. US Congress, Office of Technology Assessment. The Costs and Effectiveness of Screening for Cervical Cancer in Eldey Women. Washington, DC: US Govt Printing Office; February 1990. Background paper OTA-BP-H-65. 4. US Congress, Office of Technology Assessment. Breast Cancer Screenig for Medicare Beneficianes: Effectiveness, Cost to Medicare, and Medical Resources Required. Washington, DC: US Govt Printing Office; November 1987. 5. Pub L No. 101-354, and Title XV amendment to the Public Health Service Act (42 USC §201 et seq).
American Journal of Public Health 253
*f . * -:-f::-f:
Leslie P. Boss, MPH, PhD, and Fredenck H. Guckes
Intrducion Mammography coupled with physical breast examination and the Papanicolaou smear (Pap) are accepted screening tools for breast and cervical cancer, respectively, but not all women receive these tests at recommended intervals. A substantial barrier for routine screening is cost, and poor women are less likely to receive the tests at recommended intervals than are other women.' The Medical Assistance Program, or Medicaid, mandates coverage of diagnostic and certain preventive services but not of breast and cervical cancer screening. Beyond services mandated by law, those covered by Medicaid are defined by each state based on a list of optional services. Medicare coverage, defined nationally, includes both screening mammography and Pap exams. Many elderly persons are eligible for coverage by both Medicaid and Medicare. When dual coverage exists, Medicare takes precedence. Based on the per capita income of a state, federal Medicaid funds are available to match state expenditures. In 1989, the federal share ranged from 50% to 78%.2 As benefits such as screening mammography are added to a state's Medicaid program, the state is responsible for payment and receives matching federal funds at the preassigned matching rate. Knowledge of individual state practices regarding coverage of screening tests for breast and cervical cancer is important information for health practitioners and program planners. It can also be of value in efforts to mobilize support for increasing existing benefits.
rollment for females was not readily available for all states, the age distribution of all females in states reporting to CFA was applied to the total HCFA estimate of female Medicaid recipients to obtain estimates of the number of recipient females in the age groups of interest. The estimated numbers of screening-eligible women for whom Medicaid-financed screening coverage could be provided in each state were summed to estimate the total number of screens that could occur and be covered, given current Medicaid regulations.
Results
Methods
In 1989, there were approximately 24 million Medicaid recipients, 15 million (63%) ofwhom were female. Of all female recipients, approximately 9.4 million (64%) were aged 15 to 84 years, roughly corresponding to American Cancer Society guidelines for Pap smear screening. Similarly, roughly 3.3 million female Medicaid recipients (22%) were between the ages of 45 and 84, ages appropriate for routine mammographic screening. Twenty-seven states allow coverage of Pap smears as a screening tool for all women eligible for Medicaid (Table 1). In another nine states and the District of Columbia, Pap smears are covered only with a physician's order. In five states, only the laboratory cost of the Pap smear is covered. In seven states, representing 22% of the total US population, women of childbearing age seen in family planning or maternity clinics are eligible for Medicaid coverage of Pap screening. Two states (2.8% of the US population) provide no coverage for screening for cervical cancer. It is estimated that there are 680 000 Medicaid eligible women for
A person responsible for cancer control activities in health agencies in each state (including the District of Columbia in this category) was asked about Medicaid coverage for screening for his or her state's population. When additional information was needed, the'state Medicaid office was also contacted. General Medicaid statistics were obtained from the Health Care Financing Administration (HCFA). Because age-specific en-
Leslie Boss is in the Epidemiology Program Office at the Centers for Disease Control in Atlanta; Frederick Guckes is at Eastern Virginia Medical School. Requests for reprints should be sent to Leslie P. Boss, Epidemiology Program Office, Centers for Disease Control, MS C08, 1600 Clifton Road NE, Atlanta, GA 30333. This paper was submitted to the journal January 23, 1991, and accepted with revisions August 23, 1991.
February 1992, Vol. 82, No. 2
Public Health Briefs
whom even partial payment for a Pap exam is not covered. In 23 states, coverage of screening mammography is provided for all Medicaid-eligible women; in an additional 15 states and the District of Columbia, coverage depends on a physician's order (Table 2). These 38 states represent 72% of the US population. No coverage is provided in 12 states. It is estimated that there are 570 000 Medicaid-eligible women ages 45 to 84 in these 12 states for whom mammography is not covered. Legislation requiring third-party payors to provide coverage of screening for breast and cervical cancer exists in 33 and 8 states, respectively. The availability of Medicaid coverage in these states is shown in Tables 1 and 2.
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...
X, X
-------
..........
...
Discussion The current interest in and awareness of early detection of breast cancer has led to increased use of mammography, changes in payment practices, and legislative and regulatory activity at both the state and national levels. Payment for diagnostic tests and appropriate follow-up care for cancer are generally covered by Medicaid, whereas screening procedures frequently are not adequately covered. However, expenditures for treatment of cancer can be decreased by cost-effective use of screening tests.3,4 It is not known how many screening procedures have been described as diagnostic tests so that costs would be covered under current regulations. Medicaid is one of many third-party payors of medical care. Third-party payment laws vary considerably in their mandate. In this assessment of coverage, we chose to include all existing legislation, given that such legislation signifies a certain level of consciousness in that legislative body concerning the importance of cancer screening.
In 1990, Congress passed Public Law 101-354, Preventive Health Measures with Respect to Breast and Cervical Cancers. A major part of its purpose is "to screen women for breast and cervical cancer as a preventive health measure," "to provide appropriate referrals for medical treatment of the women screened," and "to ensure, to the extent practicable, the provision of appropriate follow-up services."5 The law is meant to provide a pay-
February 1992, Vol. 82, No. 2
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ment of last resort; it is not to pay for a service forwhich payment can be made by any other state or federal compensation or health benefits program such as Medicaid or Medicare or under any other insurance or prepaid program. The law requires that low-income women be given priority for these services. Unfortunately, implementation of this act will be gradual, as appropriations to support the law will be incremental. Low-income women are particularly in need of opportunities for early diagnosis of cancer. Appropriate screening results in improved survival. Thus, legislators, caregivers, and public health professionals alike need to maximize the use of the benefits available to millions of American women through such government compensation programs as Medicaid. O
References 1. Dawson DA, Thompson GB. Breast cancer risk factors and screening: United States, 1987. Vital Health Statstics; Series 10, No. 172. Hyattsville, Md: National Center for Health Statistics; 1989. 2. Health Care Financing Administration. A Statistical Report on Medical Care Pro vided by Title XIXofthe Social SecwityAct. Unpublished report. 3. US Congress, Office of Technology Assessment. The Costs and Effectiveness of Screening for Cervical Cancer in Eldey Women. Washington, DC: US Govt Printing Office; February 1990. Background paper OTA-BP-H-65. 4. US Congress, Office of Technology Assessment. Breast Cancer Screenig for Medicare Beneficianes: Effectiveness, Cost to Medicare, and Medical Resources Required. Washington, DC: US Govt Printing Office; November 1987. 5. Pub L No. 101-354, and Title XV amendment to the Public Health Service Act (42 USC §201 et seq).
American Journal of Public Health 253
