We found that a large number of women—4 million women or 8.5% of all U.S. women aged 40 to 64—were uninsured during 2002–2003 and had incomes below 250% of the federal poverty level, meeting Program eligibility requirements. Of these, only about 13.2% received mammograms funded through the Program. Although many of the estimates for groups of women classified by race/ethnicity were imprecise, as indicated by wide CI, there was clearly wide variation in numbers and percentages of women eligible for the Program and in the percentages of eligible women who were screened. The percentage of eligible women screened was highest among American Indians and Alaska Natives. Although the estimates of eligible women in each state were also imprecise, the findings clearly showed wide variability. The percentage of eligible women screened in each state ranged from approximately 2% to approximately 79%.
The Program is an important source of mammography screening services for low-income, uninsured women, but neither NBCCEDP nor other providers that serve this population are able to meet the current needs. The Program has grown since 1991/1992 when 38,476 women were screened in 12 states [8
] to screen over 500,000 women during 2002/2003 in all states. A large number of federally funded community health centers, hospitals, clinics, and voluntary associations provide mammography screening services to underserved women. The numbers of women screened by these programs are not readily available. However, we know from the 2003 National Health Interview Survey (NHIS) that only 42.3% of women with no health insurance and family incomes less than 250% of the poverty level reported having had a mammogram during the previous two years (Robert Uhler, MS, Personal Communication, February 2006). Of the 4 million women we have identified in this study as eligible for the Program, the NHIS results indicate that about 1.7 million women were screened, meaning that approximately 1.2 million received screening outside of the Program. However, this leaves about 2.3 million low-income, uninsured women who did not obtain those services from either the Program or other sources.
The largest numbers of women eligible for the Program were non-Hispanic White women. In contrast, the largest percentages of women eligible for the Program were from minority groups, except for women of Two or More Races. Hispanic and non-Hispanic American Indian/Alaska Native groups had the highest percentages of eligible women. We were limited in our ability to assess the extent to which the Program met the mammography screening needs of women by race/ethnicity because about 12,000 women screened in the Program were of unknown race/ethnicity. If we had been able to correctly allocate these women to their appropriate race/ethnic groups, the percentages of women screened would have differed from those shown, potentially by an important margin. However, the findings indicate that the Program was most successful in meeting the needs of American Indian/Alaska Native women, approximately 49% of whom were screened. A possible reason for this success may be that these populations are the focus of health services through which the Program operates. In 1993, Congress amended the Breast and Cervical Mortality Prevention Act, Public Law 108-183, to authorize funding for American Indian/Alaska Native organizations and provided the opportunity to direct resources to these populations, specifically four grantees in Alaska and another nine geographically distributed across the contiguous United States.
The number and percentage of women who were eligible for the Program varied greatly from state to state, because of differences in population size, age, and sex distributions, as well as differences in income and insurance coverage, including Medicaid [18
]. In addition to the aforementioned factors, reasons for variations in the percentage of eligible women screened include differences in income eligibility criteria, presence of American Indian/Alaska Native grantee, CDC funding levels, other sources of funding, and organization and efficiency of the screening Programs. The upper and lower bounds of the CI indicate that some estimates were not precise, but were useful nevertheless. These estimates have been made available to each state for their use in Program planning to better understand the need for screening services in their states.
Our study is subject to a number of limitations. As already noted, many of the estimates are imprecise because the numbers of women in the CPS ASEC sample who are eligible for the Program are relatively small. In addition, health insurance coverage could be underreported in the CPS ASEC given that the survey uses annual retrospective questions and respondents may have difficulty recalling the information [18
]. Also, some women are eligible for the Program even if they have health insurance, but are underinsured, meaning the insurance does not cover mammography screening services, or there is a high copayment. Since CPS ASEC insurance questions do not measure covered services, these underinsured eligible women are not included in the denominators of our screening percentages. It is uncertain how many low-income women in the United States population are underinsured. Finally, our inability to define the race or ethnicity of some women in the study could result in an underestimate of the participation rate for any given race or ethnic group.
We suggest two strategies to improve screening rates: increasing efficiencies of the Programs and improving their collaboration with other organizations. First, the Program must seek ways of increasing its efficiency to serve more women with existing resources. A study of Program costs found that the average cost of screening a woman through the Program was lower for grantees screening greater numbers of women because of economies of scale, that is, average cost decreased as number of women screened increased [20
]. States with small populations in larger geographical areas may have limited opportunities to achieve such economies of scale. CDC has recently initiated a cost-effectiveness evaluation of the Program and is developing methods to better collect and analyze information on resources and how they might be used more efficiently. A variety of means to increase efficiency will need to be pursued. For example, many women in the Program are screened annually. The U.S. Preventive Services Task Force recommends screening every 1–2 years because it has found little evidence that annual screening is more effective than biennial screening [3
]. Many European programs provide screening every 2–3 years [21
]. The Program may need to evaluate the potential balance of health benefits from adopting a biennial schedule that could serve more women.
Second, the Program needs to improve collaboration and coordination with other providers that serve a similar client population. The Program already coordinates substantially with private and nonprofit organizations, businesses, and other groups involved in breast cancer screening, but that coordination needs to be increased to recruit the women who are not currently being served. For example, in addition to providing screening services, the Program provides diagnostic services for eligible women screened by organizations outside of the Program. Alternative sources of diagnostic services may need to be pursued to free resources for increased screening of eligible women.
Although greater efficiency and improved coordination with other screening providers could better meet the needs of underserved women, they are unlikely to be enough. Given that about 2.3 million low-income uninsured women did not obtain recommended breast cancer screening services in 2003 and that the Program provided those services to about 500,000 women; increased efficiency and coordination alone will be insufficient to meet the needs of the eligible population.
In 2000, when Healthy People 2010
first set out its objectives of eliminating health disparities and increasing the proportion of women aged 40 and older who have received a mammogram within the previous two years to 70% [12
], the greatest disparities in breast cancer screening were for women who had no health insurance, those who had no usual source of care, and recent immigrants [5
]. Although progress has been made since 1987 in increasing mammography screening among low-income and uninsured women, the increases for low-income women are less than those for higher-income women, and screening among the uninsured lags far behind screening among women with private or public health insurance [5
]. The Program contributes substantially to the effort to provide breast cancer screening services to those women by serving 13.2% of those eligible. However, the Healthy People 2010
objectives are still far from being met.