Our model indicates that millions more low-income women will gain health insurance coverage after implementation of the ACA, which should lead to increases in levels of cancer screening among this population. The increase in screening among newly insured women should help to improve the national screening rate, which has remained steady (mammograms) or declined slightly (Pap tests) for a decade (1
). Although the ACA will reduce the number of uninsured women, the NBCCEDP will still be needed to support access for millions of women who will remain uninsured. If future numbers of women served by NBCCEDP are comparable to recent numbers, the program will still only be able to meet the needs of one-fifth to one-third of those eligible. Like many public health programs, NBCCEDP is a grant program, and its funding is limited by federal and state appropriations; the program has never had sufficient funds to serve all eligible women.
This study has several limitations. While forecasts are useful, they are necessarily based on assumptions. One such assumption is that past trends can predict future trends. We assumed that the ACA will be implemented in 2014 and that its national effect will be similar to the effect of the Massachusetts reform. Even if the ACA is fully implemented as passed, complete implementation of the insurance expansions may take more time. Our model assumed that economic and social circumstances (eg, employment, income) in 2014 will be similar to those in 2009. Our projections also relied on survey data, which introduces the potential for measurement and respondent recall errors.
Our model differed from the insurance simulation models developed by the Congressional Budget Office (22
) and the Urban Institute (23
). These complex models are designed to compare national budgetary effects of alternative policies and are based on an amalgam of sources, particularly the Current Population Survey and the Medical Expenditure Panel Survey. These models require many submodels and assumptions about behavioral responses to various policies; models that have only slightly different assumptions may yield different results (24
). Our model used a larger sample (the ACS) and a more transparent set of assumptions. However, our results still depended heavily on our assumptions.
We focused on uninsured women because we anticipate that almost no insured women will be underinsured for breast or cervical cancer screening after implementation of the ACA, which requires screening coverage without cost-sharing. However, some insured women may be eligible for NBCCEDP services for diagnostic tests, such as biopsies or other imaging, which may be subject to deductibles or copayments even after implementation of the ACA. Diagnostic tests are used for further assessment of abnormal screening results and for women who have a prior history of cancer. Thus, while almost no insured women should be underinsured for screening after implementation of the ACA, some may be underinsured for diagnostic testing purposes, and these women could receive free care through the NBCCEDP.
Our analyses indicate 3 shifts in the population of women who will remain eligible for NBCCEDP services. First, the geographic distribution of low-income uninsured women eligible for services will change, possibly prompting changes in the allocation of funds among states or the location of services within states. This shift will occur because the number of women projected to gain insurance varies by state. Generally speaking, the largest gains in insurance coverage were projected in states with lower per capita incomes and lower 2009 Medicaid eligibility standards for nonelderly adults. Conversely, states with more generous current Medicaid eligibility standards for adults and higher per capita incomes were projected to have smaller gains in insurance coverage. Thus, in addition to providing health insurance for millions of low-income women, health reform will change the distribution of the remaining uninsured population.
A second major shift will occur because the remaining population of eligible women will include a higher percentage of women who have a limited education and limited English proficiency. Local programs may need to adapt their educational and outreach approaches to meet the needs of these women. NBCCEDP providers should be able to provide language assistance to women who have limited English proficiency; such assistance is required under federal policy (26
). Many women who have limited English proficiency are immigrants, who are an important population for public health screening because they are less likely to obtain cancer screening than other women (27
). The third major shift is that the remaining population of NBCCEDP-eligible women will have a greater percentage of Hispanic and Asian women, the very women least likely to obtain regular breast and cervical cancer screening (1
). In addition, the women who will remain uninsured despite large increases in coverage may be harder to reach with health-related messages. Lack of awareness (health literacy) (29
) and transportation/geographic access (30
) are barriers to cancer screening. These barriers are likely to be relevant for a larger share of the women who will remain uninsured women after implementation of the ACA.
One option to consider is to increase the percentage of NBCCEDP funds that can be spent on cancer outreach and patient navigation services, which is now capped at 40%. Currently, 60% of program funds must be spent on screening and diagnostic services and on referrals for treatment. Many more low-income women in 2014 will have access to screening through insurance coverage, so it may be appropriate to dedicate a larger share of program funds to outreach and navigation so that women, whether insured or uninsured, receive encouragement and assistance to be screened. Given that the NBCCEDP-eligible population is expected to be harder to reach with health care messages, such efforts may be critical to ensuring the program reaches its target population. This option would also help insured women who may be unaware of the need for cancer screening or who may face other barriers. Because 80% of unscreened women who have access to health care report not receiving a recommendation for a mammogram (31
), there is clearly a need for additional education efforts.
Another option is to expand eligibility guidelines to include higher income levels. In addition to promoting cancer screening among moderate-income uninsured women, this policy option would help women who need diagnostic tests after screening indicates an abnormality. The NBCCEDP provides diagnostic tests without cost-sharing (whereas the ACA eliminates cost-sharing only for cancer screening services). If low- and moderate-income women are unable to afford cost-sharing for diagnostic services after receiving an abnormal screening result, they may not receive early treatment.
Millions of American women do not get screened for breast or cervical cancer. The ACA offers an opportunity to increase screening, early detection, and treatment of these cancers. Our analyses indicate insurance coverage will increase for low-income women. The Oregon trial (9
) showed that simply increasing insurance coverage can boost screening rates for breast and cervical cancer. Despite this encouraging news, millions of low-income women will remain uninsured after implementation of the ACA. The NBCCEDP will continue to play a role in helping to ensure that low-income uninsured women have access to cancer screening services, but it may need to adapt its policies to meet new programmatic needs.
This analysis was conducted and written before the Supreme Court’s June 2012 decision to give states the option to not expand Medicaid. Several governors have since announced they will not expand Medicaid, but how many states will not implement the expansion remains unclear. For states that expand Medicaid, our state-specific estimates should be reasonable approximations of uninsured rates, but in states that do not, future uninsured rates will likely be between our estimates and their 2009 baselines. Other elements of the ACA, such as health insurance exchanges, tax credits, and the requirement to purchase insurance or pay a tax penalty, will still lead to gains in women’s insurance coverage, although the poorer women could still be denied Medicaid. If some states are also able to block the health insurance exchanges, their insurance rates should remain closer to their 2009 baselines. Because some of the states most likely to resist Medicaid expansion have higher uninsured levels, the optional nature of the Medicaid expansion means that national gains could be much lower than anticipated, as recent estimates of the Congressional Budget Office indicate (32
). The number of future uninsured low-income women will depend on state policy choices and will remain high in states that fail to implement Medicaid expansions. In those states, the demand for screening services under NBCCEDP will increase.