On January 29, the House Oversight and Government Reform Committee held a hearing, “Addressing the Screening Gap: The National Breast and Cervical Cancer Early Detection Program (NBCCEDP).”
In his opening statement, Chair Henry Waxman (D-CA) said, “In 1990, Congress stepped in to give women access to early cancer detection…By passing this law, we sent the message that no woman should have to forgo life-saving tests because she can’t afford them. In 2000, we strengthened this program by passing a law allowing states to cover these women, if a cancer is detected, within their Medicaid programs. Since that time, all states have elected this Medicaid option.” He continued, “We’re here today to talk about what the National Breast and Cervical Cancer Early Detection Program has accomplished and what is left to be done. Over the past 16 years the program has served over three million women. In 2006 alone, the program detected over 4,000 cases of breast cancer, and over 5,000 cervical cancers and pre-cancerous lesions… But overall, the women served only represent less than 15 percent of the eligible population…It is ironic that we spend money to create cancer awareness and urge women to get mammograms, but then have clinics with long waiting lists for actually getting them. It is tragic that this underfunding and these waiting lists undoubtedly mean that women whose cancers could have been caught early and treated instead find out when their disease has progressed and spread.” Rep. Waxman went on to discuss the racial and ethnic disparities in breast and cervical cancer diagnosis and treatment rates. He closed by urging his colleagues to support expanded funding of the NBCCEDP.
Ranking Member Tom Davis (R-VA) said, “Today’s discussion gives the committee an important opportunity to emphasize the priceless value of screening and early detection in the fight against breast and cervical cancer…Despite clear success in reaching a vulnerable population, the percentage of eligible women reached through the program remains low nationwide and varies significantly from state to state. The CDC [Centers for Disease Control and Prevention] and U.S. Census Bureau found in 2002-2003 that only 13 percent of eligible women across the U.S. received a program-funded mammogram. Likewise, only six percent of eligible women received a Pap test through the program. Within that number, the study found a staggering variation in screening rates from just two percent to as high as 63 percent among eligible women between the ages of 40-64, the highest priority population. This is an unmistakable indication some states have found ways to be far more effective than others at using federal funds to reach eligible women. Is it just a question of money, or are there important lessons all states can learn about increasing the efficiency and effectiveness of this vital public health effort? Despite the fact [that] prevention pays for itself many times over in avoided costs and improved lives, resources for programs like this will always be more limited than anyone would like. Today, we need to talk about appropriate funding levels and about the innovations and best practices that will make sure those funds reach as many women as possible.”
Rosemarie Henson, deputy director of the National Center for Chronic Disease Prevention and Health Promotion at the CDC, began her testimony with an overview of the NBCCEDP program. Since the program’s inception in 1991, the funding level has risen from $30 million to $182 million in FY2008 to cover some 22,000 providers in every state, five territories, and 12 tribal areas. Ms. Henson shared the most recent screening demographic information with the committee, saying: “Reaching the most at-risk populations is an ongoing priority of the NBCCEDP, including serving women who are rarely, or never, screened and racial and ethnic minorities that are disproportionately affected by breast and cervical cancer.” She noted the CDC’s commitment to ongoing program evaluation and that programs with “strong performance based on the above criteria are eligible for small budget increases pending resource availability. The performance-based system ensures the efficient and appropriate distribution of program funds awarded to states, tribes, and territories based on their ability to screen women, deliver high quality services, and adhere to program guidelines.” Ms. Henson said that the CDC is working to reach underserved women by increasing public education and awareness campaigns, assigning case managers to ensure follow-up among women with abnormal test results, and offering continuing professional education for providers.
Shelley Fuld Nasso, director of public policy for the Susan G. Komen for the Cure Advocacy Alliance, recommended several improvements to the NBCCEDP, including increased funding: “From a high of $210 million in FY2004, funding for the NBCCEDP has either declined or remained essentially flat for the subsequent years. In FY2008, the program received only approximately $200 million, despite an authorization level of $225 million…Programs run out of money mid-way through the year and are forced to suspend screening and referral services; states are forced to implement months-long waiting lists, which can cost women critical time in treatment; and programs do not have enough money to engage in outreach to hard-to-reach, vulnerable populations.” Further complicating the lack of funding is the emergence of digital mammography. Some studies suggest that digital mammography is a more effective screening tool in women younger than 50, who have denser breast tissue; however, digital mammography costs more than traditional screening and many providers are unwilling to accept lower NBCCEDP reimbursement rates for this service. Ms. Nasso said that the NBCCEDP must confront barriers to screening, “such as poverty, cultural issues and beliefs, lack of awareness about early detection programs and the benefit of screening, and geography” to ensure that African American and Hispanic women are served at the same rate as Caucasian women. In closing, she said, “The NBCCEDP is an important, cost-effective, life-saving program. In order to truly close the gaps that make breast cancer deadlier for some women than others, we need the federal government, as well as state governments, to step up their commitment to funding the program.”
Gail Carye, a breast cancer survivor, shared her story with the committee. Ms. Carey worked in New York in advertising; however, after the attacks on the World Trade Center in 2001, she was laid off and lost her health insurance benefits. Only a few weeks after losing her job, Ms. Carey found a lump in her breast, but was unable to pay for a mammogram or other health screening. Unable to find another job with health benefits, Ms. Carey turned to The Healthy Woman’s Partnership, New York’s NBCCEDP program. After a mammogram and biopsy, she was diagnosed with advanced breast cancer and underwent a mastectomy. “I feel blessed to have found this NBCCEDP program that covered my screening and ensured I would have access to treatment,” she said. “Without them, I likely would not have survived. Throughout this whole ordeal, I was treated with such dignity. This program is a phenomenon. I thought I was going to die because I didn’t have coverage, and nobody should have that as their only option.”
Dr. Otis Brawley, chief medical officer of the American Cancer Society; Dr. Thomas Hoerger, senior fellow at RTI, International; and Pamela Joyner, program director of the Washington State Breast and Cervical Cancer Health Program, also testified.
