One fundamental barrier to cancer screening imposed by the structure of the U.S. health care system is that a large proportion of the eligible population lacks access to health care. The policy issues surrounding the amelioration of the current situation in which some 39 million Americans (14 percent of the population) lack some type of health insurance are beyond the scope of this report, but the situation clearly constitutes a fundamental obstacle to optimizing the potential of cancer screening in the United States (

Even among persons with health insurance, the private payers and governmental programs that finance health care services face economic barriers to offering coverage for cancer screening. For payers and employer benefits managers, monetary costs pose an impediment to offering coverage for cancer screening, as they do for many other health care services, although the literature suggests that their cost-effectiveness ratios generally fall within affordable ranges. Managed care plans, whose members often remain enrolled for an average of just a few years, may be reluctant to extend coverage to screening tests with high up-front costs. Public insurance programs, such as Medicare and Medicaid, face similar concerns and statutory restrictions against covering prevention services, although the latter have been less of a concern in recent years. Between 1965 and 1990, the U.S. Congress introduced 453 bills proposing coverage for prevention services under Medicare, but the first prevention service was not covered until 1980 (Schauffler, 1993).

Developments in recent years have shifted payer policy toward more extensive coverage for cancer screening tests, making insurance coverage less of an impediment to screening than it was as recently as one decade ago. In addition, the competitive marketplace of private health insurance and the public’s interest in obtaining preventive care have made coverage of cancer screening a potent marketing tool, with coverage of cancer screening heavily promoted by the managed care industry, thereby providing an infrastructure for the delivery of cancer screening services. In fact, at least some studies suggest that patients who belong to health maintenance organizations are more likely to receive cancer screening tests than those covered by indemnity plans (Phillips et al., 2000; Gordon et al., 1998; Hsia et al., 2000).

Data from the Health Plan Employer Data and Information Set (HEDIS) reported to the National Committee for Quality Assurance reflect the successes of this infrastructure in the delivery of cancer screening at 273 organizations (health maintenance organizations, point-of-service plans, and other managed care plans) that collectively cover 63 million Americans. In 2000 these organizations reported that 76 percent of their female members

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