approach (Darby, 1998). General Motors, the nation’s largest private employer, has recently collaborated with CDC to examine barriers to the use of prevention services and to devise strategies to improve the rate of use of such services by its employees. Partnership for Prevention, a national nonprofit organization, provides guides for employers and health plans regarding highest value preventive health services (http://www.prevent.org/publications.htm).

Actions taken on behalf of federal employees in some areas of cancer control provide models that private-sector employers can emulate. In 1997, an executive order established smoke-free environments for the more than 1.8 million civilian federal employees and members of the public visiting or using federal facilities. In 2001, federal departments and agencies were directed to establish a policy that provides up to 4 hours of excused absence each year, without a loss of pay or a charge to leave, for participation in preventive health screenings. Agencies were also directed to develop or expand programs offered at the worksite to help employees understand their risks for disease, obtain preventive health services, and make healthy lifestyle choices. The Office of Personnel Management has issued guidance for a model smoking cessation program and is compiling a list of best practices to be shared with agencies. Agencies can pay the costs incurred by employees participating in agency-authorized smoking cessation programs, including payment for nicotine replacement therapy when purchased as part of an agency’s smoking cessation program (www.opm.gov/ehs).

Other opportunities to encourage prevention include employer-sponsored wellness and physical fitness programs, either through on-site facilities or through discounts to local gymnasiums or fitness programs. Relatively few employers offer such benefits, and employees with the least access to them are blue-collar or service workers and those working for small firms.

Recommendation 5: The U.S. Congress should increase support for programs that provide primary care to uninsured and low-income people (e.g., Community and Migrant Health Centers and family planning programs of Title X of the Public Health Service Act). These programs increase the use of cancer prevention and early detection services among medically underserved populations.

A pervasive problem in the United States is poor access to health care because of a lack of health insurance. Persons with health insurance are more likely to have a primary care provider and to have received appropriate preventive care such as recent cancer screening tests. Adults with health insurance are twice as likely as adults without health insurance to receive a routine checkup. In 2001, an estimated 15 percent of the U.S. population (41.2 million individuals) was uninsured during the entire year (U.S. Census



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