with more extensive prevention services, and can create financial incentives for health plans to meet performance goals. Employers can also support wellness and physical fitness programs either through on-site facilities or through employee discounts to local gymnasiums or fitness programs.

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. People 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. In 2001, an estimated 15 percent of the U.S. population (41.2 million individuals) was uninsured during the entire year (U.S. Census Bureau, 2002). Many others are underinsured, with poor coverage for interventions that have been proven to be effective, such as smoking cessation counseling and products.

Individuals who are uninsured (or underinsured) rely on a patchwork of public and private programs for primary care (IOM, 2000d). Community and Migrant Health Centers and Title X family planning clinics are vital sources of primary health care and are important providers of cancer prevention and early detection services. Full support for these programs enhances the nation’s health care safety net and at the same time extends the availability of cancer prevention and early detection services to vulnerable populations. Even with increased program support, however, many people would likely remain underserved, given the fragmented and limited nature of the nation’s health care safety net.

Recommendation 6: Support for the Centers for Disease Control and Prevention’s National Breast and Cervical Cancer Early Detection Program should be increased so that the program can reach all uninsured women using innovative delivery strategies. Support is also needed for a similar program at the CDC to provide screening for colorectal cancer for uninsured and low-income men and women.

Underfunding of CDC’s National Breast and Cervical Cancer Early Detection Program (NBCCEDP) contributes to lost opportunities for prevention. NBCCEDP has succeeded in improving screening rates among medically underserved populations, but the program reaches only 15 percent of eligible women because of limited financial support. This is especially unfortunate insofar as racial, ethnic, and socioeconomic disparities in cancer mortality can often be traced to under-use of screening services.

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