comparison, approximately 9 million women between the ages of 40 and 65 lacked health insurance that year. (Women over 65 are eligible for Medicare and so would have little need for this program.)

Community-based programs, such as the North Carolina Breast Cancer Screening Program, also disseminate information about prevention and guide women to mammographic services.32

Equal access is a prerequisite for reducing the unequal burden of breast cancer, but other factors that contribute to equal use of health care services are also critical and must be taken into account.

IMPROVING MAMMOGRAPHY

Quality Assurance by Law

Mammography is possibly the most heavily legislated medical procedure in history. Between 1980 and 1994 alone, 43 state laws were passed concerning different aspects of screening for breast cancer.44 As a rule, state laws regulating mammography have been enacted before federal mammography laws. For example, 33 states had already passed laws supporting treatment and care following the detection of a breast malignancy when a similar federal law, the Breast and Cervical Cancer Prevention and Treatment Act (BCCPTA), was passed in 2000. Currently, more than 10 federal laws specifically address breast cancer screening, including laws governing quality and access (Box 3-3).

When Congress enacted the Medicare program as part of the Social Security Amendments in 1965, preventive services were explicitly excluded. (Although breast screening does not prevent the occurrence of breast cancer, it is considered secondary prevention because early detection can prevent deaths from breast cancer and, thus, mammography is considered a preventive service.) Since 1965, many preventive services have been added, but each addition requires a specific Act of Congress. Not every benefit recommended by experts has been added, and some have been added that were not recommended (such as bone density and prostate serum antigen [PSA] screening). Mammography benefits were initially included in the Medicare Catastrophic Act of 1988, which was repealed the following year, but subsequently included in the 1990 Budget Reconciliation Act. Women’s health and breast cancer advocacy groups were instrumental in the inclusion of mammography benefits.43

A Sweeping Act for Technical Quality

The MQSA was enacted in 1992 to ensure that all women have access to quality mammography for the detection of breast cancer in its earliest,



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