this program so that they have access to treatment (CDC, 2004; CMS, 2004b). Medicaid coverage is not limited to treatment of breast and cervical cancer. However, the coverage ends when a woman’s course of treatment is completed (CMS, 2004d). The scope and duration of Medicaid coverage under this program needs to be clarified because evidence suggests there is confusion about what services are covered and for how long (e.g., coverage of Tamoxifen therapy, which is typically prescribed for 5 years) (Kenny et al., 2004). In terms of access to this gateway for coverage for treatment, CDC’s early detection program is severely limited—the program reaches fewer than 15 percent of women who are eligible for screening by virtue of their income, age, and insurance status (CDC, 2005). In addition, once enrolled in Medicaid, women in some states may encounter other limits on covered benefits. In Texas, for example, Medicaid covers only three prescription drugs per month.

Limited access to private insurance Individuals who are uninsured, without access to group coverage, and not eligible for public programs may try to purchase private health insurance on an individual basis, but for those with a history of cancer, such coverage may be unavailable, very costly, or restrictive. Common circumstances that lead people to seek individually purchased health insurance include self-employment, early retirement, working part-time, divorce or widowhood, or “aging off” a parent’s policy (Pollitz et al., 2001). An estimated 17 million individuals had individually purchased health insurance coverage in 2002 (Williams and Fuchs, 2004). One in four adults have a need for individual health insurance at some point over a 3-year period (Duchon et al., 2001). The barriers to obtaining private individual coverage can be categorized as those of availability, affordability, and adequacy (referred to as “the three A’s”) (Box 6-10).

The three “A’s” barriers facing cancer survivors in the individual health insurance market are well illustrated by a study commissioned by the Kaiser Family Foundation. As part of this study, 19 insurance companies and health maintenance organizations (HMOs) in eight markets around the country were asked to consider for coverage (using rates in effect in 2000) hypothetical applicants with different health histories (Pollitz et al., 2001). One of the scenarios was for a 48-year-old, 7-year breast cancer survivor. Insurers reviewing the “applicants” determined whether or not they would be offered coverage and on what terms. The application made on behalf of the breast cancer survivor was rejected 43 percent of the time (i.e., in 26 of 60 applications filed for this case). Of the 34 offers of coverage received, 18 had limits on benefits covered. Most often the policies had riders excluding coverage for her treated breast, her implant, or cancer of any type. Eighteen offers imposed a premium surcharge, ranging from 40 to 100 percent (including 13 that were accompanied by some other benefit restriction). A

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