states if they have a history of cancer. Cancer survivors may also face surcharged premiums for coverage because of their cancer history, depending on where they live and what type of coverage they seek. The improvements in the care of cancer survivors envisioned by the committee can not be achieved without health insurance that is accessible, adequate, and affordable.

Health insurance provides protection from the very high costs of cancer care. Most cancer survivors have health insurance through the federal Medicare program because they are aged 65 and older. Nevertheless, more than 4 million cancer survivors are under the age of 65. Eleven percent of cancer survivors ages 25 to 64 (approximately 572,000 individuals) are uninsured, and for these individuals, the costs of cancer care can be financially devastating. These younger uninsured cancer survivors report problems in access to care due to concerns about cost—51 percent report delays in obtaining medical care; 44 percent report not getting needed care; and 31 percent report not getting needed prescription medicine. The financial problems posed by cancer loom larger, because even those with health insurance can have trouble paying for prescription drugs and other types of care.

Some evidence indicates that individuals without health insurance have worse cancer outcomes because they receive less appropriate care. Even for those with health insurance, however, out-of-pocket expenditures for cancer care can be high. According to the committee’s analyses of the 2001–2002 Medical Expenditure Panel Survey, health-related out-of-pocket expenditures made by those reporting health effects of cancer are high, averaging $1,267 annually for those ages 25 to 64 (13.5 percent of total expenditures) and $1,456 annually (12.5 percent of total expenditures) for those aged 65 and older. These expenditures are significantly higher than those of individuals without a history of cancer.

Since 2000, most states have provided Medicaid coverage to poor and uninsured women who are diagnosed with breast or cervical cancer through the Centers for Disease Control and Prevention’s (CDC’s) state-based screening programs. Such coverage affords women treatment and follow-up services. The screening program currently serves only 15 percent of the low-income, uninsured women it is intended to serve, so this is not an avenue for many women to ultimately get coverage for their breast or cervical cancer.

State reforms of the individual health insurance market have improved access to coverage among those with chronic health conditions; however, there is evidence that the increased premiums have led some who had individual coverage to forego insurance. High-risk pools are available in most states as insurers of last resort for those ineligible for public or private insurance programs. However, costs of coverage are high and many have limited benefits. The federal government for the first time in 2002 has