Medicare Covers Preventative Cancer Screening: Is it enough?

President Clinton recently announced that beginning in 1998 Medicare recipients would pay less for a wide variety of cancer screenings. Medicare will now cover annual mammograms, colon-rectal cancer screening tests, and Pap smears every three years for women over 65 or every year for women at high risk. Both mammograms and Pap smears will carry no deductible.

These tests are an essential step towards the prevention and treatment of cancer. Mammograms are extremely effective in detecting breast cancer in its earliest and most treatable stages, and Pap smears have dramatically decreased the incidence of cancer in women who have been screened. Screening for colon-rectal cancer is not done frequently enough and is an important test, as cancers of the colon and rectum account for 15% of cancer deaths. All of these tests can be critical in helping a person to survive cancer, and in the case of Pap smears to avoid cervical cancer all together.

One of the important changes to Medicare is the coverage of Pap smears every three years. Many women over 65 are not given Pap smears by their doctor or health care provider. We believe that a woman over 65 should have a Pap smear at least every three years. This is particularly important for women who have not received regular Pap smears in the past. Although the risk of cervical cancer decreases with age, cancer that is found in older women is usually more advanced and more deadly. For this reason we think that women who have not had regular Pap smears should be tested every year for the first three years and less frequently from then on. Women over 65 who have had regular Pap smears should be tested every three years. Women over 65 with a history of abnormalities should be tested every year.

All three of these screenings have been shown to have great effect on both cancer prevention and cancer survival rates; the challenge lies in making these tests accessible to every woman, and also in assuring that women actually follow through on recommendations to be screened. The new measures described by Clinton do act towards making the test more accessible, financially. In the past Medicare would only cover mammograms every second year, forcing the cost of an annual mammogram to come out of the pocket of the patient. Secondly, Medicare would only cover Pap smears for women over 65 who had a "medically necessary" reason for being screened. Lastly, Medicare would not cover colon-rectal cancer screenings at all. So any woman who wished to be screened, but was not able to afford the tests had no access to these essential preventative measures.

But the question of whether a woman has access to these tests is a little more complicated than it appears. Although increasing Medicare coverage is an important step towards making screening widespread, more needs to be done to encourage women on Medicare and uninsured women to be screened. The CDC stated in its weekly report on Mortality (Dec.5, 1997), that "health-care coverage alone does not ensure use of preventive services". Women on Medicare include the most underscreened population, those women who are older than 65, poor and are part of an ethnic minority. Some of the reasons women have not been screened are: a lack of a regular doctor or health care provider, a lack of follow up to recommendations for screening, a lack of information on why screening is important or how it is done, and a lack of access to testing sites and the money needed for these tests. Any efforts to encourage women to be screened need to increase a woman's financial, informational, cultural, and geographical access to these tests. With 40% of older people in the U.S. living in poverty, and a disproportionate amount of those being minority women, special attention needs to be given to the barriers that keep them from being tested. Although full Medicare coverage is essential it addresses only one part of a larger issue.

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