Seven months after freezing new admissions to a program that screens low-income women for breast cancer, California’s Public Health Department is still spending money to educate those women about a service they can no longer receive.

The department has contracts with nonprofit groups around the state to provide education and outreach about the program, known as Every Woman Counts.

But while the state began blocking new admissions to the program on Jan. 1 to save money, it did not reduce spending or change the requirements in its contracts to inform women about the screenings and encourage them to get mammograms.

Some of the contractors have acted on their own to change their message and are working to find other places where women can get screened for breast cancer. Others are emphasizing the need for cervical cancer screenings, which are still available through the state program. But their contracts with the state to provide outreach about mammograms remain the same as they were before the enrollment freeze.

California’s independent state auditor says the department could shift some of its money from outreach, education and administration to the clinics that screen women for cancer. Shifting just half of that money, the auditor says, would free up money to screen 27,500 women for breast cancer this year.

Many of those women would be found to have breast cancer if they were given mammograms by the state, based on records of the outcomes of cancer screenings in years past. Moreover, a federally funded breast cancer treatment program administered by the state is allowed to treat only women who are diagnosed through the Every Woman Counts program, so by ending those screenings, the state is also blocking low-income women from receiving treatment through that program.

Department officials say they don’t think they can free up money for more screenings because of guidelines that control how the state spends federal money that finances part of the program – a conclusion that is disputed by the auditor and the federal government.

At the same time, however, the Public Health Department cannot even say how much it is spending on outreach now, because its contracts cover many services at once and the state does not keep track of how much is spent on each.

Last year, the Every Woman Counts program served 350,000 low-income women. Tobacco taxes provide about 89 percent of the funding for the program, with the rest coming from the federal government. But the continuing decline in the number of people smoking has resulted in less revenue for the program, forcing the department to ask for money from the state’s general fund to cover its costs.

In response, Gov. Arnold Schwarzenegger announced late last year that the eligibility requirements to receive a mammogram under Every Woman Counts would be raised from 40 years old to 50 years old and that any new enrollment to the program would be frozen from Jan. 1 until July 1, when a new state budget was supposed to be in place. Now the budget is nearly six weeks late, and the delay has stalled the reopening of enrollment to EWC breast screenings.

The state Auditor’s reviewed the program earlier this year and concluded that the Department of Public Health could redirect money from non-clinical activities and still receive federal funding. The auditor said federal guidelines require that at least 60 percent of the federal dollars the state receives for the program must be spent on clinical services, but the state could spend a larger percentage on the cancer screenings if it wanted to.

An official with the Centers for Disease Control and Prevention, which administers the federal grant, confirmed the auditor’s conclusion.

“They have to do at least 60 percent,” said Melonie Thomas, a program consultant for the CDC. “They can do more, if that is what is within the best interest of their program.”
Thomas said California was also free to spend its own money on clinical services if it was worried about violating the federal guidelines. But state officials said they find it simpler to spend all the money under the federal rules.

She also said that California could ask for permission to shift its funds outside of CDC requirements because of unexpected circumstances, such as the decline in tobacco tax money that led to a freeze in enrollment.

“Programs do that all the time,” she said.

But instead of doing all it can to increase the number of screenings it provides, the state has chosen to continue to spend money on other parts of the program. Department of Public Health officials said that before the enrollment freeze they had already shifted about 25 percent of their non-clinical budget to cancer screenings, but they don’t think federal guidelines will allow them to shift any more.

Even if they could shift the money, officials say they might not want to do so because they want to keep a balance between providing services and educating the broader community about the importance of cancer screenings.

“It is a balance of both serving these women that are eligible and at the same time changing the medical practice as well as the awareness on the part of women around the importance of breast and cervical cancer screening, with an overall aim of saving lives,” said Kevin Reilly, chief deputy director of Public Health. “Not just the women targeted for screening, but for the general population.”

Outreach and education typically consist of working with churches, senior centers, food pantries, and homeless shelters to find new eligible women, educate them in small group settings on the importance of regular cancer screenings and the benefits EWC can provide them.

Steve Carpowich of Scripps Health, which manages the EWC program in the San Diego area, said Scripps did not cut its non-clinical services when eligibility changed. Carpowich said the program is “still required to promote exactly the same breast cancer screening guidelines/education to the same amount of women as in prior years. This has not changed to date for the other regions.”

Barbra Clifford, a manager with the California Health Collaborative, which manages EWC programs throughout the Bay Area and Northern California, said the Department of Public Health made no formal change in the scope of work the contractors fulfill when the eligibility requirements changed.

But even without direction from the department or a change in their contracts, the California Health Collaborative and most other organizations changed the kind of outreach and education they were doing.

One thing they have done is change their focus to cervical cancer, which the state still pays the clinics to screen for. But because many low-income women get cervical cancer screenings through Planned Parenthood and other sources, those tests typically make up only about 1 percent of the program’s caseload.

“Since we weren’t enrolling new women for breast cancer screenings, we focused our educational efforts on cervical cancer,” Clifford said.

When enrollment was frozen, regional umbrella organizations that had once referred patients to EWC providers also had to find alternative sources that could provide free or low-cost mammograms.

“We had to help those women who were no longer eligible for the program identify new providers,” said Brian Monteryo of the Public Health Foundation Enterprises in Los Angeles. “Likewise, we had to educate our providers regarding the changes.”

Susan G. Komen for the Cure and the American Breast Cancer Foundation, among others, have provided funding for diagnostics and screenings to help women in need of screenings who can no longer enroll in EWC.

Clifford of the California Health Collaborative said outside funds were previously used “as a last resort,” but this year the American Breast Cancer Foundation funding was exhausted in May because of the high volume of women who needed services but could not enroll in EWC.