Dr. Milcah Larks is all too familiar with the cost of delaying preventative cancer screenings for women.
As an oncologist in the Immunology Clinic at Ventura County Medical Center, a hospital in Ventura focused on underserved populations, she prescribes treatment for patients with breast and cervical cancer. Often, patients come to her at late stages of the disease, requiring drastic interventions such as surgery, radiation and chemotherapy. These are treatments that could have been avoided, or at least made more effective, if the patients had been diagnosed sooner through routine mammograms and Pap smears.
“It’s frustrating,” said Dr. Larks, as she relaxed recently in the hospital’s cafeteria after a long workday. “I’m saddened when I have to tell a young person with young children that they may not be there to see their grandkids, to see their kids graduate form high school.”
Under the Affordable Care Act, the hope is that fewer women will find themselves in this situation. Hundreds of thousands of once uninsured women in California now qualify for insurance under the state’s version of Medicaid, called Medi-Cal, or for government-subsidized private insurance plans. And the health care law requires all insurance plans to cover routine breast and cervical cancer screenings without charging women a co-pay.
But despite the expanded coverage under health reform, thousands of women are still falling through the cracks, and many will turn to a state and federally funded program called Every Woman Counts. The California Department of Health Care Services estimates slightly more than 300,000 women in the state will obtain breast and cervical cancer screenings through Every Woman Counts this fiscal year, which runs July 2014 through June 2015. That’s up from 264,800 women the previous fiscal year.
The state received $6.9 million for the program from the federal Centers for Disease Control and Prevention this fiscal year. The federal agency has not indicated that the grant funding will be reduced as the Affordable Care Act takes effect, the state Health Care Department said.
Many patients wait too long
Many of Dr. Lark’s patients are low-income women referred to her through primary-care providers. Every Woman Counts provides free breast and cervical cancer exams to women without health insurance, or whose insurance doesn’t cover the screenings.
The goal of the program is to detect breast and cervical cancers early, before symptoms appear and when treatment is most effective. But by the time patients reach Dr. Lark, they’ve often put off screenings for years and only enter the program after they’ve felt a lump in their breast or are experiencing pain or other later-stage symptoms.
“That’s what we don’t want,” Dr. Larks said. “To wait until it gets to that point.”
René Mollow, deputy director of benefits and eligibility at the Department of Health Care Services, said the number of women screened through Every Woman Counts is eventually expected to decline as health reform moves forward, although officials don’t yet know by how much. Nevertheless, Mollow said demand for the program will continue because many women still don’t qualify for health insurance, or haven’t signed up under Covered California, the state’s health insurance exchange.
“Because of the critical nature of the services (under Every Woman Counts) it’s still a much needed program,” she said. “This does still provide an option of coverage for women who, for whatever reason, may not avail themselves of coverage through Medi-Cal or Covered California.”
Program serves many undocumented women
One of the main reasons some women don’t obtain health insurance under the Affordable Care Act is residency status. Immigrants living in the country illegally are not eligible for health reform benefits. In California, that’s about 2.6 million people, or 7 percent of the population, according to the Public Policy Institute of California.
Every Women Counts, on the other hand, does enroll women in the country illegally, as does a follow-up program: the state’s Breast and Cervical Cancer Treatment program, which provides time-limited treatment to women diagnosed with breast and cervical cancer. Applicants must meet other criteria, including being 40 or older for breast exams, 21 or older for cervical exams, and have a household income at or below 200 percent of the federal poverty line, about $48,000 a year for a family of four.
Immigrants, including those here legally, face other barriers to care, program officials said. They may not be able to find a doctor who speaks their language, lack knowledge about the services available to them, or regard the health care system with mistrust. For some immigrants there is also a cultural stigma associated with cancer and women’s health concerns, said June English, regional director of the Every Woman Counts program in Santa Barbara, Ventura and San Luis Obispo counties.
For low-income women in general, just getting to a clinic to be screened can be a problem. That’s particularly the case among women living in rural areas, who may have to travel miles to see a doctor, said Debbie Garrett, project director for the Every Woman Counts program in nine Central Valley counties.
Even when women have health insurance, it may not cover diagnostic testing that follows after screening results come back positive, Garrett said. Other women can’t afford private insurance, but earn too much to qualify for Medi-Cal, which sets lower income limits for eligibility, English said.
“People become very, very stretched financially,” English said. “It may be a choice between rent and food, versus a preventative screening.”
For Catalina Perfino, 66, a legal Mexican immigrant who lives in Ojai, mistrust was the main reason she and her husband didn’t apply for Medi-Cal, even though they had little income and may have qualified. Perfino said the couple felt uncomfortable providing so much information about themselves to the government.
Perfino did sign up for Every Woman Counts, however, at a community clinic where she liked the staff because they spoke Spanish. She was diagnosed with breast cancer in 2008 during a routine mammogram, was treated by Dr. Larks and is now cancer-free.
“When they told me I had cancer, I thought I was going to die,” Perfino said. “Well, I didn’t die. Look: Here I am, thanks to God. I’m so grateful for those programs.”
Outreach still needed
Reaching women at risk of not being screened is key to Every Woman Counts, English said. That means partnering with community organizations, trusted local leaders and health care workers who speak the language of a targeted population and can get the word out. English said she works with farmworker support groups, food pantries, churches, and organizations serving the homeless and disabled, among others.
In June, the state launched a 24-hour automated hotline that provides referrals to Every Woman Counts providers, replacing a hotline with limited hours that connected to a telephone service center. The service is available in several languages, including Spanish, Tagalog, Russian and Mandarin. A provider locator is also available online.
Both outreach and screenings have rebounded since 2010, when the state temporarily froze new enrollments in breast cancer screenings due to budget problems, English said. The number of women reached in her region through outreach almost doubled between 2010 and 2013, from 543 to nearly 1,000, she said. The 300,000 breast and cervical cancer screenings projected for this fiscal year are nearly 50 percent more than in fiscal year 2009-10, when 210,100 women were screened through the program.
For Dr. Larks, however, more outreach is still needed to ensure as many women as possible receive the life-saving cancer screenings.
“Early detection is extremely important,” she said. “Every Woman Counts is a necessary program that needs to actually have more resources placed in to it so it can be utilized by more people.”