Cancer Screening and Indigent Health Care

Should Cancer Screening Be a Part of Indigent Health Care in Texas?

By S. Van McCrary, Health Law & Policy Institute

The Texas Legislature will convene its 76th Session in January 1999. Among the issues to be addressed during the upcoming session is possible revision of the Indigent Health Care and Treatment Act of 1985 ("Act"), as discussed in Should the Texas Indigent Health Care and Treatment Act Be Amended. Under the current version of the Act, counties are ineligible for state matching funds for providing certain primary and preventive health care services to indigent persons otherwise eligible for coverage by the Act; thus, some counties are not providing such services. This absence of preventive care frequently results in delays in diagnosis. When patients seek treatment after such delays, it is often more expensive and less effective. In fact, one of the major problems of cancer among indigent Texans is that the disease is often discovered too late to provide any treatment other than pain relief--resulting in much unnecessary suffering and death in this population.

Cancer is the second leading cause of death among Texans. In 1996, 31,959 deaths among Texas residents were due to cancer, constituting 23% of all deaths. Yet many cancers are preventable. Simple screening services are currently available that have been proven to be beneficial in terms of increased patient survival. By providing cancer screening services, malignant disease can be detected sooner among indigent Texans, potentially offering better prognoses and more cost-effective care. Such Texans may have their lives extended in a way that provides them an opportunity to become more productive citizens. Amending the Act to include coverage for selected cancer screening services likely would further many of these goals.

Some cancer screening services that could potentially be included in indigent health care coverage are:

(1) Pap tests--cervical cancer is more prevalent among Hispanic and black women, and numerous clinical studies indicate that Pap test screening significantly decreases death rates from cervical cancer;

(2) mammography with clinical breast exam--the number of breast cancer deaths increased in Texas by 25% from 1987 to 1993 (from 1,914 to 2,400 deaths); strong evidence suggests that screening mammography reduces mortality by up to 30% in women ages 50-69; mammography from age 40-49 is controversial, but the American Cancer Society recommends that screening begin at age 40;

(3) fecal occult blood ("FOB") tests and sigmoidoscopy--the number of colon cancer deaths increased in Texas by 19% from 1987 to 1993 (from 2,237 to 2,667 deaths); FOB tests detect cancer earlier and significantly reduce projected mortality; research suggests that sigmoidoscopy after a positive FOB test increases early detection of disease and lowers mortality rates;

(4) prostate-specific antigen ("PSA") tests--the incidence in Texas of prostate cancer is 115 cases per 100,000 population for black males, 108 for white males, and 60 for Hispanic males (1,973 deaths in 1996); PSA testing has been shown to detect this cancer earlier, but it is uncertain whether there is a corresponding reduction in mortality.

None of the cancer screening tests discussed above are available to all medically-eligible persons covered under the current Indigent Health Care Act. A number of policy options would enable the Texas Legislature to provide cancer screening services during its reconsideration of the Act. These options include: (1) enacting a provision including "medically indicated, patient-appropriate cancer screening" as part of the list of mandatory services specified in Texas Health and Safety Code § 61.028; or (2) enacting a provision including specifically identified tests used for cancer screening as part of the list of mandatory services specified in Texas Health and Safety Code § 61.028 (in the event adequate funds are not available to provide coverage for all four tests, then priority could be given to pap tests and mammography, followed by FOB and PSA tests, based on benefit in terms of survival); or (3) enacting a provision in the Act making county expenditures on cancer screening eligible for state matching funds, but not mandatory. Because the Working Group on County Indigent Health Care has recommended that primary care and preventive services be a part of the services covered by the Act, it seems to be an ideal time explicitly to include cancer screening as part of such changes in coverage. Pursuing one of these three policy options would be a significant step in promoting the health of indigent Texans.

11/10/98