by BACKGROUND
The Wisconsin Well Woman Program (WWWP) is part of a national program established by Congress known as the National Breast and Cervical Cancer Early Detection Program (NBCCEDP). Since 1994, it has made mammograms and pap screenings available at no cost to women living in Wisconsin, ages 45-64 with household incomes below 250% FPL (Federal Poverty Level). If someone is diagnosed with cancer through the program, it also provides immediate enrollment in Medicaid so that treatment is not delayed. (WBCC advocates worked to get Wisconsin to “opt in” to this treatment component of the program in the late 1990s). County Coordinators—for each of the 72 counties in Wisconsin—provided outreach, education and case management for women enrolled in the WWWP. It was, by all measures, a very successful program.
In December 2013, Wisconsin’s Department of Health Services announced drastic changes to the program. Breast cancer advocates—as well as the County Coordinators—were surprised by this announcement. The rationale for the changes was that future access to insurance coverage through the Affordable Care Act (ACA) would reduce the need for the WWWP. No research had been conducted on this and no data was provided to support that rationale. WBCC and our partners at the local Susan G. Komen affiliates arranged a meeting with the head of the program at which dozens of stakeholders were able to ask questions and discuss our concerns. WBCC and The Wisconsin Alliance for Women’s Health opened a line of communication at DHS and acted as a conduit to the breast cancer community going forward. We were able to get a one-year delay in the changes, and most importantly, a seat at the table for all stakeholders, including the County Coordinators, as changes were discussed and revised. However, in July 2015, the programmatic changes were instituted. These changes included a reduction in coordinators from 72 to 14 (an 80% reduction) and a 55% reduction in the approved provider network.
In 2017, WBCC conducted a survey of the remaining 14 program coordinators and found several concerning issues. Among other findings, 64% of the coordinators believed the women they serve had been negatively impacted by the changes. (Read our letter to DHS with more findings HERE.)
EVALUATION
A study, recently published online*, sought to evaluate whether there was an uptake in insurance in the WWWP’s target population as a result of the ACA, as the Department of Health Services had predicted. The following is a summary of that study’s findings.
The ACA had three components meant to accomplish higher rates of insurance coverage:
- Subsidized insurance coverage on a new federal marketplace that would allow individuals to buy policies they could “afford”
- However, limitations to uptake on the Federal Marketplace include limited insurance literacy and the complexity of choices for a population that may not have experience in this area. ACA did provide states funding for navigators to help people navigate the process to enroll, however federal funding for those navigators was severely cut in 2017, resulting in an 85% cut in marketplace navigation services in Wisconsin.
- Eliminated cost sharing for preventive screening services such as those the WWWP provides
- Unfortunately, despite preventive services being available at no cost, since 2014 mammography use nationwide has only increased by 1.5%.
- Provided for states to expand their Medicaid programs to provide more coverage for individuals up to 138% FPL
- However, Wisconsin chose to only partially expand our Medicaid program to childless adults under 100% FPL, providing less opportunity for eligible WWWP clients to find alternative services. Our legislature has to date resisted fully expanding the program to 138%.
So, did women seek insurance through the ACA as an alternative to the Well Woman Program? And how has the contraction of WWWP affected its target population’s access to critical cancer screenings?
The authors point out that to their knowledge there is no publicly available population based data that could be used to answer those questions. Instead, they used the Census Bureau’s Small Area Health Insurance Estimates paired with county-level data for WWWP service utilization between 2008-2018. They identified “most served” and “least served” counties based on WWWP utilization before 2014. They found that most- served counties had on average higher minority populations that were poorer, less employed, more rural and have smaller populations than least- served counties.
Their research showed a large drop in utilization of WWWP services over 2014-2018. In the counties least served prior to the ACA and WWWP changes, the service utilization rate dropped from 18 per 1000 women in the target population to 3 per 1000. In the counties most served prior to the ACA and WWWP changes, the rate precipitously dropped from 86 women per 1000 in the target population to 7 per 1000. Insurance coverage during that same time frame rose from about 79% to 89% in the least-served counties and from 77% to about 88% in the most-served counties.
The authors looked at published data from Illinois—a Medicaid expansion state that made no changes to their NBCCEDP program. Most of the women in their NBCCEDP program got new Medicaid coverage (56.7%), while the rest found coverage through the Illinois Health Exchange (18.5%), their employer (13.3%) or remained uninsured (11.4%). While there was no significant change in access to preventive screenings, the authors of the paper cite research that found women with Health Exchange coverage were 4.58 times more likely to report uncovered medical costs in the previous year than those with Medicaid coverage.
This suggests that gaining insurance coverage, while important, might not translate to better access to preventative screenings and treatment among this target population. As noted previously, barriers such as low health literacy, the complexity of coverage choices and socioeconomic and geographic challenges may undermine access—regardless of what kind of health coverage someone has. In this respect, the Wisconsin Well Woman Program, pre-reform, provided its clients excellent care coordination and easy access to providers that are integral to screening utilization.
The authors suggest that even with significant insurance gains among WWWP’s target population, the usage of mammography and other preventive screenings might still have been negatively impacted. In the most-served counties, only about 17% of the WWWP target population was under 100% FPL, while in least-served counties about 12% were under 100% FPL. Meaning that the vast majority of WWWP clients didn’t qualify for Medicaid. Full expansion of our Medicaid program to 138% FPL would have increased insurance coverage for all women between 100-138% FPL.
Since the authors found only small differential insurance gains in the counties more dependent on the WWWP pre-reform over those least dependent, the authors suggest that the shrinking of WWWP has potentially left previously served women with unmet cancer care needs.
The changes to the Wisconsin Well Woman Program left women with lower access to cancer screening and treatment (through the WWWP’s Medicaid Treatment component)—potentially putting them at risk for later diagnosis and more advanced stage cancers. The authors suggest that taking advantage of the full expansion of Medicaid coverage to 138% FPL and expanding the WWWP’s education and care coordination services would help avoid poorer health outcomes moving forward.
*Mikaela M. Becker and Mustafa Hussein, “Retrenchment of Wisconsin’s Well Woman Program and Changes in Insurance Coverage around the Affordable Care Act,” Preventive Medicine Reports 30, December 2022. http:/doi.org/10.1016/j.pmedr.2022.101996.