Like many states, California is facing a massive budget shortfall, to the tune of about $20 billion. To offset the massive debt, the state has had to make serious cuts to public services such as raising university tuition by more than 30 percent, extending furlough days for state employees, even closing courts once a month to save money.
Relative to those far-reaching changes, a $10 million cut to Every Woman Counts, a cancer-screening program for low-income women, should have been a minor item on the list of public services being scaled back. For seven years, the program has provided free mammograms and cervical-cancer screenings to women earning less than $21,660 a year. In the face of tighter budgets, the California Department for Public Health decided in early December to shrink the program by raising the minimum age for free mammograms from 40 to 50.
The change may save the state a few million dollars, but it has also bought a giant political headache. Because just 21 days before California changed the Every Woman Counts age requirements the U.S. Preventive Services Task Force caused widespread outrage by making the same policy recommendation: that the minimum age for mammograms should be raised 10 years to 50.
California's Public Health Department came to the same conclusion independently months ago, using its own data and analysis of mammogram screenings and diagnoses. The state is now among the first to put into practice an unpopular, highly publicized, polarizing policy. Women's groups are nervous that California's action so quickly after the federal task-force recommendations may be a harbinger of things to come, part of a larger sea change against mammograms for women in their 40s. "First with the federal guidelines, and now with California, other states seeing this might follow suit," says Donna Sanderson, executive director at the Sacramento Valley affiliate of Susan G. Komen for the Cure. "We know the eyes of the rest of the nation are looking at California. We want to make sure the right message gets out: this is not an appropriate way to balance a budget."
The Every Woman Counts program began in 2002. Screenings are funded mostly through a tobacco tax revenue, which has decreased alongside the number of smokers in the state. Moreover, the dismal economy has made more women eligible for—and interested in—the program. Last year, the California approved an additional $14 million in emergency funding, from the state's general fund, to keep the program afloat. But this year, without any emergency funds available, the Department of Public Health had to scale back the program.
The Department of Public Health had discussed the possibility of raising the eligibility age for the program as early as last spring, when they realized that their funding would be lower. "We knew that we faced an unprecedented fiscal situation and we needed to do something," says Al Lundeen, a spokesperson for the California Department of Public Health. "We would prefer to offer these services to everyone." But since they cannot afford to, the program will stop enrolling new patients this Friday, January 1. And when the program does reopen in July 1, free mammogram screenings will only be available to women 50 and above.
Lundeen says the task-force recommendation gave them increased confidence that, since they did have to cut the program, they were doing it in the least harmful way possible; that cutting women under 40 from the program would have the smallest public-health repercussions. "On a parallel level, the task force was reaching the same kind of conclusion," says Lundeen. "Perhaps that's reassuring." They are now in the curious position of distancing themselves from a new federal recommendation. "Our decision is completely financial," says Lundeen. "We do not want to be following the recommendations. We would prefer to offer mammograms to women under 50."
California legislators and advocacy groups are outraged. "It definitely is not appropriate," says Komen's Sanderson. "We see this as a crisis situation." The frustration among women's groups in California mirrors the nationwide outrage at the initial task-force recommendations. While statistics indicate that early screenings can often lead to harm and unnecessary treatment, many in breast-cancer advocacy groups speak of women who have benefited from, even had their lives saved, by early detection. Like Sanderson, who was diagnosed with breast cancer at 46. "I would not have been alive if I had to wait until 50 for a screening," she says. "That's the whole point."
Mostly though, they're worried that the task-force guidelines, bolstered by this change in California policy, could ripple throughout the nation. Twenty states have scaled back their free cancer screenings in the past 18 months, according to an unofficial survey by the American Cancer Society's Cancer Action Network. Sanderson worries that state legislatures will see mammograms for women in their 40s as an expendable test. "To close down these programs and serve fewer women because the guidelines come out runs against so much that we've worked on for years," she says. "It's taken so long to get doctors to agree on these screenings, and now we could see less women being served because new guidelines come out."
Women's groups are unsure what happens next. Last Wednesday, as Christmas Eve neared, they gathered with legislators and representatives from California's Department of Public Health. They agreed to an audit of the department's budget to understand what happened to the money and why additional support could not be provided for the program. They say that they'll continue to look for additional sources of funding if the state does not come through; already, they have received one donation of $100,000. "People are working on this on many different levels," says Sanderson. They hope that, by doing so, they can prevent the issue from rising to the national level.