Public Health: Federal Programs Provide Screening and Treatment for Breast and Cervical Cancer

What GAO Found

The Centers for Disease Control and Prevention (CDC) operates the National Breast and Cervical Cancer Early Detection Program (the Early Detection Program) to provide cancer screening and diagnostic services to people who are low-income and uninsured or underinsured. For those screened under the program who require treatment, the Breast and Cervical Cancer Prevention and Treatment Act of 2000 (the Treatment Act) allows states to extend Medicaid eligibility to individuals not otherwise eligible for Medicaid.

GAO analysis of CDC data show that the Early Detection Program screened 296,225 people in 2018, a decrease from 550,390 in 2011 (about 46 percent). The largest decrease occurred from 2013 to 2014 (see figure). According to a CDC-funded study, the number of people eligible for the Early Detection Program decreased from 2011 through 2017, by about 48 percent for breast cancer and about 49 percent for cervical cancer. CDC officials attributed these declines in screening and eligibility, in part, to improved access to screening under the Patient Protection and Affordable Care Act (PPACA). For example, PPACA required health plans to cover certain women’s preventive health care with no cost sharing.

Number of People Screened by CDC’s Early Detection Program, 2011-2018

GAO analysis of Centers for Medicare & Medicaid Services’ (CMS) data found that, in 2019, 43,549 people were enrolled in Medicaid under the Treatment Act to receive treatment for breast or cervical cancer, a decrease from 50,219 in 2016 (13.3 percent). Thirty-seven states experienced a decrease in Medicaid enrollment under the Treatment Act during this time period, 13 states experienced an increase, and one state had no change. CMS officials noted that Medicaid expansion to adults with incomes at or below 133 percent of the federal poverty level under PPACA (the new adult group) is a key factor that contributed to these enrollment trends. CMS officials said that, in Medicaid expansion states, there were some people who previously would have enrolled in Medicaid based on eligibility under the Treatment Act who instead became eligible for Medicaid in the new adult group. The CMS data show that total enrollment under the Treatment Act in Medicaid expansion states decreased by 25.6 percent from 2016 to 2019. In contrast, total enrollment under the Treatment Act in non-expansion states increased by about 1 percent during this time period.

Why GAO Did This Study

According to the CDC, tens of thousands of people die each year from breast or cervical cancer. Early screening and detection, followed by prompt treatment, can improve outcomes and, ultimately, save lives. Federal programs, like CDC’s Early Detection Program, are intended to improve access to these services.

GAO was asked to examine the implementation of the Early Detection Program and the states’ use of Medicaid under the Treatment Act. This report provides information on the number of people who were 1) screened through the Early Detection Program and 2) enrolled in Medicaid under the Treatment Act.

GAO analyzed CDC data on the number of people screened by the Early Detection Program from calendar years 2011 through 2018—the most recent available. GAO also analyzed CMS Medicaid enrollment data from 2016 through 2019—the most recent available. Additionally, GAO reviewed a 2020 study funded by CDC that examines the number of people eligible for the Early Detection Program from 2011 through 2017. Finally, GAO interviewed CDC and CMS officials and reviewed relevant CDC and CMS documents.

For more information, contact John E. Dicken, (202) 512-7114, dickenj@gao.gov.

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    The Department of Defense (DOD) is closer to being able to use military code (M-code)—a stronger, more secure signal for the Global Positioning System (GPS) designed to meet military needs. However, due to the complexity of the technology, M-code remains years away from being widely fielded across DOD. M-code-capable receiver equipment includes different components, and the development and manufacture of each is key to the modernization effort. These include: special M-code application-specific integrated circuit chips, special M-code receiver cards, being developed under the Air Force Military GPS User Equipment (MGUE) programs, and the next generation of GPS receivers capable of using M-code signals from GPS satellites. DOD will need to integrate all of these components into different types of weapon systems (see figure for notional depiction of integration for one system). Integration across DOD will be a considerable effort involving hundreds of different weapon systems, including some with complex and unique integration needs or configurations. Global Positioning System User Equipment Integration The Air Force is almost finished—approximately one year behind schedule—developing and testing one M-code card for testing on the Marine Corps Joint Light Tactical Vehicle and the Army Stryker vehicle. However, one card intended for use in aircraft and ships is significantly delayed and missed key program deadlines. The Air Force is revising its schedule for testing this card. The M-code card development delays have had ripple effects on GPS receiver modernization efforts and the weapon systems that intend to use them. For example, an Air Force receiver modernization effort that depends on the new technology will likely breach its schedule and incur additional costs because of the delay. In turn, DOD planned to incorporate that receiver into its F/A-18 fighter aircraft, AV-8B strike aircraft, and the MH-53E helicopter, but it no longer plans to do so because of the delay. DOD has not yet determined the full extent of the development effort to widely integrate and field M-code receivers across the department. The amount of additional development and integration work is expected to vary for each weapon system and could range from a few weeks to several years. DOD is taking steps to enable fielding modernized receivers that use M-code cards by working to identify integration and production challenges. DOD has been developing the capability to use its more jam-resistant military-specific GPS signal for 2 decades. The Air Force launched the first GPS satellite capable of broadcasting the M-code signal in 2005, but is only now completing development of the software and other equipment needed to use it. The GPS modernization effort spans DOD and the military services, but an Air Force program office is developing M-code cards for eventual production and integration into weapon systems. The National Defense Authorization Act for Fiscal Year 2016 included a provision that the Air Force provide quarterly reports to GAO on next-generation GPS acquisition programs, and that GAO brief congressional defense committees. Since 2016, GAO has provided briefings and reported on various aspects of GPS. This report discusses DOD's progress and challenges (1) developing M-code receiver cards, and (2) developing receivers and taking other steps to make M-code-capable receivers available for fielding. GAO reviewed schedules and cost estimates for the Air Force's MGUE programs; military service and DOD M-code implementation data; and test and integration plans for aircraft, ships, and ground vehicles. GAO also reviewed strategies for continued access to microelectronics and interviewed officials from the MGUE programs, military services, and DOD, and representatives from microelectronics developers. For more information, contact Jon Ludwigson at (202) 512-4841 or ludwigsonj@gao.gov.
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  • Columbia Class Submarine: Delivery Hinges on Timely and Quality Materials from an Atrophied Supplier Base
    In U.S GAO News
    The Navy's schedule for constructing the first submarine of the new Columbia class is threatened by continuing challenges with the computer-aided software tool that Electric Boat, the lead shipbuilder, is using to design the submarine. These challenges will likely impede construction because the shipbuilder is late in completing design products used for building the submarine. To ensure construction begins on schedule, the Navy modified its design contract with Electric Boat to include an option for constructing the first two submarines and requested sufficient authority from Congress for fiscal year 2021 to exercise it. Navy officials stated, however, that the Navy's budget request is lower than its current cost estimate, and it is not informed by an independent cost assessment. As a result, the program will likely need more funding to reflect the increased estimate. Quality problems with supplier materials caused delays during early construction. These quality problems included missile tubes (depicted below) with defective welds. As the shipbuilders expand outsourcing to suppliers, quality assurance oversight at supplier facilities will be critical for avoiding further delays. Quad Pack of Four Submarine Missile Tubes However, the Navy has not comprehensively reassessed when to seek additional inspections at supplier facilities that could better position it to identify quality problems early enough to limit delays. The Navy plans to invest about $128 billion in 12 Columbia class nuclear-powered ballistic missile submarines. The shipbuilders will construct the Columbia class at the same time as the Virginia class attack submarines. They plan to rely on materials produced by a supplier base that is roughly 70 percent smaller than in previous shipbuilding booms. Congress included a provision in statute for GAO to examine the program's status. This report assesses the Navy's efforts to complete the design for the lead Columbia class submarine and actions the shipbuilders and the Navy have taken to prepare for construction and ensure the lead submarine is delivered according to schedule and quality expectations. GAO assessed Navy and shipbuilder design progress against cost and schedule estimates, reviewed documents, and interviewed officials about supplier readiness and quality assurance. This is a public version of a sensitive report that GAO issued in November 2020. Information that the Department of Defense (DOD) deemed sensitive has been omitted. GAO recommends that the Navy (1) provide Congress with updated cost information, (2) include information on supplier readiness in its annual report to Congress, and (3) reassess when to seek additional inspections at supplier facilities. DOD concurred with the recommendations but disagreed with some of the report's details. GAO incorporated DOD's comments as appropriate and maintains the validity of the findings, as discussed in the report. For more information, contact Shelby S. Oakley at (202) 512-4841 or oakleys@gao.gov.
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    A former Drug Enforcement Administration (DEA) public affairs officer was sentenced today to seven years in prison for defrauding at least a dozen companies of over $4.4 million by posing falsely as a covert officer of the Central Intelligence Agency (CIA).
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  • Michigan Restaurant and Strip Club Owner Sentenced to Two Years n Prison for Tax Crimes
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    A Walled Lake, Michigan, business owner was sentenced today to two years in prison, announced Principal Deputy Assistant Attorney General Richard E. Zuckerman of the Justice Department’s Tax Division.
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    Each weekday, the Department of Justice will highlight a case that has resulted from Operation Legend.  Today’s case is out of the Western District of Missouri.  Operation Legend launched in Kansas City on July 8, 2020, in response to the city facing increased homicide and non-fatal shooting rates.
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  • Grants Management: Agencies Provided Many Types of Technical Assistance and Applied Recipients’ Feedback
    In U.S GAO News
    Technical assistance refers to programs, activities, and services provided by federal agencies to strengthen the capacity of grant recipients and to improve their performance of grant functions. Technical assistance can improve the performance or management of grant program recipients. Technical assistance includes the improvement of grant outcomes, grant management, grantee compliance, project monitoring and evaluation, and interactions with stakeholders. The technical assistance provided by the selected agencies—the Department of Education (Education), the Department of Health and Human Services' Administration for Children and Families (ACF), and the Department of Labor's Employment and Training Administration (ETA)—is designed to align with the requirements of each agency's grant programs and the individual grantee's needs. The types of technical assistance provided by agencies varied and included a range of delivery methods shown below. Types of Technical Assistance Provided by Selected Agencies Education tailors its approach to provide technical assistance to grantees based on recipients' needs and their efforts to obtain technical assistance. According to ACF, some grant programs have extensive, dedicated technical assistance that is grant specific, while other grant programs share technical assistance resources provided by multiple technical assistance centers. ACF's technical assistance can be based on program office oversight of the grantees that includes financial and internal control reviews and site visits. For ETA, state and local grantees administer ETA-funded programs throughout the country and technical assistance plays a role in ensuring these programs' successful implementation. According to ETA officials, technical assistance activities are based on grant program objectives. The 10 grant programs GAO reviewed evaluated technical assistance, collected feedback from recipients of the technical assistance, and incorporated feedback into technical assistance. For example, a School Safety National Activities evaluation of one of its national centers included targets for multiple performance measures and the actual performance for each measure. These measures included the percentage of milestones achieved and the percentage of technical assistance and dissemination products and services deemed to be high quality by an independent review panel. The overall goal of technical assistance is to enhance the delivery of agency programs and help ensure grantee compliance. GAO was asked to review issues related to technical assistance for grants at Education, ACF, and ETA. This report (1) describes how Education, ACF, and ETA provide technical assistance to grantees; and (2) examines to what extent these agencies evaluate the technical assistance. For this review, GAO selected 10 grant programs from the three agencies based on fiscal year 2018 funding information and the purpose of the grant. GAO reviewed documents and interviewed agency officials about the technical assistance provided, the provider and recipient of technical assistance, and the amount obligated in fiscal year 2018 for the 10 grant programs reviewed. GAO also reviewed documents and interviewed agencies about the extent to which they evaluated technical assistance, whether they gathered feedback from the recipients of technical assistance, and whether feedback was included in the evaluations for the 10 grant programs reviewed. For more information, contact Michelle Sager at (202) 512-6806 or SagerM@gao.gov.
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  • Hanford Cleanup: DOE’s Efforts to Close Tank Farms Would Benefit from Clearer Legal Authorities and Communication
    In U.S GAO News
    The Department of Energy (DOE) has retrieved nuclear waste from all the tanks at C-farm—the first of 18 tank farms (i.e., groupings of tanks) at DOE's Hanford site in southeastern Washington State. The waste is a byproduct of decades of nuclear weapons production and research. DOE is obligated under agreements with the state's Department of Ecology (Ecology) and the U.S. Environmental Protection Agency to move waste from older, single-shell tanks to newer, more durable, double-shell tanks and ultimately to dispose of it. Example of a Tank and of Waste in a Tank at Hanford DOE intends to “close” the C-farm by leaving the nearly empty tanks in place and filling them with grout. However, DOE faces challenges, in part because this approach depends on: (1) DOE's determination under its directives that residual tank waste can be managed as a waste type other than high-level waste (HLW) and (2) Ecology's approval. DOE has started the determination process, but as GAO has previously found, DOE is likely to face a lawsuit because of questions about its legal authority. Ecology has raised concerns that the Nuclear Regulatory Commission (NRC) has not independently reviewed DOE's analysis for this determination. By Congress clarifying DOE's authority at Hanford to determine, with NRC involvement, that residual tank waste can be managed as a waste type other than HLW, DOE would be in a better position to move forward. Another challenge DOE faces in closing C-farm is how to address contaminated soil caused by leaks or discharges of waste from the tanks. DOE and Ecology officials do not agree on a process for evaluating contaminated soil at C-farm or on what role NRC should play in this process. They interpret their agreement differently, particularly regarding whether NRC must review DOE's analysis of contaminated soil. If the two parties cannot resolve this issue, Ecology may deny DOE a permit for C-farm closure. By using an independent mediator to help reach agreement with Ecology on how to assess soil contamination, including NRC's role, DOE would be better positioned to avoid future cleanup delays. DOE has not developed a long-term plan for tank-farm closure, in part, because a plan is not required. However, leading practices in program management call for long-term planning. In addition, DOE faces technical challenges that may take years to address as noted by representatives from various entities or tribal governments. For example, an internal DOE document states there is a 95 percent probability DOE will run out of space in its double shell tanks—space needed to continue retrieval operations. Planning for and building new tanks requires years of work. By developing a long-term plan, DOE could better prepare to address technical challenges. The Hanford site in Washington State contains about 54 million gallons of nuclear waste, which is stored in 177 underground storage tanks. In fiscal years 1997 through 2019, DOE spent over $10 billion to maintain Hanford's tanks and retrieve waste from them. DOE expects to spend at least $69 billion more on activities to retrieve tank waste and close tanks, according to a January 2019 DOE report. Senate Report 116-48, accompanying the National Defense Authorization Act for Fiscal Year 2020, included a provision for GAO to review the status of tank closures at Hanford. GAO's report examines the status of DOE's efforts to retrieve tank waste, challenges DOE faces in its effort to close the C-farm, as well as DOE's approach for closing the remaining tank farms. GAO toured the site; reviewed DOE documents, laws, and regulations; and interviewed officials and representatives from local, regional, and national entities and tribal governments. Congress should consider clarifying DOE's authority at Hanford to determine, with NRC involvement, whether residual tank waste can be managed as a waste type other than HLW. GAO is also making three recommendations, including that DOE (1) use an independent mediator to help reach agreement with Ecology on a process for assessing soil contamination, including NRC's role and (2) develop a long-term plan for its tank waste cleanup mission at Hanford. DOE concurred with all three recommendations. For more information, contact David C. Trimble at (202) 512-3841 or trimbled@gao.gov.
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    Alexander Yuk Ching Ma, 67, a former Central Intelligence Agency (CIA) officer, was arrested on Aug. 14, 2020, on a charge that he conspired with a relative of his who also was a former CIA officer to communicate classified information up to the Top Secret level to intelligence officials of the People’s Republic of China (PRC). The Criminal Complaint containing the charge was unsealed this morning.
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    Two United States citizens who were detained by the Syrian Democratic Forces (SDF) and recently transferred to the custody of the FBI have been charged with material support violations relating to their support for the Islamic State of Iraq and al-Sham (ISIS), a designated foreign terrorist organization.
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    A Somerset County, New Jersey, man admitted today that he concealed his attempts to provide material support to Hamas, Assistant Attorney General John C. Demers of the U.S. Department of Justice’s National Security Division, U.S. Attorney Craig Carpenito, FBI-Newark Special Agent in Charge George M. Crouch Jr., and FBI Assistant Director for Counterterrorism Jill Sanborn announced.
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    In Crime News
    The Justice Department announced today that the Town of Irmo, South Carolina, has agreed to pay $25,000 to a homeowner with a disability as part of a settlement agreement resolving the government’s Fair Housing Act (FHA) lawsuit. 
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    A United Kingdom national pleaded guilty today to conspiring to commit aggravated identity theft and computer fraud, and was sentenced to five years in federal prison.
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  • China-Based Executive at U.S. Telecommunications Company Charged with Disrupting Video Meetings Commemorating Tiananmen Square Massacre
    In Crime News
    A complaint and arrest warrant were unsealed today in federal court in Brooklyn charging Xinjiang Jin, also known as “Julien Jin,” with conspiracy to commit interstate harassment and unlawful conspiracy to transfer a means of identification.  Jin, an employee of a U.S.-based telecommunications company (Company-1) who was based in the People’s Republic of China (PRC), allegedly participated in a scheme to disrupt a series of meetings in May and June 2020 held to commemorate the June 4, 1989 Tiananmen Square massacre in the PRC.  The meetings were conducted using a videoconferencing program provided by Company-1, and were organized and hosted by U.S-based individuals, including individuals residing in the Eastern District of New York.  Jin is not in U.S. custody.
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  • Public Health: Federal Programs Provide Screening and Treatment for Breast and Cervical Cancer
    In U.S GAO News
    The Centers for Disease Control and Prevention (CDC) operates the National Breast and Cervical Cancer Early Detection Program (the Early Detection Program) to provide cancer screening and diagnostic services to people who are low-income and uninsured or underinsured. For those screened under the program who require treatment, the Breast and Cervical Cancer Prevention and Treatment Act of 2000 (the Treatment Act) allows states to extend Medicaid eligibility to individuals not otherwise eligible for Medicaid. GAO analysis of CDC data show that the Early Detection Program screened 296,225 people in 2018, a decrease from 550,390 in 2011 (about 46 percent). The largest decrease occurred from 2013 to 2014 (see figure). According to a CDC-funded study, the number of people eligible for the Early Detection Program decreased from 2011 through 2017, by about 48 percent for breast cancer and about 49 percent for cervical cancer. CDC officials attributed these declines in screening and eligibility, in part, to improved access to screening under the Patient Protection and Affordable Care Act (PPACA). For example, PPACA required health plans to cover certain women's preventive health care with no cost sharing. Number of People Screened by CDC's Early Detection Program, 2011-2018 GAO analysis of Centers for Medicare & Medicaid Services' (CMS) data found that, in 2019, 43,549 people were enrolled in Medicaid under the Treatment Act to receive treatment for breast or cervical cancer, a decrease from 50,219 in 2016 (13.3 percent). Thirty-seven states experienced a decrease in Medicaid enrollment under the Treatment Act during this time period, 13 states experienced an increase, and one state had no change. CMS officials noted that Medicaid expansion to adults with incomes at or below 133 percent of the federal poverty level under PPACA (the new adult group) is a key factor that contributed to these enrollment trends. CMS officials said that, in Medicaid expansion states, there were some people who previously would have enrolled in Medicaid based on eligibility under the Treatment Act who instead became eligible for Medicaid in the new adult group. The CMS data show that total enrollment under the Treatment Act in Medicaid expansion states decreased by 25.6 percent from 2016 to 2019. In contrast, total enrollment under the Treatment Act in non-expansion states increased by about 1 percent during this time period. According to the CDC, tens of thousands of people die each year from breast or cervical cancer. Early screening and detection, followed by prompt treatment, can improve outcomes and, ultimately, save lives. Federal programs, like CDC's Early Detection Program, are intended to improve access to these services. GAO was asked to examine the implementation of the Early Detection Program and the states' use of Medicaid under the Treatment Act. This report provides information on the number of people who were 1) screened through the Early Detection Program and 2) enrolled in Medicaid under the Treatment Act. GAO analyzed CDC data on the number of people screened by the Early Detection Program from calendar years 2011 through 2018—the most recent available. GAO also analyzed CMS Medicaid enrollment data from 2016 through 2019—the most recent available. Additionally, GAO reviewed a 2020 study funded by CDC that examines the number of people eligible for the Early Detection Program from 2011 through 2017. Finally, GAO interviewed CDC and CMS officials and reviewed relevant CDC and CMS documents. For more information, contact John E. Dicken, (202) 512-7114, dickenj@gao.gov.
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    The Department of Justice announced today that Visa Inc. and Plaid Inc. have abandoned their planned $5.3 billion merger.
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    A Great Falls, Montana, businessman pleaded guilty today to employment tax fraud, announced Principal Deputy Assistant Attorney General Richard E. Zuckerman of the Justice Department’s Tax Division and U.S. Attorney Kurt G. Alme for the District of Montana.
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