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How Do You

MEASURE
A Progress Report on State Legislative Activity
to Reduce Cancer Incidence and Mortality
2014
12th Edition
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Mission Statement
American Cancer Society Cancer
Action Network (ACS CAN)
ACS CAN, the nonprot, nonpartisan advocacy
afliate of the American Cancer Society, supports
evidence-based policy and legislative solutions
designed to eliminate cancer as a major health
problem. ACS CAN works to encourage elected
ofcials and candidates to make cancer a top
national priority. ACS CAN gives ordinary people
extraordinary power to ght cancer with the training
and tools they need to make their voices heard. For
more information, visit www.acscan.org.
Our 12th Edition
The 12th edition of How Do You Measure Up?
illustrates where states stand on issues that play a
critical role in reducing cancer incidence and death.
The goal of every state should be to achieve green
in each policy area delineated in the report. By
implementing the solutions set forth in this report,
state legislators have a unique opportunity to take a
stand and ght back against cancer. In many cases,
it costs the state little or nothing to do the right
thing. In most cases, these solutions will save the
state millions and perhaps billions of dollars through
health care cost reductions and increased worker
productivity. If you want to learn more about ACS
CANs programs and/or inquire about a topic not
covered in this report, please contact the ACS CAN
state and local campaigns team at (202) 661-5700
or call our toll-free number, 1-888-NOW-I-CAN, 24
hours a day, seven days a week, and we can put you
in contact with ACS CAN staff in your state. You can
also visit us online at www.acscan.org.
12th Edition
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More CAN, Less Cancer
On September 1, 2012, American Cancer Society divisions across the country
integrated their advocacy programs with ACS CAN. By aligning all federal, state
and local advocacy efforts within a single, integrated nationwide structure, our
advocacy work has become more efcient and effective, and we will sooner achieve
our shared mission to save lives from cancer. Like the Society, ACS CAN continues
to follow the science and supports evidence-based policy and legislative solutions
designed to eliminate cancer as a major health problem. ACS CAN also remains
strictly nonpartisan. The only side ACS CAN is on is the side of cancer patients.
How Do You Measure Up?
Tackling Tobacco Use . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
Tobacco Excise Taxes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
Smoke-Free Laws . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
Tobacco Cessation Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
Tobacco Control Program Funding . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14
Obesity, Nutrition and Physical Activity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17
Indoor Tanning . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21
Access to Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23
Access to Colorectal Cancer Screening . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33
Funding for Breast and Cervical Cancer Screening . . . . . . . . . . . . . . . . . . . . . 34
Palliative Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38
Cancer Pain Control: Advancing Balanced State Policy . . . . . . . . . . . . . . . . . . 41
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44
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In the ght against cancer, its important to celebrate victories. Today in the United States, there are
nearly 14 million cancer survivors and 400 more lives are being saved from this disease each day than
just over a decade ago. In the last twenty years, there has been a 20 percent drop in cancer death rates.
Despite this progress, there is still much work to be done. This year alone, more than 1.6 million
people living in the United States will be diagnosed with cancer thats more than 4,500 individuals
every single day. Sadly, an estimated 580,000 of those will lose their battle with the disease.
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The number of scientic breakthroughs in the past several decades is astounding. New treatments
that better target cancer cells have been developed, we know more about specic genes linked to
specic cancers and weve greatly improved screenings to help detect cancer early and, in some
cases, prevent it altogether. However, the ght against cancer wont be won solely in a research
lab or medical facility. This battle also takes place in our communities and in our state capitol
buildings. Our state, local and federal lawmakers have a hand in this ght and a responsibility to
pass strong public policies that make preventing, detecting, treating and beating cancer easier.
Research shows that if everyone were to quit tobacco, exercise regularly, eat a healthful diet, achieve
and maintain a healthy weight, and get recommended cancer screenings, a substantial portion of
all cancer deaths could be prevented. But this is easier said than done. Too many people living in
the United States dont have access to affordable, healthy foods or safe places for physical activity
and barriers prevent many of them from receiving recommended cancer screenings and accessing
cessation services to help them quit tobacco. This is where lawmakers can be so effective at reducing
cancer rates through their decisions, creating a legacy of better health for their constituents.
For the 12th year, ACS CAN has published a blueprint for state legislators on how to save more
lives from cancer. Framed entirely on evidence-based policy approaches, How Do You Measure Up?
provides an outline of what states can do to reduce the cancer burden and provides a snapshot of
how states are progressing on critical public health measures.
Tobacco Control Saves Lives
We have come a long way as a nation in passing strong policies to reduce tobacco use and
secondhand smoke exposure, through comprehensive, statewide smoke-free laws, regular and
signicant increases in tobacco excise taxes and funding for tobacco control programs that work
How Do You Measure Up?
12th Edition
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to prevent youths from becoming addicted to these products and
help individuals already addicted to quit. This hard work is paying
off. In the past two decades, youth smoking rates have been cut in
half and the Centers for Disease Control and Prevention recently
announced they are at an all-time low.
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Despite these accomplishments, nearly 176,000 of the estimated
585,720 cancer deaths this year will be caused by tobacco use and
tobacco is still the number one cause of preventable death nationwide.
While smoking rates among youths have fallen, the popularity of
other tobacco products including little cigars and smokeless tobacco
among youths is as strong or stronger than it has ever been.
As the tobacco industry continues to work hard to addict more people,
tobacco control efforts are not keeping up. As of June 2014, no state
had passed a signicant tobacco tax increase and no state had passed
a comprehensive, statewide smoke-free law covering all workplaces,
restaurants and bars this year. States were expected to spend less than
2 percent of the tobacco tax and master settlement agreement revenue
they will collect on prevention and cessation services in 2014.
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Efforts
to reduce tobacco use through public policy must increase if we are to
continue making progress in the ght against tobacco use.
Access to Health Care is Critical
Whether or not an individual has health insurance can be a signicant
determinant of their chances of beating cancer. Research shows those who
lack health insurance are more likely than the insured to be diagnosed
with cancer at a later stage and are more likely to die from the disease.
The Affordable Care Act (ACA) is helping to ensure that cancer patients
and survivors can no longer be denied coverage or dropped from their
plans. However, there are still signicant barriers in place for some cancer
patients and survivors trying to access the screening and treatments they
need to give them a ghting chance against this disease.
State lawmakers currently have the opportunity to accept federal
funds already set aside to increase access to health coverage for
thousands of low-income residents through Medicaid. Unfortunately,
only 26 states and Washington, D.C. had done so as of June 2014.
Leaving this money on the table denies millions of people and families
access to the care and preventive services they need.
While the health law has helped make insurance more affordable for
many, there are still barriers to coverage that need to be addressed.
ACS CAN is working to increase access to oral chemotherapy
drugs, ensure balanced policies for pain treatment, improve access
to palliative care and prevent tobacco users from being charged
more than non-tobacco users for health coverage.
Many Cancers are Preventable
Throughout the past year, ACS CAN advocates have been working hard
to pass and protect laws and policies focused on disease prevention.
Skin cancer is the most commonly diagnosed cancer in the United
States with rates increasing signicantly in the last 30 years.
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Despite the risks associated with UV exposure, many people
continue to engage in high-risk behavior such as using indoor
tanning devices. ACS CAN has been urging states to prohibit young
people from using these devices. As of June 2014, seven states had
passed strong indoor tanning policies to protect youths.
Many states are also working on policies and programs to reduce
cancer risk related to poor nutrition, lack of physical activity, and
obesity. For the majority of Americans who do not use tobacco,
weight control, smart dietary choices and physical activity are the
best ways to prevent cancer.
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ACS CAN encourages state legislators
to make a commitment to creating healthy environments.
Research has led to highly effective cancer screenings that can not
only catch cancer early, but also prevent it altogether in some cases.
However, screenings only work when patients have access to them.
Today, only half of women who are recommended to be screened have
received a mammogram in the past year and only two in three adults
at the recommended age levels are getting screened for colorectal
cancer.
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ACS CAN urges lawmakers to continue funding programs
that help individuals access and afford these lifesaving screenings.
Across the states, ACS CAN continues to work on all of these issues
because too many cancer patients are still suffering from pain
unnecessarily, families continue to be forced to declare bankruptcy
due to a cancer diagnosis, more than 3,000 youths still pick up
their rst cigarette every day and cancer patients continue to die
simply because they do not have access to lifesaving treatments.
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Cancer is a non-partisan disease, and ACS CAN believes that
ghting it should be a national priority. Passing strong policies that
help people prevent cancer, detect it early and access lifesaving
treatments is a win-win-win for legislators: these policies save
lives, save money and are consistently supported by the public.
How does your state measure up?
How Do You Measure Up?
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The burden of tobacco use is staggering. The 50th anniversary Surgeon Generals report, The
Health Consequences of Smoking
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, released January 2014, reported that more than 20 million
premature deaths over the last half century can be attributed to cigarette use. Tobacco use costs
our nation $289 billion in health care and productivity losses each year.
On June 12, 2014 the Centers for Disease Control and Prevention (CDC) released results from the
Youth Risk Behavior Surveillance (YRBS) survey showing cigarette use among youths has declined
to 15.7 percent, a historic low.
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This low cigarette smoking rate among youths is proof that mass
media efforts about the hazards of smoking and proven public health policies that raise tobacco
taxes, establish smoke-free places as the social norm and fund tobacco prevention programs are
working. However, the decline in cigarette smoking rates among youths is only half of the story
presented in this data. Some youths are turning to other tobacco products that either are less
expensive because the product is not taxed at the same rate as cigarettes or are not yet regulated by
the Food and Drug Administration (FDA). The CDC survey showed no decline in use of smokeless
products among youths and a slowing decline in the use of cigars, and a CDC study released last
year showed a doubling in the use of e-cigarettes among middle and high school-aged students. A
separate CDC study released earlier this year showed a doubling in the use of e-cigarettes among
middle and high school-aged students.
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ACS CAN calls on the FDA to quickly nalize its proposal to regulate all other tobacco products
including e-cigarettes and urge federal and state lawmakers to combat the industrys tactics
by subjecting these products to tobacco control policies that increase the price, limit the use and
help people quit.
Progress has been made in the battle against tobacco addiction in this country, but we cannot rest on
past success. According to the Surgeon General, 5.6 million youths are expected to die prematurely
from tobacco-related disease if we do not take further action. If were going to achieve a tobacco-
free generation, lawmakers must continue to utilize the evidence-based solutions they have at their
ngertips to reduce use of all tobacco products among youths.
Fortunately, we know what works to reduce the number of youths who start using tobacco, to help
more adults quit, and to reduce exposure to secondhand smoke. ACS CAN supports a comprehensive
approach to tackling tobacco use through policies that:
1. Increase the price of all tobacco products through regular and signicant tobacco tax increases.
2. Implement comprehensive smoke- and tobacco-free policies; and
3. Fully fund and sustain evidence-based, statewide tobacco use prevention and cessation programs.
Like a three-legged stool, each component works in conjunction with the others, and all three are
necessary to overcome this countrys tobacco epidemic. ACS CAN works in partnership with state
and local policymakers across the country to ensure tobacco use is addressed comprehensively in
each community.
More than 20 million premature deaths over the last half century
can be attributed to cigarette use.
Tackling Tobacco Use
12th Edition
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Challenge
By increasing taxes on cigarettes, cigars, little cigars, smokeless tobacco and all other tobacco
products (OTP), states can save lives, reduce health care costs and generate much-needed revenue.
Evidence clearly shows raising tobacco prices through regular and signicant tobacco tax increases
encourages tobacco users to quit or reduce their usage and helps prevent kids from ever starting
to use tobacco. In fact, for every 10 percent increase in the retail price of a pack of cigarettes, youth
smoking rates drop by 6.5 percent and overall cigarette consumption declines by 4 percent.
1,2
ACS CAN advocates for increased excise taxes on cigarettes and OTP and urges legislators to reject
any proposals to roll back tobacco taxes. The average state cigarette excise tax is currently $1.54 per
pack, but state cigarette excise tax rates vary widely, from a high of $4.35 per pack in New York to a
low of 17 cents per pack in Missouri. In the past 12 years, all but three states California, Missouri,
and North Dakota have raised their cigarette tax in more than 100 separate instances. In 2013, two
states signicantly increased their tobacco taxes. Minnesota increased its cigarette tax by $1.60 to
$2.83 per pack, and Massachusetts increased its tax by $1 to $3.51 per pack, making it the second
highest in the country. Both states also increased their OTP taxes. Unfortunately, there had been no
signicant cigarette or OTP tax increases as of June 2014.
Tobacco Excise Taxes
State Cigarette Excise Tax Rates
Alabama
$0.425
Arizona
$2.00
Arkansas
$1.15
California
$0.87
Colorado
$0.84
Florida
$1.339
Georgia
$0.37
Idaho
$0.57
Illinois
$1.98
Indiana
$0.995
Iowa
$1.36
Kansas
$0.79
Kentucky
$0.60
Louisiana
$0.36
Maine
$2.00
Michigan
$2.00
Minnesota
$2.83
Mississippi
$0.68
Missouri
$0.17
Montana
$1.70
Nebraska
$0.64
Nevada
$0.80
New Mexico
$1.66
New York
$4.35
North Carolina
$0.45
North Dakota
$0.44
Ohio
$1.25
Oklahoma
$1.03
Oregon
$1.31
Pennsylvania
$1.60
South
Carolina
$0.57
South Dakota
$1.53
Tennessee
$0.62
Texas
$1.41
Utah
$1.70
Vermont
$2.75
Virginia
$0.30
Washington
$3.025
West
Virginia
$0.55
Wisconsin
$2.52
Wyoming
$0.60
Hawaii
$3.20
Alaska
$2.00
District of Columbia
$2.50
How Do You Measure Up?
Connecticut
$3.40
Delaware
$1.60
Maryland
$2.00
Massachusetts
$2.51
New Hampshire
$1.78
New Jersey
$2.70
Rhode Island
$3.50
Above the national average of $1.54 per pack
Between $0.77 and $1.53 per pack
Equal to or below $0.77 per pack (50% of national average)
Source: Orzechowski and Walker. The Tax Burden on Tobacco, Vol. 48, 2013.
As of July 1, 2014
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For every 10 percent increase in the retail
price of a pack of cigarettes, youth smoking
rates drop by 6.5 percent and overall
cigarette consumption declines by 4 percent.
The Solution

Many state lawmakers have recognized the public health and
economic benets of tobacco tax increases, as evidenced by the
fact that 15 states, the District of Columbia, Puerto Rico and Guam
have cigarette taxes of $2 or more per pack. ACS CAN challenges
states to raise cigarettes and OTP taxes regularly by a signicant
percentage of the retail price, which the research says is the best
way to curb tobacco use.
In addition to assessing state progress based solely on the amount of the
states cigarette tax rate, ACS CAN will also take into account how recently
the state raised its cigarette tax. States should increase their tax at a
minimum frequency of at least once every six years or three legislative cycles.
ACS CAN, along with the American Heart Association, the American Lung
Association and the Campaign for Tobacco-Free Kids, recommends that
states increase their cigarette tax by at least $1.00 per pack or an amount that
would result in at least a 10 percent increase in the retail price, whichever is
greater. States should also raise taxes on OTP to an equivalent percentage of
the manufacturers price as the tax on cigarettes. ACS CAN also encourages
states to earmark tobacco tax revenues for tobacco prevention and cessation
programs, along with other programs that will benet cancer patients.
Measuring the Public Health and Economic Benets of State Tax Increases
ACS CAN, in partnership with the Campaign for Tobacco-Free Kids, has
developed a model to estimate the public health and economic benets
State Cigarette Tax Increases
Alabama
Arizona
Arkansas
California Colorado
Florida
Georgia
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
South
Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West
Virginia
Wisconsin
Wyoming
Hawaii
Alaska
District of Columbia
How Do You Measure Up?
Connecticut
Delaware
Maryland
Massachusetts
New Hampshire
New Jersey
Rhode Island
At least $1.00 tax increase over the last 6 years
Tax increase over the last 6 years between $.50 and $.99
No tax increase over the last 6 years or total tax increase less than $.50
Based on changes in tax rates in effect between 7/1/08 and 7/1/14 .
Source: Orzechowski and Walker. The Tax Burden on Tobacco, Vol. 48, 2013.
Tobacco Excise Taxes
12th Edition
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of meaningful increases in state cigarette excise taxes. The model can
predict the amount of new annual revenue from increases in the states
cigarette tax, as well as the following public health and economic benets:
Reduction in adult smokers
Reduction in future smokers
Adult smoker and future smoker deaths prevented
Smoking-affected births prevented
Lung cancer health care cost savings
Heart attack and stroke health care cost savings
Smoking-affected pregnancy and birth-related health care cost savings
Medicaid program savings for the state
Long-term health care cost savings
Achieving Tax Parity
As states increase their taxes on cigarettes and smoking rates decline,
increasing the tax on OTP to achieve tax parity becomes particularly
important. In many states, cigarettes are taxed at a much higher rate
than OTP, making the lower-priced tobacco alternatives such as
cigars, snus and newer products such as dissolvable orbs more
appealing to youths. When OTP are taxed at a much lower rate than
cigarettes, smokers may switch to another lower-priced tobacco
product instead of quitting or cutting back on tobacco use. Youths
are particularly price sensitive, and are most likely to be impacted
by this price differential. Further compounding the issue, some OTP,
such as orbs, look like candy and use avorings to appeal to kids.
Justication for Tax Parity
The 2009 federal tax increase on cigarettes, roll-your-own tobacco
and small cigars produced a disparity with the taxes on pipe
tobacco, small cigars and other tobacco products. Usage of higher
taxed products decreased while consumption of lower taxed large
cigars and pipe tobacco increased signicantly. Between 2008 and
2009, consumption of pipe tobacco increased by 142 percent and
consumption of large cigars increased 73 percent.
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Lower taxes on
OTP combined with the tobacco companies aggressive marketing
practices made these products more attractive to youths and other
price-sensitive consumers. Taxing all OTP at a comparable rate to
cigarettes would help to curb these price disparities and cut down
on overall usage.
Success Story Guam
Over the last 12 months, Guam was successful in achieving tax parity for OTP equivalent to the current cigarette tax rate.
In addition, several states introduced tobacco tax legislation but were ultimately not successful. ACS CAN continues to
make the case that increasing tobacco taxes saves lives by reducing tobacco consumption and helping to keep kids from
ever starting. This, in turn, helps reduce future health care costs.
Pipe tobacco
(federal excise tax increase
of $1.73/pound)
Roll-your-own tobacco
(federal excise tax increase
of $23.68/pound)
12.9%
35.0%
65.0%
87.1%
Year prior to
April 1, 2009
Year following
April 1, 2009
Shift in Total Sales from Roll-Your-Own to Pipe Tobacco After the
Federal Tax Increase on Roll-Your-Own Tobacco
U.S. Government Accountability Ofce. Large Disparities in Rates for Smoking Products Trigger Signicant Market Shifts to Avoid Higher Taxes. GAO-12-475. April 18, 2012. Available at http://
www.gao.gov/products/GAO-12-475. Accessed July 10, 2014. Figure 13.
Tobacco Excise Taxes
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The Challenge
According to the U.S. Surgeon General,
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there is no safe level of exposure to secondhand smoke. It
contains more than 70 known or probable carcinogens and more than 7,000 substances, including
formaldehyde, arsenic, cyanide, and carbon monoxide.
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Each year in the United States, secondhand
smoke causes approximately 42,000 deaths
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among nonsmokers, including up to 7,300 lung cancer
deaths, and can also cause or exacerbate a wide range of other adverse health issues, including
respiratory infections and asthma.
As of July 1, 2014, 24 states, Puerto Rico, the U.S. Virgin Islands, Washington, D.C., and 627
municipalities across the country, have laws in effect that require 100 percent smoke-free workplaces,
including restaurants and bars.
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Combined, these laws protect 49 percent of the U.S. population.
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According to a 2011 report by the Centers for Disease Control and Prevention, all states could
have comprehensive smoke-free policies by 2020 if current progress continues. Reaching that goal
will require faster progress in parts of the country where there are no comprehensive smoke-
free laws.
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As of June 2014, 12 states had a statewide smoke-free law covering one or two of the
following: non-hospitality workplaces, restaurants and bars. Fourteen states still did not have
a statewide smoke-free law covering any of these three types of venues. In addition, 20 states,
Puerto Rico and the U.S. Virgin Islands had a law in effect requiring all state-regulated gaming
facilities to be 100 percent smoke-free.
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Unfortunately, progress in passing comprehensive statewide smoke-free laws has stalled in recent
years. No state has implemented a comprehensive statewide smoke-free law covering all workplaces,
restaurants, or bars since 2012. As a result, certain segments of the population, such as hospitality
and gaming facility workers in states or communities without comprehensive laws, continue to be
denied their right to breathe smoke-free air.
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Smoke-free Laws
12th Edition
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The Solution
The best way to reduce exposure to secondhand smoke is to make all public places 100 percent
smoke-free. Smoke-free laws reduce exposure to secondhand smoke, encourage and increase
quitting and cutting back among current smokers, and reduce health care, cleaning and lost
productivity costs.
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Smoke-free laws also reduce the incidence of cancer, heart disease and other
conditions caused by smoking and exposure to tobacco smoke.
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The Institute of Medicine and the Presidents Cancer Panel recommend that comprehensive smoke-
free laws cover all workplaces, including restaurants, bars, hospitals, health care facilities, gaming
facilities and correctional facilities.
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Implementing comprehensive smoke-free laws has been
proven to have immediate health benets.
Smoke-Free Legislation at the State, County and City Level
Alabama
Arizona
Arkansas
California Colorado
Florida
Georgia
Idaho
Illinois
Indiana
Iowa
Kansas
Louisiana
Maine
Michigan
Minnesota
Missouri
Montana
Nebraska
Nevada
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
South
Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
Wisconsin
Wyoming
Hawaii
Puerto Rico American Samoa
U.S. Virgin Islands Guam
Commonwealth
of Northern
Mariana Islands
Alaska
How Do You Measure Up?
State and Commonwealth/Territory Law Type
100 percent smoke-free in non-hospitality workplaces, restaurants and bars
100 percent smoke-free in one or two of the above
No 100 percent smoke-free state law
District of Columbia
Connecticut
Delaware
Maryland
Massachusetts
New Hampshire
New Jersey
Rhode Island
Note: American Indian and Alaska Native sovereign tribal laws are not reflected on this map.
Source: American Nonsmokers' Rights Foundation U.S. Tobacco Control Laws Database(c)
In effect as of July 1, 2014
Local Laws with 100% Smoke-free
Non-Hospitality Workplaces, Restaurants
and/or Bars
County
City
Kentucky
Mississippi
West
Virginia
Mississippi
Smoke-free Laws
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Across the country, elected ofcials at the state and local levels are
recognizing the health and economic benets of comprehensive
smoke-free laws. However, despite the evidence of the positive
impact of the laws on peoples health, legislators in several states
are considering repealing or weakening existing smoke-free laws by
adding exemptions for places such as cigar bars, hookah bars and
gaming facilities. ACS CAN staff and volunteers are ghting for the
health of all workers and have successfully defended strong laws in
states in which comprehensive smoke-free laws have been challenged.
ACS CAN urges state and local ofcials to pass or maintain
comprehensive smoke-free laws in all workplaces, including
restaurants, bars and gaming facilities, in order to protect the health
of all employees and patrons. Policymakers are also encouraged
to overturn and prevent preemption that restrict a lower level of
government from enacting stronger smoke-free laws than laws that
exist at a higher level of government. ACS CAN believes everyone has
the right to breathe smoke-free air and no one should have to choose
between their health and a paycheck.
Missed Opportunities
ACS CAN advocates and partner organizations succeeded in getting
comprehensive smoke-free bills introduced in both houses of the
Alaska State Legislature in 2014, but neither bill made it through
the legislative process. Despite the missed opportunity this year, we
were able to build considerable momentum for another attempt in
2015. Advocates delivered 1,700 supporter cards to legislators in
February and shared a list of more than 400 business and community
organization resolutions of support. ACS CAN is building momentum
for a victory in 2015.
ACS CAN once again strongly supported the Smoke Free Kentucky
Act which would protect the rights of employees and patrons to
breathe clean, smoke-free indoor air in workplaces. The 2014
session marked the rst time in Kentuckys history that a smoke-
free bill was introduced in the Senate, with the proposal ultimately
receiving an informational hearing. Additionally, the primary
smoke-free bill passed a House committee for the third straight
session. Despite receiving bipartisan support, the legislation did
not receive a vote by the full House. With consistent, statewide
polling showing majority support for protecting the right to breathe
smoke-free indoor air, and with more than a third of Kentuckys
communities covered by such policies, action by the Kentucky
General Assembly is long overdue.
Progress
Minnesota passed legislation that prohibits the use of electronic
cigarettes in government-owned or government-licensed buildings
such as hospitals, schools, correctional facilities, daycares and many
other places. While we are disappointed that the legislation did not
prohibit the use of electronic smoking devices in all workplaces,
restaurants and bars, the bill as passed represents a good step forward.
The Problem with E-cigarettes
Electronic cigarettes, or e-cigarettes, are battery-operated devices that allow the user to inhale a vapor produced from
cartridges lled with nicotine, avors and other chemicals. E-cigarette companies often market them as healthier, more
convenient, and more socially acceptable alternatives to traditional combustible cigarettes. Regardless of how they are
marketed or used, e-cigarettes are often made to resemble traditional cigarettes, making it difcult for business owners
to distinguish between the two and making enforcement of smoke-free laws difcult. In addition, the vapor produced by
e-cigarettes could be harmful to the user and bystanders. As a result, states should prohibit the use of e-cigarettes in all
venues where cigarette smoking is prohibited including workplaces, restaurants, bars and gaming facilities.
Smoke-free laws reduce exposure to secondhand smoke, encourage and increase quitting
and cutting back among current smokers, and reduce health care, cleaning and lost
productivity costs.
Smoke-free Laws
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The Challenge
Public health experts have long supported proven strategies to prevent children and adults from
using tobacco and help current tobacco users quit. Almost 70 percent of current smokers say
they want to quit, and 52 percent made a quit attempt in the past year. However, only 6 percent
were successful. All tobacco users need access to a range of treatments to nd the most effective
cessation tools. States with comprehensive tobacco prevention and cessation programs that
includes cessation services for a wide scope of their population experience faster declines in
cigarette sales, smoking prevalence and lung cancer incidence and mortality rates than states
that do not invest in these programs.
Medicaid beneciaries have a smoking rate that is 50 percent higher than the general population
30.1 percent of adult Medicaid beneciaries ages 18 - 64 smoke, compared with 18.1 percent of
adults of all ages. However, only seven states Connecticut, Indiana, Massachusetts, Minnesota,
Nevada, Pennsylvania and Vermont provide comprehensive tobacco cessation coverage
under Medicaid that includes individual and group counseling and all seven tobacco cessation
medications approved for that purpose by the U.S. Food and Drug Administration (FDA). While
Medicaid programs in all 50 states and Washington, D.C. provide access to some tobacco cessation
coverage, many barriers exist. Common barriers include duration limits (40 states for at least
some populations or plans), annual limits (37 states), prior authorization requirements (36 states)
and copayments (35 states).
The Affordable Care Act (ACA) requires Medicaid programs to offer cessation services to all
pregnant women at no cost. Additionally, the ACA requires non-grandfathered private health
plans to offer tobacco cessation coverage without cost-sharing for patients. Federal guidance
for non-grandfathered private health plans species that plans must cover screening for
tobacco use telephone, individual and group-based counseling and provide access to all
FDA-approved medications for at least two quit attempts per year.
Under the ACA, states have an incentive to improve access to cessation services with an A rating
by the U.S. Preventive Services Task Force, in the form of a 1 percent increase in the amount of
funds the federal government provides to support the program. Additionally, states that accept
the federal funds, broadening access to health care coverage to individuals earning up to 138
percent of the federal poverty level, are required to provide all A rated tobacco cessation services
to the newly eligible adults.
Requiring that health insurance plans for all state employees,
Medicaid beneciaries and other tobacco users cover a
comprehensive cessation benet, including a range of
treatment options, will curb tobacco-related death and
disease in states and ultimately save money.
Tobacco Cessation Services
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USPSTF A rated Counseling and Interventions to Prevent
Tobacco Use and Tobacco-caused Disease in Adults include
counseling for all adults about tobacco use combined with
therapy and medications for all tobacco users. FDA-approved
pharmacotherapy includes nicotine replacement therapy,
sustained-release bupropion and varenicline.
State funding for telephone cessation counseling is far below what
is considered to be adequate according to the Centers for Disease
Control and Prevention (CDC) funding recommendations in the
2014 publication Best Practices for Comprehensive Tobacco
Control. Only four states Maine, North Dakota, South Dakota
and Wyoming fund telephone-based tobacco cessation services
(quitlines) at the CDC-recommended level through state funds.
The Solution
Requiring that health insurance plans for all state employees,
Medicaid beneciaries and other tobacco users cover a
comprehensive cessation benet, including a range of treatment
options, will curb tobacco-related death and disease in states and
ultimately save money. Covering all population groups through
insurance plans is critical, especially for low-income populations
that need it most. Throughout the implementation of the ACA,
ACS CAN will work to ensure that the full range of cessation
services is covered at all levels of benets and in all plans. State
and local governments should also take advantage of the CDCs
community-based grants, which support efforts to reduce chronic
diseases such as heart disease, cancer, stroke and diabetes.
CDCs Tips Campaign Success
The CDCs Tips from Former Smokers campaign
was a huge success in 2012 and 2013. An
estimated 1.6 million people made a quit
attempt due to the 2012 campaign, and more
than 100,000 smokers quit successfully. Weekly
calls to 1-800-QUIT-NOW, which connects
callers to their state quitlines, increased by
75 percent during 2013 and visitors to the
website increased 38-fold. The evidence is clear
that quitline calls signicantly increase the
rates of users who successfully quit and that
quitlines are a great return on state investment
in addition to saving lives. The CDC already
released Tips from Former Smokers in 2014 with
a focus on tobacco-related illnesses that were
not highlighted in previous campaigns.
Smoking caused Roses lung cancer.
She had to move from the small town she
loved to get the treatment she needed,
including chemo, radiation and having part
of her lung removed. Recently, her
cancer spread to her brain. You can quit.
CALL 1-800-QUIT-NOW.
#CDCTips
1.577 pt
Be prepared.
Your lung cancer can
spread to your brain.
Be prepared.
Your lung cancer can
spread to your brain.
Rose, age 59, Texas Rose, age 59, Texas
Tobacco Cessation Services
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Medicaid Coverage of Tobacco Cessation Treatments
Alabama
Arizona
Arkansas
California Colorado
Florida
Georgia
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine**
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Mexico
New York
North Carolina
North Dakota
Ohio***
Oklahoma
Oregon
Pennsylvania
South
Carolina
South Dakota*
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West
Virginia
Wisconsin
Wyoming
Hawaii
Alaska
How Do You Measure Up?
Both individual and group counseling and all 7FDA-approved
tobacco cessation medications covered for all enrollees
At least 1 type of counseling (individual or group) and at least 1
FDA-approved tobacco cessation medication covered for all enrollees
No type of counseling (individual or group) or no FDA-approved
tobacco cessation medication covered for all enrollees
District of Columbia
Connecticut
Delaware
Maryland
Massachusetts
New Hampshire
New Jersey
Rhode Island
Source unless otherwise noted: Singleterry J, Jump Z, Lancet E, et al. State Medicaid Coverage for Tobacco Cessation Treatments and Barriers to Coverage United States, 2008-2014. MMWR 63(12): 263-269.
* Data not available on coverage for counseling and two types of medications. All other medications are not covered for all enrollees.
** Source: MaineCare. Preferred Drug Lists. Updated June 9, 2014. Available at http://www.mainecarepdl.org/pdl. Accessed June 24, 2014.
*** Source: Ohio Department of Health. Medicaid Billing for Tobacco Cessation Treatment. Updated June 2014.
As of July, 1, 2014
Success Story Connecticut
In 2014, Connecticut was able to secure $3.4 million for Medicaid cessation and $3.5 million for tobacco control efforts with
the potential of an additional allocation up to $12 million. Additionally, the Connecticut Tobacco & Health Trust Fund, which
is charged to support and encourage development of programs to reduce tobacco use through prevention, education and
cessation programs among other health priorities, beneted from legislation that restored funds for scal year 2016.
Tobacco Cessation Services
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The Challenge
The 2014 U.S. Surgeon Generals report on tobacco concluded that comprehensive statewide
and community tobacco control programs prevent initiation of tobacco use and reduce the
prevalence of tobacco use among youth and adults, and furthermore, called for fully funding these
programs at the Centers for Disease Control and Prevention (CDC)-recommended level as part of
the comprehensive strategy to accelerate progress in eliminating tobacco death and disease.
1
The
level of funding and the emphasis states place on proven prevention and cessation programs over
time directly inuence the health and economic gains from their tobacco control interventions.
Comprehensive, adequately-funded tobacco control programs reduce tobacco use and tobacco-
related disease, resulting in reduced tobacco-related health care costs.
Unfortunately, states currently spend only a small percentage of the revenues from tobacco taxes
and Master Settlement Agreement (MSA) payments billions of dollars in yearly installments
the tobacco companies agreed to pay states and territories as compensation for costs associated
with tobacco-related diseases on tobacco control programs. In scal year 2014, states budgeted
a total of $481.2 million for tobacco prevention and cessation programs, a modest increase from
last years $459.5 million.
2
While states will collect $25 billion in tobacco revenue this year, they
will devote less than 2 percent of it to support prevention and cessation efforts. Additionally,
the $481.2 million represents only 14.6 percent of the CDC-recommended level of funding for
statewide tobacco control programs. Only two states currently fund their programs at the CDC-
recommended level (Alaska and North Dakota), and only ve states are funding at even half the
CDC-recommended level (Delaware, Hawaii, Maine, Oklahoma and Wyoming). It would take only
13.2 percent of annual state tobacco tax and settlement revenue to fund all states programs at
the CDC-recommended level. The current low in funding threatens the viability of state tobacco
control programs that promote the health of residents, reduce tobacco use and provide services
to help people quit.
Comprehensive, adequately-funded tobacco control programs
reduce tobacco use and tobacco-related disease, resulting in
reduced tobacco-related health care costs.
The Solution
The CDC released an updated version of its evidence-based guide for state investment in tobacco
control, Best Practices for Comprehensive Tobacco Control Programs, in 2014.
3
As outlined in the
guide, these programs should consist of all the following ve components to be most effective:
1. State and community interventions, which include supporting and implementing programs
and policies to inuence societal organizations, systems and networks that encourage and
support individuals to make behavior choices consistent with tobacco-free norms;
2. State health communication interventions, which deliver strategic, culturally
appropriate and high-impact messages about the health impact of tobacco use;
Tobacco Control Program Funding
12th Edition
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3. Cessation interventions ensuring that all patients are screened for tobacco use, receive
brief interventions to help them quit and if needed, more intensive counseling services
and FDA-approved cessation medications, as well as telephone-based cessation (quitline)
counseling for all tobacco users who wish to access the service;
4. Surveillance and evaluation to monitor the achievement of overall tobacco prevention and
cessation program goals and to assess the implementation and outcomes of the program and
demonstrate accountability; and
5. Implementation of effective tobacco prevention and control programs requires
substantial funding. An adequate number of skilled staff enable programs to plan their
strategic efforts, provide strong leadership, and foster collaboration between the state and
local tobacco control communities.
Fiscal Year 2014 State Funding for Tobacco Prevention
Alabama
Arizona
Arkansas
California Colorado
Florida
Georgia
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
South
Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West
Virginia
Wisconsin
Wyoming
Hawaii
Alaska
How Do You Measure Up?
50% or more of the CDC recommended funding level
25-49% of the CDC recommended funding level
1-24.9% of the CDC recommended funding level
No funding
District of Columbia
Connecticut
Delaware
Maryland
Massachusetts
New Hampshire
New Jersey
Rhode Island
Sources: Robert Wood Johnson Foundation, Campaign for Tobacco-Free Kids, American Cancer Society Cancer Action Network, American Heart Association, and American Lung Association.
A Broken Promise to Our Children: The 1998 State Tobacco Settlement 15 Years Later. December 2013. Available at http://www.tobaccofreekids.org/what_we_do/state_local/tobacco_settlement/.
Centers for Disease Control and Prevention (CDC). Best Practices for Comprehensive Tobacco Control Programs 2014. Atlanta: U.S. Department of Health and Human Services, CDC, National Center
for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, 2014. Current annual funding includes state funds for FY2014 and does not include federal funds directed to states.
Tobacco Control Program Funding
16
State
Alaska
North Dakota
Delaware
Wyoming
Hawaii
Oklahoma
Maine
Colorado
Arkansas
Vermont
Minnesota
Utah
Montana
South Dakota
Florida
Mississippi
Arizona
New Mexico
Oregon
NewYork
West Virginia
California
Maryland
Iowa
Idaho
Louisiana
Nebraska
Virginia
South Carolina
Connecticut
Wisconsin
Illinois
Indiana
Tennessee
Massachusetts
Pennsylvania**
District of Columbia
Texas
Kentucky
Kansas
Nevada
Rhode Island
Georgia
Michigan
North Carolina
Washington
Ohio
New Hampshire
Alabama
Missouri
New Jersey
Tobacco Prevention
Spending (FY14)*
$10.1 million
$9.5 million
$8.3 million
$5.1 million
$7.9 million
$22.7 million
$8.1 million
$26.0 million
$17.5 million
$3.9 million
$21.3 million
$7.5 million
$5.4 million
$4.0 million
$65.6 million
$10.9 million
$18.6 million
$5.9 million
$9.9 million
$39.3 million
$5.3 million
$64.8 million
$8.5 million
$5.1 million
$2.2 million
$8.0 million
$2.4 million
$9.5 million
$5.0 million
$3.0 million
$5.3 million
$11.1 million
$5.8 million
$5.0 million
$4.0 million
$7.0 million
$495,000
$11.2 million
$2.1 million
$946,671
$1.0 million
$388,027
$2.2 million
$1.5 million
$1.2 million
$756,000
$1.5 million
$125,000
$275,000
$76,364
$0.0 million
CDC Recommended
Spending
$10.2 million
$9.8 million
$13.0 million
$8.5 million
$13.7 million
$42.3 million
$15.9 million
$52.9 million
$36.7 million
$8.4 million
$52.9 million
$19.3 million
$14.6 million
$11.7 million
$194.2 million
$36.5 million
$64.4 million
$22.8 million
$39.3 million
$203.0 million
$27.4 million
$347.9 million
$48.0 million
$30.1 million
$15.6 million
$59.6 million
$20.8 million
$91.6 million
$51.0 million
$32.0 million
$57.5 million
$136.7 million
$73.5 million
$75.6 million
$66.9 million
$140.0 million
$10.7 million
$264.1 million
$56.4 million
$27.9 million
$30.0 million
$12.8 million
$106.0 million
$110.6 million
$99.3 million
$63.6 million
$132.0 million
$16.5 million
$55.9 million
$72.9 million
$103.3 million
StateTobacco Preven-
tion Spending % of
CDC Recommended
99.4%
97.1%
64.0%
60.0%
57.3%
53.7%
50.7%
49.1%
47.6%
46.4%
40.2%
39.1%
37.0%
34.2%
33.8%
29.9%
28.9%
26.0%
25.2%
19.4%
19.2%
18.6%
17.8%
17.1%
14.1%
13.4%
11.4%
10.3%
9.8%
9.4%
9.2%
8.1%
7.8%
6.6%
5.9%
5.0%
4.6%
4.2%
3.7%
3.4%
3.3%
3.0%
2.1%
1.4%
1.2%
1.2%
1.1%
0.8%
0.5%
0.1%
0.0%
State Tobacco Prevention Spending
* Only state government allocations are included in this chart.
** Source for PA funding allocation: Tobacco Settlement Fund Status of Appropriations. April 2014; Commonwealth of
Pennsylvania, Pennsylvania Office of the Budget. 2013-14 Mid-Year Budget Briefing. December 18, 2013.
Source for Tobacco Prevention Funding, unless otherwise noted: Robert Wood Johnson Foundation, Campaign for To-
bacco-free Kids, American Cancer Society Cancer Action Network, American Heart Association, Americans for Nonsmok-
ers' Rights, and American Lung Association. Broken Promises to Our Children: The 1998 State Tobacco Settlement 15
Years Later. December 2013. Available at http://www.tobaccofreekids.org/what_we_do/state_local/tobacco_settlement/.
State Tobacco Prevention Spending
Funding statewide tobacco
control programs as outlined in
the CDCs best practices guideline
and at the CDC-recommended
levels will result in millions
of fewer tobacco users and
hundreds of thousands of lives
saved from premature tobacco-
related deaths.
Funding statewide tobacco control programs as outlined
in the CDCs best practices guideline and at the CDC-
recommended levels will result in millions of fewer
tobacco users and hundreds of thousands of lives saved
from premature tobacco-related deaths. ACS CAN
challenges states to combat tobacco-related illness and
death by sufciently funding comprehensive tobacco
control programs at the CDC-recommended level or above;
implementing strategies to continue that funding over
time; and applying the specic components delineated in
the CDCs Best Practices guideline. Legislators are urged
to resist sacricing tobacco prevention and cessation
programs in tough economic times as short-term
budgetary xes and to instead consider the long-term
health and economic burden that such cuts will ultimately
put on the state and its population.
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The Challenge
For the majority of Americans who do not use tobacco, the greatest behavioral risk factors for cancer
are weight, diet and physical activity levels. In fact, one-quarter to one-third of all cancers are tied to
poor nutrition, physical inactivity, and excess weight.
1
Being overweight or obese increases a persons
risk for many cancers, including colon, endometrium, esophagus, gallbladder, kidney, pancreas,
rectum and possibly postmenopausal breast cancer.
2
There is also highly suggestive evidence of
a link between being overweight or obese and cancers of the cervix, liver and ovary, for multiple
myeloma, Hodgkin disease and aggressive prostate cancer.
3
In addition to increasing the risk for
cancer and other chronic diseases, overweight and obesity place a huge nancial burden on the
health care system in the United States. Obesity alone costs the nation $147 billion in direct medical
costs each year, approximately half of which is paid for by Medicaid and Medicare.
4
Excess weight and obesity has become an epidemic in this country, with more than double the rate for
adults and triple the rate for youths from just 30 years ago. Today, approximately two in three adults and
one in three youths are overweight or obese.
5,6
The increase in childhood excess weight and obesity are
particularly troubling because children who are overweight and obese are much more likely to be so as
adults. Excess weight and obesity rates vary widely by geography and by racial and ethnic group, with
many Southeastern states, African Americans and Hispanics having disproportionately high rates.
7
Lack of physical activity is a factor in obesity. Just one in ve adults are meeting recommendations
for at least 150 minutes of moderate physical activity, or an equivalent amount of vigorous physical
activity, per week and muscle-strengthening activity at least twice a week.
8
Fourteen percent of
high school students do not get the recommended daily hour of physical activity on any day of the
week.
9
Americans also consume too few fruits, vegetables and whole grains and too many rened
grains, added sugars, unhealthy fats and calories overall. In fact, a recent survey found that more
than one in three adults (37.7 percent) eat fruits or vegetables less than once per day.
10
The rapid increase in excess weight and obesity during the past few decades is also attributable
to environmental and social changes. Many communities lack pedestrian-friendly infrastructure,
such as sidewalks and parks, which can facilitate daily physical activity among children and adults.
Large portions of inexpensive high calorie foods and beverages with little to no nutrition value are
abundant and widely marketed. Together, environmental and social factors have contributed to the
excess weight and obesity epidemic in our country. Increasing opportunities for physical activity,
healthy eating and promoting good choices offer a critical opportunity for cancer prevention.
One-quarter to one-third of all cancers are tied to poor
nutrition, physical inactivity and excess weight.
The Solution
The American Cancer Society Guidelines on Nutrition and Physical Activity for Cancer Prevention
recommend individuals achieve and maintain a healthy weight; adopt a physically active lifestyle;
consume a healthy diet with an emphasis on plant-based foods like whole grains, legumes, fruits,
Obesity, Nutrition and Physical Activity
18
and vegetables; and limit consumption of alcoholic beverages.
11
The guidelines also recommend
that public, private and community organizations work collaboratively at all levels of government
to implement policy and environmental changes that increase access to affordable, healthy
foods in communities, schools and at work; decrease access to and the marketing of foods
with low nutritional value, particularly to youths; and provide safe, enjoyable and accessible
places for physical activity at school, work and in local communities.
12
Both the individual and
community recommendations in the guidelines are consistent with the 2010 Dietary Guidelines
for Americans and other evidence-based recommendations from the Centers for Disease Control
and Prevention,
13
the Institute of Medicine
14
and other experts. Overall, these recommendations
focus on making healthy choices easier meaning healthy foods should be more convenient and
affordable and physical activity should be more easily incorporated into a persons daily routine.
School Nutrition and Wellness
There are signicant opportunities for states to pass and implement policies to improve the food
and physical activity environments. As a result of the Healthy, Hunger-Free Kids Act of 2010, the
federal government has recently set updated national nutrition standards for school meals and
updated national nutrition requirements for snacks and beverages, which will begin to take effect as
students go back to school in Fall 2014. While the federal requirements set a minimum baseline, it
is not preemptive. States and localities have the opportunity to ll in gaps, including strengthening
the federal standards, extending them beyond the end of the ofcial school day, closing loopholes
and setting nutrition standards for school-sponsored fundraisers. Local communities also have an
opportunity to set stronger school nutrition and wellness requirements by reviewing and updating
their local wellness policies, which is also required by federal law. Local wellness policies must:

Include goals for food marketing, nutrition education and promotion, physical activity,
nutrition standards for foods sold in schools and other school-based wellness activities
Be developed with input from a broad group of stakeholders
Be widely disseminated throughout the community
Setting Priorities
ACS CANs nutrition, physical activity and obesity policy priorities include:
Establishing strong nutrition standards for all foods and beverages sold or served in schools;
Increasing the quality and quantity of physical education in K-12 schools, supplemented by additional school-
based physical activity;
Increasing funding for research and interventions focused on improving nutrition, increasing physical activity and
reducing obesity;
Reducing the marketing of unhealthy foods and beverages, particularly to youths
ACS CAN recommends legislators focus their efforts on changing policies in these key areas, which are likely to have a
signicant impact on making healthy choices easier, particularly for youths.
Obesity, Nutrition and Physical Activity
12th Edition
19
Physical Education
State legislators can also help to increase physical activity
by setting strong requirements for physical education in
schools. The U.S. Department of Health and Human Services
(HHS) report Physical Activity Guidelines for Americans,
recommend children and adolescents engage in at least
one-hour of physical activity daily,
15
and the Institute of
Medicine recommends children have opportunities to
engage in an hour of physical activity at school each day,
half of which should be during the regular school day.
16,17

Quality physical education is the best way for youths to get a
signicant portion of their recommended physical activity,
improve their physical tness and obtain the knowledge
and skills they need to be physically active throughout
their lifetimes.
18
Physical education may even increase
students academic achievement. Physical education
should be part of a comprehensive school physical activity
program, which also provides opportunities for and
encourages students to be active before, during and after
school through recess, classroom physical activity breaks,
walk-to-school programs, joint- or shared-use agreements
that allow community use of school facilities and vice
versa, and after-school physical activity programs, such
as competitive, intramural and club sports and activities.
However, these other opportunities for physical activity
before, during and after school should supplement rather
than supplant physical education.
ACS CAN recommends states provide resources to all
school districts to develop and implement a planned K-12
physical education curriculum that adheres to national
and state standards for health and physical education
for a minimum of 150 minutes per week in elementary
schools and 225 minutes per week in middle and high
schools. In addition to increasing the quantity of physical
education, there are a number of strategies to improve
the quality of physical education in schools that are
important for states to implement, regardless of how
frequently physical education is offered:
Encourage students to engage in moderate to
vigorous physical activity for at least 50 percent of
physical education class time.
Hire a state-level physical education coordinator to
provide resources and offer support to school districts
throughout the state, and a district-level coordinator
to provide support to physical education teachers.
Key:
State requires at least 150 minutes per week of physical education at the elementary school
level or at least 225 minutes per week at the middle and high school levels, for all grades
State requires at least 90 minutes per week of physical education for all grades, but less
than the recommended 150 or 225 minutes per week
State requires less than 90 minutes per week of physical education or does not require
physical education at all
Requirement is not yet in effect as of 7-1-14
Footnotes:
* Physical education required for 2 or more years in high school, but not all 4 years, or an exemption from physical education
permitted for up to 2 years in high school
^ Daily physical education required at all school levels, but a specific number of minutes has not been set
~ Required number of minutes also includes time for health and safety education
Sources:
National Cancer Institute. Classification of Laws Associated with School Students (CLASS) Database. 2010. Available at
http://class.cancer.gov.
American Heart Association and National Association for Sport and Physical Education. 2012 Shape of the Nation Report:
Status of Physical Education in the USA. Reston, VA: NASPE.
Additional research by ACS CAN.
Physical Education Time Requirements
State
Alabama
Alaska
Arizona
Arkansas
California*
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois*^
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada*
New Hampshire
New Jersey
~
New Mexico
NewYork
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah*
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Elementary Schools Middle Schools High Schools
Physical Education Time Requirements
20
Urge school districts or schools to complete comprehensive self-assessments of their
physical education programs; report their ndings to parents, community members, and
the school board; and integrate the results into the district or schools long-term strategic
planning, improvement plan, or wellness policy.
Offer regular professional development opportunities to physical education teachers that are
specic to the eld and require physical education teachers to be highly qualied and certied.
Add valid tness, cognitive, and affective assessments in physical education based on
student improvement and knowledge gain.
Provide physical education programs with appropriate equipment and adequate facilities,
and require class size consistent with other subject areas.
States should also support schools and school districts in increasing opportunities for additional school-
based physical activity, as long as this does not come at the expense of physical education. Ways to
increase physical activity include implementing classroom-based physical activity breaks, daily recess
in elementary schools, and before and after school physical activity programs. Such programs include
competitive and intramural sports and activity clubs, walk-and-bike-to-school programs and joint-use
agreements, in which the school allows community use of their facilities outside of school hours.
ACS CAN recommends states provide resources to all school
districts to develop and implement a planned K-12 physical
education curriculum that adheres to national and state
standards for health and physical education for a minimum
of 150 minutes per week in elementary schools and 225
minutes per week in middle and high schools.
The Problem with Preemption
While some states and localities have advanced policies aimed at promoting healthier foods and beverages, other states
have passed laws that would prevent localities within their state from doing so. For example, a law in Mississippi
the state with the highest obesity rate prevents localities from taking action on policy relating to calorie labeling in
restaurants, zoning to increase access to healthy foods and decrease access to fast-food restaurants and other unhealthy
food vendors in underserved areas, and setting nutrition standards for restaurant meals that include toy giveaways. It
is important for localities across the country to have the opportunity to put their own innovative initiatives in place that
have the potential to improve nutrition, increase physical activity and decrease obesity in order to increase the health of
residents. Just as is the case with tobacco control, local control is essential for good public health.
Multifaceted policy approaches across a population can signicantly enhance nutrition and physical activity and reduce obesity
rates by removing barriers, changing social norms and increasing awareness. ACS CAN stands ready to work with state and local
policymakers to plan, implement and evaluate these strategies and move the nation toward a healthier future one with less cancer.
Obesity, Nutrition and Physical Activity
12th Edition
21
I
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The Challenge
Skin cancer is the most commonly diagnosed cancer in the United States and rates have been rising
for the past 30 years.
1
In 2014, an estimated 76,100 cases of melanoma will be diagnosed, in addition
to millions of basal and squamous cell skin cancers. In total, nearly 13,000 men and women will die
of skin cancer and 9,710 of those deaths will be from melanoma.
2
Exposure to UV radiation, through
sunlight and indoor tanning devices, is one of the most avoidable risk factors for skin cancer. In fact, UV
radiation from indoor tanning devices is so harmful that the World Health Organizations International
Agency for Research on Cancer (IARC) categorized the devices into its highest cancer risk category
carcinogenic to humans.
3
This IARC report, in addition to countless research articles published on
the harms of tanning, has led advocates around the world to call for new restrictions on access.
Despite the dangers, misconceptions about the risks and benets of indoor tanning exist. Users
mistakenly believe a base tan has a protective effect against burns, UV light is the only way to get
Vitamin D and the risk of cancer from using tanning devices is low. These misconceptions are due,
in part, to misleading advertising and health claims put forth by the tanning industry.
4,5
Youths are especially susceptible to the harmful effects of UV radiation. Knowing this is a serious
cause for concern as teens are tanning at increasingly high rates. In the past year, one in ve
high schools girls have used a tanning bed with numbers increasing to one in three high school
girls by their senior year.
6
This is especially worrisome since studies have shown using an indoor
tanning device before the age of 35 increases the risk of melanoma by 59 percent, squamous cell
carcinoma by 67 percent and basal cell carcinoma by 29 percent.
7,8
The Solution
Laws which prohibit the use of indoor tanning devices for everyone under the age of 18 can go a
long way toward reducing skin cancer incidence and mortality rates across the country. Parental
consent laws are not sufcient in effectively deterring minors from using tanning devices, but age
restrictions have been shown to be effective.
9

To protect youths from the harmful effects of UV radiation, legislation is needed to restrict youth
access, without exceptions, in every state. In addition, states need to ensure oversight mechanisms
are in place to guarantee youths are not gaining access to these harmful devices.
Skin cancer is the most commonly diagnosed cancer in the
United States and rates have been rising for the past 30 years.
ACS CAN commends the Food and Drug Administration (FDA) for nalizing its order to reclassify indoor tanning devices from a class I
to a class II medical device, imposing greater control over their manufacture and distribution. This is a critical step to protect Americans
from the dangers of indoor tanning devices. The nalized order means the FDA will require manufacturers to display labels that warn
against the use of tanning devices by those under 18, and hold manufacturers to stricter safety and performance standards. The FDA
order helps move the mark forward on prohibiting minors from the use of indoor tanning devices on the state and local level.
Thank you for protecting Indianas kids.
Both tanning beds and cigarettes cause cancer. This year, our state
legislators passed a bill to protect kids under 16 from the dangers of
tanning. Next year, lets show our kids we care and protect all minors
from the deadly efects of indoor tanning.
For more information, visit ACSCAN.org/IN
Paid for by the American Cancer Society Cancer Action NetworkSM
When it comes to cancer, one of
these things is just like the other.
Indoor Tanning
22
Missed Opportunity
In March, Nebraska passed and the governor signed into law a bill that does not
go far enough in ensuring all minors are protected from the dangers and lifelong
damage of indoor tanning. This weak bill only prohibits youths under 16 years of age
from using tanning equipment unless the person is accompanied by a parent or legal
guardian. We are very proud of the work our ACS CAN staff and volunteers did to
educate legislators on why parental consent and accompaniment is insufcient in
protecting minors from the increased risk of skin cancer incurred by UV radiation.
We hope the Nebraska lawmakers will use the 2015 legislative session to strengthen
this weak bill by prohibiting access to youths, without exceptions.
Laws which prohibit the use of indoor tanning
devices for everyone under the age of 18 can
go a long way toward reducing skin cancer
incidence and mortality rates across the country.
State Tanning Device Restrictions
Alabama
Arizona
Arkansas
California Colorado*
Florida
Georgia
Idaho*
Illinois
Indiana
Iowa*
Kansas*
Kentucky
Louisiana
Maine
Michigan
Minnesota
Mississippi
Missouri
Montana*
Nebraska
Nevada
New Mexico*
New York
North Carolina
North Dakota
Ohio
Oklahoma*
Oregon
Pennsylvania
South
Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West
Virginia
Wisconsin
Wyoming
Hawaii*
Alaska*
District of Columbia*
How Do You Measure Up?
Connecticut
Delaware
Maryland
Massachusetts
New Hampshire
New Jersey
Rhode Island
State law prohibiting tanning for minors (under age 18) with no exemptions.
State law prohibits tanning for those under 17 (NY, NJ, CT, PA), or under 16 (WI, IN). State law requires parental
accompaniment for every visit for those under 18 (UT), allows for physician prescription under 18 (OR, WA), or
prohibits tanning for under age 18 unless a signed parental permission slip is obtained for every two visits (RI).
No state law regarding tanning (indicated with an *), state law prohibits those 14 or 15 or under, law allows
for signed parental permission, or law requires parental accompaniment for every visit under 16 or younger.
Sources: Health Policy Tracking Service & Individual state bill tracking services
Legislation signed by Governor as July 2, 2014
Success Story
Hawaii, Louisiana
and Minnesota
While many states struggled to pass
comprehensive legislation, three states
(Hawaii, Louisiana and Minnesota) were
beacons of success passing comprehensive
laws prohibiting all minors from the
dangers of indoor tanning beds. Legislation
in all three states passed with support from
both political parties, demonstrating that
protecting minors from increased risk of
skin cancer is a bipartisan issue.
12th Edition
23
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Access to health care is a signicant determinant of whether or not an individual diagnosed with
cancer will survive. Individuals without health insurance are more likely to be diagnosed with cancer
at a later stage and more likely to die from the disease.
1
ACS CAN believes all Americans should have
access to affordable, quality health insurance. In 2014, ACS CAN focused on improving access to
care in the following areas: access to prescription drugs, oral chemotherapy fairness, eliminating the
tobacco rating, health plan network adequacy, increasing access to Medicaid and the preservation
of the Medicaid breast and cervical cancer treatment programs.
Access to Care: Prescription Drug Transparency
and Cost-Sharing
The Challenge
In 2009, direct medical spending for cancer care in the United States was $86.6 billion.
2
While private
and public health insurance provides coverage for many cancer patients, these patients often face
high out-of-pocket costs due to their plans cost-sharing requirements or coverage limitations.
In addition, the increase in availability of oral chemotherapy medications has led to more cancer
patients relying on their prescription drug benets to cover chemotherapy regimens. Therefore,
it is critically important for cancer patients to have access to clear, consistent and comparable
information on prescription drug coverage and cost-sharing, including coverage of physician-
administered drugs, in order to choose the right health plan.
In January 2014, ACS CAN undertook a study of cancer drug coverage in plans offered in the new
health insurance marketplace to determine:
The transparency of information;
Comprehensiveness of the plans formulary, or list of covered drugs; and
The level of cost-sharing required for cancer patients.
We found the following:
Prescription drug formularies for plans sold in the marketplace can be inconsistent in the
drugs they include and incomplete in the information they provide to patients, posing a
signicant challenge for patients trying to make apples-to-apples comparisons of plans.
Patients undergoing chemotherapy administered by a physician would nd it nearly
impossible to determine if the chemo drug is covered.
The cancer drugs we examined were generally covered in marketplace plans, but the plans
listed the drugs on the highest tier for patient cost-sharing 83 percent of the time and
required prior authorization 84 percent of the time. Many plans require patients to pay a
percentage of the cost of the cancer drug, which can be far more expensive than charging a
set copayment.
Plan designs vary widely, making it critical that patients are able to compare potential out-
of-pocket costs when choosing a health plan.
ACS CAN believes all Americans should have access to
affordable, quality health insurance.
Access to Care
24
The Solution
ACS CAN urges state insurance departments and/or marketplace
boards to adopt the following recommendations to improve
prescription drug formulary transparency and reduce patient
cost-sharing:
Require health plans to post standardized prescription drug
formularies on their websites, including lists of physician-
administered drugs covered under the medical benet (see
Success Story).
Develop a prescription drug search tool on state marketplace
websites to allow patients to search for plans that cover the drugs
they need.
Develop out-of-pocket cost calculators that help patients
compare plans based on the cost of premiums, as well as
cost-sharing for services and prescription drugs they are
likely to use during a coverage year.
Standardize cost-sharing designs offered in marketplace
plans with an emphasis on copayments, which require
patients to pay xed, per-service amounts, rather than on
coinsurance, which require the patient to pay a percentage
of the service cost that is often much higher than the service.
Provide robust oversight of prescription drug benets to ensure
that formulary designs do not discriminate against patients
needing certain expensive drugs for diseases such as cancer.
There is little evidence that nancial
penalties through insurance premiums
change individual behavior.
Access to Care: Oral
Chemotherapy Fairness
The Challenge
Scientic advancements during the past several years have increased
the availability and effectiveness of oral medications for cancer
treatment. Approximately one-quarter of all oncology drugs in
the development pipeline are oral medications,
3
and many oral
chemotherapy drugs have been approved by the Food and Drug
Administration (FDA). However, health plans often require higher
cost-sharing for oral chemotherapy drugs than for drugs administered
intravenously (IV) by a physician. This disparity can affect patient
and physician decision-making about treatment options and may
lead patients to forgo the best treatment for their situation. In
addition, research suggests high cost-sharing for oral chemotherapy
medications may lead patients to abandon treatment.
4

Oral chemotherapy, when available, can offer advantages to
patients and caregivers, such as:
Less frequent visits to a doctors ofce or cancer treatment center;
Less need to schedule long appointments for infusions; and
Less worry about nding transportation to and from appointments.
This exibility is particularly important for people living in rural
areas who otherwise would have to travel long distances to the
nearest treatment facility, as well as for employed patients and
family members who are trying to reduce hours away from work
during treatment. A recent study found cancer patients with
Success Story California
ACS CAN is leading efforts to support California Senate Bill 1052, which aims to improve the drug coverage and cost
sharing information available to consumers shopping for plans sold in Californias individual and small group markets.
Specically, the legislation would require the California Department of Managed Care to develop a standard formulary
template. Carriers would be required to use a standardized formulary template to allow consumers to compare coverage
more easily among available plans. Additionally, for all drugs included on a plan formulary, carriers would have to disclose
whether coverage is subject to additional hurdles such as prior authorization or a requirement that patients rst try less
expensive or preferred drugs prior to receiving coverage for a more expensive drug. Plans will be required to provide
better information about out of pocket expenses or drugs subject to coinsurance. In sum, the bill would provide important
tools and information that enable consumers to buy the plan that best meets their individual health needs.
Access to Care
12th Edition
25
monthly cost-sharing of $500 or more were four times more likely
to abandon the prescribed chemotherapy drug than cancer patients
with cost-sharing of $100 or less per month.
5
The Solution
To date, 34 states and Washington, D.C. have passed oral
chemotherapy fairness legislation to help equalize patient out-
of-pocket costs for oral chemotherapies and IV chemotherapies.
These laws generally require state-regulated health insurance
companies and group health plans to apply cost-sharing to orally
administered anticancer drugs on a basis no less favorable than
IV administered ones. Over time, states have added additional
protections for cancer patients, such as prohibiting insurance
companies from increasing IV chemotherapy cost-sharing to
comply with the law.
Cancer patients access to anticancer oral drugs has improved as a result
of these states legislative efforts and successes. ACS CAN applauds
these state efforts and encourages all states to pursue similar legislation.

Access to Care: Tobacco Rating
The Challenge
The ACA allows insurers in the individual market to charge
tobacco users up to 50 percent higher premiums than they charge
non-tobacco users. However, states have the authority to reduce or
eliminate the penalty that can be imposed on tobacco users.
A health insurance surcharge for tobacco use is not an effective way
to discourage tobacco use. In fact, penalizing smokers with higher
insurance costs will likely result in adverse consequences. Tobacco
users are the ones who most need access to the smoking cessation
services offered through health insurance policies. Unfortunately,
they are also the very ones most affected by nancial penalties.
Unaffordable premiums may price them out of the very coverage
they need to help them ultimately quit tobacco use.
There is little evidence that nancial penalties through insurance
premiums change individual behavior. Further, while many people
are having their premiums reduced because they are eligible for
federal subsidies, adding the tobacco surcharge to the reduced rate
could make premiums unaffordable for many patients. As a result,
a tobacco surcharge will lead to higher health insurance premiums
and will create an affordability barrier for individuals who need
coverage the most, including access to smoking cessation services.
A 2012 study estimated, in California alone, between 200,000 and
400,000 people would remain uninsured because the 50 percent
tobacco surcharge would make coverage unaffordable.
6
ACS CAN believes making insurance coverage more expensive for
tobacco users goes against the intent of the new law to provide more
Americans with access to quality, affordable health insurance. The ACA
guarantees access to preventive services with no or limited cost-sharing,
To date, 34 states and Washington, D.C.
have passed oral chemotherapy fairness
legislation to help equalize patient out-
of-pocket costs for oral chemotherapies
and IV chemotherapies.
State in which Oral
Fairness Passed
Oregon
Hawaii
Indiana
Iowa
District of Columbia
Colorado
Connecticut
Kansas
Minnesota
Vermont
Illinois
New Mexico
NewYork
Texas
Washington
Delaware
Louisiana
Year Legislation
Passed
2007
2009
2009
2009
2009
2010
2010
2010
2010
2010
2011
2011
2011
2011
2011
2012
2012
State in which Oral
Fairness Passed
Maryland*
Nebraska
New Jersey
Virginia
California
Florida
Massachusetts
Nevada
Oklahoma
Rhode Island
Utah
Arizona
Georgia
Maine
Missouri
Ohio
Wisconsin
Year Legislation
Passed
2012
2012
2012
2012
2013
2013
2013
2013
2013
2013
2013
2014
2014
2014
2014
2014
2014
*Enacted legislation strengthening their original law
Oral Chemotherapy Fairness Legislation
Access to Care
26
including evidence-based tobacco cessation services. Many tobacco
users suffer from the chronic diseases associated with tobacco addiction.
Pricing tobacco users out of the health insurance market limits their
access to the cessation services they need to help them quit, and to the
screening services needed to detect cancer early and save lives.
Low-income tobacco users will face unaffordable health insurance
premiums when insurance companies charge the full 50 percent tobacco
use surcharge allowed under the ACA.
7
In addition, tobacco users,
particularly smokers, are disproportionately members of a racial minority,
are lower-income and are less educated than non-tobacco users.
8
Across
all racial groups, those who are classied as nearly poor or middle income
have higher smoking rates than those with higher incomes.
9
The Solution
To date, nine states and Washington, D.C. have passed legislation
or imposed regulations eliminating or limiting the tobacco
rating in their individual health insurance market. California,
Massachusetts, New Jersey, New York, Rhode Island, Vermont and
Washington, D.C. all prevent insurance companies from charging
smokers a higher premium for their health insurance plan.
Three additional states limit the amount insurance companies
can charge for tobacco use, with Arkansas limited to 20 percent,
Colorado limited to 15 percent and Kentucky limited to 40 percent.
ACS CAN applauds these efforts and urges all states to eliminate
the tobacco rating in the individual health insurance market.
Restrictions on Tobacco Rating
Alabama
Arizona
Arkansas
California Colorado
Florida
Georgia
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
South
Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West
Virginia
Wisconsin
Wyoming
Hawaii
Alaska
District of Columbia
How Do You Measure Up?
Connecticut
Delaware
Maryland
Massachusetts
New Hampshire
New Jersey
Rhode Island
Tobacco surcharges are prohibited
Tobacco surcharges are capped at less than 50%
Tobacco surcharges of up to 50% are allowed
Source: The Center for Consumer Information & Insurance Oversight
http://www.cms.gov/CCIIO/Programs-and-Initiatives/Health-Insurance-Market-Reforms/state-rating.html
As of April 14, 2014
Access to Care
12th Edition
27
Access to Care: Network Adequacy
The Challenge
Under the ACA, insurance companies can no longer deny coverage
or charge more due to pre-existing conditions, and all insurance
offered to individuals must cover a broad set of essential health
benets. With the rising cost of health care that began long before
the ACA, some insurance companies began limiting the range of
doctors and specialists available through their plans in an effort to
keep premiums down. This practice often results in plans having
what are called narrow networks. Studies have indicated that many
plans in the health insurance marketplace have narrow networks.
10

Cancer patients often require highly specialized care to treat their
specic form of cancer. ACS CAN is concerned cancer patients
enrolled in narrow network plans may face signicant nancial
barriers to accessing the appropriate care. In addition, ACS CAN is
concerned cancer patients in active treatment who are shopping for
insurance coverage may not be able to accurately identify plans that
cover their preferred providers and facilities at in-network rates.
Research by ACS CAN found that the information provided by
marketplace plans can make it very difcult for cancer patients to
identify marketplace plans that include their oncologist. In addition:
40 percent of silver plans offered in the 34 federally facilitated
marketplace states do not offer out-of-network coverage.
11

70 percent of plans offered in 21 urban areas have narrow
networks, meaning at least 30 percent of the largest 20 local
hospitals are not covered by the plan.
12

To date, it is unclear to what extent narrow networks may limit treatment
options for cancer patients. States and HHS are collecting very limited
or no data that would allow large-scale investigation of these effects.
The Solution
The ACA and its implementing regulations require qualied health
plans available in marketplaces to make available a provider directory
Premium after tax credit for a tobacco user
Premium after tax credit for a non-tobacco user
$57
$207
$273
$423
$500
$400
$300
$200
$100
$0
$17,200 Annual Income $34,500 Annual Income
Effect of Tobacco Rating on Affordability for a Silver Plan
with a $300 Premium
Tax credit calculations are based on the 2013 Federal Poverty Guidelines, available at http://aspe.hhs.gov/poverty/13poverty.cfm
Source: American Cancer Society Cancer Action Network calculations of the tobacco surcharge for an individual in a silver plan with a $300 annual premium.
ACS CAN believes making insurance coverage more expensive for tobacco users goes
against the intent of the new law to provide more Americans with access to quality,
affordable health insurance.
Access to Care
28
to enrollees and prospective enrollees, including information on
whether in-network physicians are accepting patients. However, many
of these directories are difcult to navigate, out-of-date or do not
include all of the required information. ACS CAN therefore urges states
and HHS to further the goal of transparency by requiring standardized
provider directories with requirements to update directories as soon as
a provider is no longer in network or no longer accepting new patients.
We also encourage requirements that provider information be made
available to consumers before they purchase a plan so shoppers can
compare provider networks for chose the plan that best suits their
healthcare needs. Eventually, all marketplaces should have a single,
easy-to-use tool that will allow consumers to sort or lter health plans
by provider name, availability of specialists and drive distance.
Considering the risks narrow networks may pose to cancer patients, its
important that states and HHS closely monitor the impact these plans
are having on individuals diagnosed with serious diseases by collecting
data on out-of-network requests and payments, patient complaints
and coverage denials. These data collections can help illuminate
network problems and drive regulatory and legislative solutions. In
addition, we urge states to apply the same network adequacy standards
for all plans in the individual and small group markets, regardless of
marketplace participation. Finally, we recommend states require an
exceptions process to allow enrollees to access out-of-network services
at in-network cost-sharing rates if no in-network providers are available
within a reasonable distance or timeframe. This will help ensure cancer
patients can access specialized treatment, even if they are diagnosed
mid-year while covered under a narrow network plan.
Access to Care: Increase Access to
Health Coverage through Medicaid
The Challenge
Medicaid is the public health care coverage program for lower-
income Americans. It is jointly nanced and administered by the
federal government and states. States have a great deal of exibility
in how they design and administer their Medicaid programs which
leads to signicant variation in eligibility, benets, and coverage
among states.
Historically, health care coverage through Medicaid was only
available to certain eligible groups such as pregnant women, the
elderly, children, people with disabilities and some parents. As of
January 1, 2014, the ACA and a decision by the Supreme Court
gave states the option to increase access to health care coverage
through Medicaid to all non-elderly adults under 138 percent of
the federal poverty level (FPL) (about $16,100 for a single adult in
2014). The federal government will pay 100 percent of the cost to
cover the newly eligible population through the end of 2016, and
will gradually reduce payments to no less than 90 percent of the
cost by 2020.
As of June 2014, 26 states and the District of Columbia had chosen
to accept the federal funds available to cover more uninsured people
through Medicaid, resulting in an estimated 7 million individuals
Success Story Washington
In 2014, Washington State adopted regulations to more clearly dene network adequacy standards for plans sold in the
individual and small-group market. The states insurance commissioner took the important step beyond federal regulations
to require greater transparency and reporting from insurers when they submit provider network proposals for approval
to be sold in the state. The rule also denes clearer standards around how insurers must assess patient requests for
out-of-network care. Finally, the rule denes maximum proximity requirements between enrollees and the many types
of providers covered under their plan. While the regulations are only a rst step in ensuring patients have access to the
providers and specialists they need, the rule will provide valuable tools to allow regulators to identify where access gaps
actually exist and how the rule can be strengthened in future years to address those gaps.
The geography and health needs of a population will differ in every state. This is why it is important for other states to follow
the lead of Washington State and adopt network adequacy rules that will best serve the unique needs of their citizens.
Access to Care
12th Edition
29
gaining access to health care coverage. However, more than 8 million
low-income adults and families below the FPL continue to lack access
to affordable health care coverage solely because their states have
not taken action to broaden access to Medicaid.
13
Nearly 5 million of
these individuals fall into the coverage gap they do not qualify for
Medicaid, they earn too little to receive federal tax credits for private
insurance and they cannot afford health coverage in the private
market. By refusing to increase access to their Medicaid programs,
governors and lawmakers in these states are denying affordable health
care coverage to their residents and asking hospitals and providers to
continue providing uncompensated care. At the same time that federal
payments to help cover the cost of uncompensated care are being cut,
these states are walking away from millions of dollars already set aside
by the federal government to help cover these individuals and thus
turning down an opportunity to return millions of their own taxpayer
dollars to their state. States that do not increase access to health
coverage through their Medicaid programs, as a whole, will lose a net
$39 billion in federal funds as a result of this decision.
14
Safety net programs and charity care for individuals and families in
the coverage gap are woefully underfunded or nonexistent in many
states and seldom provide appropriate cancer prevention and early
detection screenings and services. In addition, safety net and charity
programs are rarely able to provide affordable or adequate care to
treat a complex and expensive disease such as cancer.
States that do not increase access to
health coverage through their Medicaid
programs, as a whole, will lose a net
$39 billion in federal funds.
Children Pregnant
Women
Elderly People
with
Disabilites
Parents
20 14
Adults
20 14 20 14
Historically, Medicaid has covered people
with disabilities, children, the elderly,
pregnant women and some parents/adults.
As of January 1, 2014, states have the option
to broaden access to health care coverage to
more than 16 million Americans who earn up
to 138% of the federal poverty level (FPL)*
Improved Access to Health Care Coverage Through Medicaid, 2014
*For 2014, 138% of the FPL is equal to $16,104 for an individual and $27,310 for a family of three.
Sources: http://aspe.hhs.gov/poverty/14poverty.cfm and GAO -12-821 MEDICAID EXPANSION: States Implementation of the Patient Protection and Affordable Care Act
Access to Care
By refusing to increase access to their Medicaid programs, governors and lawmakers in
these states are denying affordable health care coverage to their residents.
30
The Solution

Providing low-income adults and families access to affordable,
comprehensive health care coverage is critical in the ght against
cancer. Governors and lawmakers have the opportunity to provide
millions of Americans health care coverage to help detect cancers
early, when treatment is more effective and less costly, and to save
lives by preventing some cancers from occurring in the rst place.
ACS CAN encourages states to protect and improve access to
health care coverage through Medicaid by:
Increasing eligibility to cover all patients under 138
percent of the FPL.
Imposing reasonable cost-sharing, consistent with that
allowed under the ACA, and limiting nancial barriers
such as high premiums, cost-sharing, wellness programs and
work search programs, so they do not create barriers to care.
Adequately covering benets and services critical to
cancer patients, such as non-emergent transportation.
Low-income cancer patients often do not have a car or
other means of transportation to treatment, and failure to
provide this benet could lead patients to skip treatment,
increasing their risk of dying from cancer.
ACS CAN believes increasing access to health coverage through
Medicaid to all low-income adults will ensure all Americans living
in poverty who qualify for Medicaid will have routine access to
cancer prevention, early detection and treatment services, which
may allow them to live longer, healthier lives.
State Decisions on Increasing Access to Health Care Through Medicaid Up to 138% FPL
Alabama
191,000
Arizona
Arkansas
California Colorado
Florida
764,000
Georgia
409,000
Idaho
55,000
Illinois
Indiana
Iowa
Kansas
78,000
Kentucky
Louisiana
248,000
Maine
34,000
Michigan*
Minnesota
Mississippi
138,000
Missouri
193,000
Montana
40,000
Nebraska
33,000
Nevada
New Mexico
New York
North Carolina
319,000
North Dakota
Ohio
Oklahoma
144,000
Oregon
Pennsylvania
South
Carolina
194,000
South Dakota
25,000
Tennessee
162,000
Texas
1,046,000
Utah
58,000
Vermont
Virginia
191,000
Washington
West
Virginia
Wisconsin
Wyoming
17,000
Hawaii
Alaska
17,000
District of Columbia
How Do You Measure Up?
Connecticut
Delaware
Maryland
Massachusetts
New Hampshire
New Jersey
Rhode Island
State has broadened Medicaid eligibility, covering individuals under 138% FPL
Legislature still in session or executive pursuing 1115 waiver / alternative expansion proposal
federal approval pending, final decision is unknown
Governor/legislature opposed to improving access to health care coverage through Medicaid,
includes estimated number of individuals under 100% Federal Poverty Level (FPL) in coverage gap
Source: ACS CAN and Kaiser Family Foundation: A Closer Look at the Impact of State Decisions Not to Expand Medicaid on Coverage for Uninsured Adults Number of Adults in Coverage Gap April 2014
State colors indicate status of each state as of June, 2014
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Missed Opportunity:
ACS CAN was one of the leading organizations in a diverse
coalition of more than 100 local, state and national organizations
working to convince the Maine legislature and Governor Paul
LePage to accept the federal funds to improve access to health
care coverage for 70,000 low-income Mainers through the state
Medicaid program. A two year, legislative and grassroots campaign,
which included press events, petition drives, story collection,
video production, print and radio ads, lobby days, and numerous
Access to Care
Success Story New Hampshire and Ohio
Since 2012, ACS CAN has been actively engaged in a number of advocacy activities, encouraging states to accept the
federal funds available to provide health care coverage to low-income Americans. Our volunteers, supporters and staff
have been the keys to our successful education and advocacy efforts. Because of their efforts, we successfully passed
legislation in New Hampshire authorizing the state to accept the federal funds and provide coverage to 58,000 Granite
Staters and in October 2013, the state of Ohio authorized Governor John Kasich to provide more than 275,000 low-
income Ohioans access to health care coverage.
1115 Waivers: States Pursuing Medicaid Program Flexibility
Over the past year, a number of states have led 1115 Research & Demonstration Project waiver asking the Centers
for Medicare and Medicaid Services to allow them to take an alternative approach to covering individuals in the newly
eligible Medicaid population. Waivers must be budget neutral and allow for meaningful public review and input.
In September 2013, Arkansas led the rst 1115 waiver requesting permission to take an alternative approach to covering
the newly eligible under the ACA. The state received permission to cover the estimated 200,000 newly eligible individuals
through a premium assistance program, known as the private option.
Since the approval of the Arkansas waiver, CMS is considering and/or has approved 1115 waivers in a number of states, including:
Iowa: Premium assistance, healthy behavior/wellness incentives, approved December 2013
Michigan: Premiums, health behavior/wellness incentives, approved December 2013
Pennsylvania: Premium assistance, managed care, HSA/premiums, healthy behaviors/wellness incentives, waiver pending CMS approval
New Hampshire: Premium assistance, premiums, healthy behavior/wellness incentives, waiver proposed
Indiana: HSA contributions, managed care, healthy behaviors/wellness incentives, waiver proposed
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meetings and communications with lawmakers were critical to
the advocacy effort. The Maine legislature passed legislation ve
different times authorizing the state to accept the federal funds,
over a two-year period, with Governor LePage vetoing each of the
bills. ACS CAN and our coalition partners came up a few votes shy
of overriding the vetoes.
Speaker of the House Mark Eves and Assistant Senate Minority
Leader Roger Katz led a number of bipartisan efforts to reach
an agreement that would gain support of more than two-thirds
of Maines legislators. Despite tremendous public support and
valiant bipartisan legislative efforts, Governor LePage and the
House Minority leadership remained opposed to accepting federal
funds. ACS CAN and coalition partners will continue its steadfast
commitment to passing legislation that will provide potentially
lifesaving health coverage to low-income Mainers.
ACS CAN strongly opposes
proposals to eliminate lifesaving
breast and cervical cancer
treatment programs.
Access to Care: Medicaid Breast and
Cervical Cancer Treatment Programs
The Challenge
On October 24, 2000, the federal Breast and Cervical Cancer
Prevention and Treatment Act was signed into law, giving states
the option to provide Medicaid coverage to eligible women who
were diagnosed with breast or cervical cancer through the National
Breast and Cervical Cancer Early Detection Program (NBCCEDP
see page 35 for more information on the screening program). In
2013, all 50 states and Washington, D.C. were providing women
diagnosed with breast or cervical cancer through state breast and
cervical cancer early detection programs access to comprehensive
Medicaid coverage through the end of their treatment, thereby
saving the lives of thousands of women.
The ACA has made further improvements in access to care for
lower-income women and men. Millions are now eligible for
tax credits to help purchase comprehensive, affordable health
insurance. States also have the option to accept federal funds
to increase access to health care coverage to childless adults
with incomes below 138 percent of FPL through their Medicaid
program or alternative options as described above. To date, 26
states and Washington, D.C. had agreed to accept federal funds to
increase access to Medicaid coverage. Several of these states are
considering or have considered proposals to eliminate their breast
and cervical cancer treatment programs, believing the program is
no longer needed. Yet, even with the changes enacted as part of the
ACA, millions of women will remain uninsured and eligible for the
program in 2014 and beyond for a number of reasons, including:
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Residence in a state that did not increase access to
coverage through Medicaid
Language or literacy challenges
An exemption from the individual mandate
Coverage disruptions
Lack of knowledge or understanding of ACA coverage options
In fact, the Congressional Budget Ofce estimates 18 million
people many of them women - will be exempt from the
individual mandate
16
and 36 million people living in the United
States are still expected to be uninsured in 2015 - leaving many
women in need of the breast and cervical cancer treatment
program.
17
Without the Medicaid breast and cervical cancer
treatment programs, these uninsured women may be unable to
access appropriate, timely treatment.
The Solution
ACS CAN strongly opposes proposals to eliminate lifesaving
breast and cervical cancer treatment programs in Medicaid. Any
attempts to eliminate the programs are premature. ACS CAN
strongly encourages states to monitor and evaluate the demand
and continued need for their treatment programs prior to
considering any proposals to eliminate eligibility for state breast
and cervical cancer treatment programs.
Access to Care
Even with the changes enacted as part of the ACA, millions of women will remain
uninsured and eligible for the program in 2014 and beyond.
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The Challenge
Colorectal cancer is the second most common cancer in men and women combined. Nearly 140,000
people in America are expected to be diagnosed with colorectal cancer this year and more than
50,300 people are expected to die from the disease in 2014. Many of these cases could have been
prevented if people received the recommended cancer screening. Colorectal cancer is unique
because it usually develops slowly as a noncancerous growth, or polyp. Through screening the polyp
can be identied and removed, thereby preventing the cancer altogether.
Screenings are only effective if people receive them in a timely manner and an appropriate setting.
Colorectal cancer screening rates have been consistently rising 59 percent for those 50 and older -
but one in three adults from ages 50 to 75 are still not getting screened as recommended. Individuals
less likely to get screened are those who are younger than 65, racial /ethnic minorities, have lower
education levels, lack health insurance, and are immediate immigrants.
In 2014, the American Cancer Society and ACS CAN joined with more than 100 organizations across
the country in embracing a shared goal to increase colorectal cancer screening rates to 80 percent
nationwide by 2018, a challenging yet achievable goal. While many states are above the national
average, with Massachusetts and New Hampshire leading the way, not one has reached an 80 percent
screening rate. On the other hand, some states, specically Alaska, Montana and Wyoming, have
screening rates below the national average and have a long way to go to improve rates.
To help increase screening rates, ACS CAN encourages policymakers to make colorectal cancer screening
a priority and to work across all sectors to increase the rates. Specically, state policymakers can:
Improve current screening programs by allocating additional funding for state screening
and treatment programs.
Establish statewide screening programs where ones do not exist.
Partner with hospitals, community health centers and other organizations to increase
knowledge and improve access to screenings.
Broaden access to health care coverage and health insurance programs, such as Medicaid.
Take action to reduce cost and access barriers to screening services.
Increase outreach to all populations, but especially those with historically low screening rates.
One in three adults from ages 50 to 75 is still not getting
screened as recommended.
In 2014, the Oregon legislature unanimously passed legislation clarifying that the removal of polyps during
a screening colonoscopy is a part of the preventive cancer screening procedure and as a result, patients
should not be subject to cost-sharing or out of pocket expenses. As a result of the ACA, individuals
age 50 and older can receive colorectal cancer screenings at no cost, however many patients who had
a screening colonoscopy and were found to have polyps, were often being charged upwards to $2,000
out-of-pocket for polyp removal. The passage of the Oregon bill requires all private insurance plans to
cover preventative colonoscopies, including the removal of any polyps, without any patient cost-sharing
(copayments/co-insurance/deductibles). Governor John Kitzhaber signed this legislation in March 2014,
removing a key barrier to Oregon residents accessing life-saving colorectal cancer screenings.
While many states are above the national average, with
Massachusetts and New Hampshire leading the way, not one
has reached an 80 percent screening rate.
Access to Colorectal Cancer Screening
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The Challenge
Evidence-based screenings are the most important tools for detecting breast and cervical cancer
early and improving survival rates. This year, more than 230,000 people living in the United States are
expected to be diagnosed with breast cancer. If detected early, the survival rate of this type of cancer
is 99 percent. But when it is diagnosed at a late stage, the survival rate drops to only 24 percent.
Unfortunately, more than 40,000 individuals are expected to die from this disease this year alone.
Cervical cancer can be prevented altogether by removing precancerous lesions found during
screenings. However, when it has spread and is diagnosed at a late stage, the survival rate is lowered
to only 16 percent. This year, an estimated 12,000 women in the United States will be diagnosed with
cervical cancer and more than 4,000 will die.
Despite the fact that screening has been shown to detect cancer early and improve survival, screening
rates are still not as high as they need to be. In fact, only 51 percent of women have received a
mammogram in the past year and 83 percent have had a Pap test in the past three years. These rates
are signicantly lower for the uninsured at 17 percent and 63 percent respectively.
Funding for Breast and Cervical Cancer Screening
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In 1990, Congress established the National Breast and Cervical Cancer Early Detection Program
(NBCCEDP) to address the problem of low screening rates and access issues among uninsured
and underinsured low- income women. The program provides direct screening services,
education and outreach to the most vulnerable women in all 50 states, Washington, D.C., ve
U.S. territories, and 11 American Indian/Alaska Native tribes or tribal organizations. Since
the program began it has served more than 4.5 million women, provided more than 11 million
screening exams, and diagnosed more than 62,000 breast cancers, 3,400 cervical cancers and 163,500
premalignant cervical lesions.
Unfortunately, limited federal and state funding has forced the program to turn away women in need
and reduced many of the outreach and educational services provided through the program.
State Appropriations for Breast and Cervical Cancer Screening Programs -
Fiscal Year 2013-2014
Alabama
8%
Arizona
59%
Arkansas
California Colorado
Florida
33%
Georgia
55%
Idaho
14%
Illinois
Indiana
4%
Iowa
21%
Kansas
14%
Kentucky
92%
Louisiana
42%
Maine
20%
Michigan
5%
Minnesota
23%
Mississippi
10%
Missouri
18%
Montana
41%
Nebraska
12%
Nevada
0%
New Mexico
31%
New York
North Carolina
47%
North Dakota
16%
Ohio
20%
Oklahoma
53%
Oregon
33%
Pennsylvania
South
Carolina
34%
South Dakota
0%
Tennessee
84%
Texas
52%
Utah
4%
Vermont
0%
Virginia
16%
Washington
49%
West
Virginia
10%
Wisconsin
73%
Wyoming
38%
Hawaii
0%
Alaska
12%
How Do You Measure Up?
State appropriations for the programs are 100% or more than the CDC award
State appropriations for the programs are between 33% - 99% of the CDC award
State appropriations for the programs are less than 33% the CDC award
No state funding
District of Columbia
32%
Connecticut
Delaware
89%
Maryland
60%
Massachusetts
New Hampshire
12%
New Jersey
Rhode Island
5%
Source: 2013-2014 data from the Centers for Disease Control and Prevention and unpublished data collected from ACS CAN and ACS Divisions, including input from NBCCEDP directors.
Updated June 2014
Funding for Breast and Cervical Cancer Screening
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Public Education and Outreach
Help women in underserved communities adhere
to cancer screening recommendations through use of
traditional media, social media, public educators and
patient navigators.
Screening Services and Care Coordination
Provide screening services to women not covered by new insurance
provisions in the ACA and help all women with positive screening
results obtain appropriate follow-up tests and treatment,
particularly in states that do not expand Medicaid eligibility.
Organized Systems
Develop more systematic approaches
to cancer screening to organize better
and unify the efforts of health care
providers. Work with Medicaid programs
and insurance exchanges to promote,
coordinate, and monitor cancer screening.
Quality Assurance, Surveillance, and Monitoring
Use existing infrastructure to monitor screening services in
every community. Develop electronic reporting mechanisms
for management of cancer cases identified through screening.
Expand CDCs quality assurance system and leverage emerging
resources to monitor screening and follow-up.
Clinical Preventitive Services
Community-Clinical Lin
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Impact of the Affordable Care Act on NBCCEDP
Success Story Colorado
With the support of patient advocates including ACS CAN, Colorado reauthorized and expanded coverage for the states
Breast & Cervical Cancer Early Detection and Treatment Program through June 2019. The bill enjoyed strong bi-partisan
support, passing the Senate 29-6, and the House 50-15. The effort to reauthorize the program began in the late fall of
2013 and was supported by groups including ACS CAN and Komen Colorado. In addition to extending the programs
sunset date from 2014 to 2019, the bill allows any eligible woman to qualify for cancer treatment services through
Medicaid, regardless of the location of diagnosis and further diversies the state and private funding for the program.
Colorados Breast & Cervical Cancer Early Detection and Treatment Program, provides breast and cervical cancer screenings, diagnostic and
treatment services for women aged 40-64 who earn less than 250 percent of the federal poverty level, who are uninsured or under-insured.
Funding for Breast and Cervical Cancer Screening
With the introduction of the Affordable Care Act, many women will be able to receive breast and cervical cancer screenings through newly acquired
insurance. With this in mind, the NBCCEDP is able to work synergistically with communities in need to put a heavier emphasis on education and
outreach about the importance of screening as well as monitoring screening rates, and organizing screening systems.
Source: Centers for Disease Control and Prevention, www.cdc.gov/cancer/nbccedp/pdf/newdirections_screening.pdf
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The NBCCEDP is a lifeline for
many women in need of screening
services. In states that have chosen
not to increase access to their state
Medicaid programs, millions of
women still rely on this lifesaving
program for cancer screening
services. Of particular concern are
the following ve states that not
only refused to increase access to
health care through Medicaid, but
also reduced or eliminated funding
for their state breast and cervical
cancer screening programs.
Oklahoma
Texas
Kansas
South Dakota
Idaho
No Funding
The Solution
One of the most important factors for ensuring women have access to breast
and cervical cancer screenings is adequate funding of state cancer screening
programs. The ACA has improved womens access to lifesaving cancer
screening services but there continues to be a critical need for the NBCCEDP.
Under the ACA states have the opportunity to increase access to health
care coverage through state Medicaid programs for Americans earning less
than 138 percent of the federal poverty level. However, not all states have
chosen to take advantage of this opportunity, leaving millions of low-income
Americans without any affordable, comprehensive health care coverage
options. In the states that have not increased access to Medicaid in particular,
the NBCCEDP program will remain a lifeline for low- income and uninsured
women. Adequate funding is necessary to continue providing benets and
services to women who have historically accessed the program for cancer
screenings, but the program will also provide educational outreach and
lifesaving screening services to women who continue to lack an affordable
health care coverage option and remain uninsured in 2014 and beyond.
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Advances in cancer research continue to provide new and more effective treatments for cancer,
but providing new therapies alone does not meet all the needs of cancer patients. Focusing
exclusively on treating a patients disease can result in a failure to address the full spectrum of
issues that arise as part of a cancer diagnosis and treatment. Those issues include emotional
concerns, assistance coordinating services and physical symptoms like pain and nausea.
Palliative care is specialized medical care that focuses on providing the best possible quality of
life for a patient and his or her family by offering relief from the pain, stress and other symptoms
of a serious illness. Contrary to some misconceptions, palliative care is not limited to end of life
care it is appropriate at any age and any stage of disease and can be provided along with curative
treatment as an extra layer of support.

Palliative care provides a coordinated and team-based approach among medical professionals
to help ensure all the patients needs are met throughout treatment and survivorship. And
because palliative care efciently uses hospital resources and other delivery systems, it provides
patients, medical institutions, the health care system and clinicians with an ongoing, effective
solution to the growing and difcult challenge of rising healthcare costs. On average, palliative
care consultation is associated with reductions of $1,700 per admission for live discharges and
reductions of $4,900 per admission for patients who die in the hospital. This means savings of
more than $1.3 million for a 300-bed community hospital and more than $2.5 million for the
average academic medical center.
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Given the benets of this type of specialized medical care, its no surprise palliative care has
become one of the fastest growing trends in health care over the past 10 years. In fact, the
prevalence of palliative care services in the U.S. hospitals with 50 or more beds has increased 157
percent over the past 11 years.
2
Demand for this type of care is expected to continue increasing as
the public becomes more aware of its benets. Recent public opinion research found once people
are informed about palliative care, 92 percent report they would be highly likely to consider it for
themselves or their families if they had a serious illness.
3
However, currently, millions of adults and
children facing serious illness do not yet have access to palliative care services from the onset of
disease to help ease their suffering.
Palliative care is specialized medical care that focuses on
providing the best possible quality of life for a patient and his
or her family by offering relief from the pain, stress and other
symptoms of a serious illness.
Palliative Care
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The Solution
Palliative care is essential to achieving the goal of comprehensive, cost-effective care. It helps patients
complete treatments, including rehabilitation to address impairments, and improves quality of life
for patients, survivors and caregivers. Studies show cancer patients receiving palliative care during
chemotherapy are more likely to complete their cycle of treatment, stay in clinical trials and report a
higher quality of life than similar patients who did not receive palliative care. According to a 2010 study
conducted at Massachusetts General Hospital and published in the New England Journal of Medicine,
patients with metastatic lung cancer who received palliative care showed improved quality of life and
less depression and lived nearly three months longer than patients who received usual care alone.
4

Palliative Care Across the United States
Alabama
Arizona
Arkansas
California Colorado
Florida
Georgia
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
South
Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West
Virginia
Wisconsin
Wyoming
Hawaii
Alaska
How Do You Measure Up?
5-6 points
2-4 points
0-1 points
District of Columbia
Connecticut
Delaware
Maryland
Massachusetts
New Hampshire
New Jersey
Rhode Island
Source: ACS CAN Points derived from 2012 National Palliative Care Report Card grade
A = 4 points, B= 3 points, C= 2 points, D= 1 point F= 0 points
Add one point if state is creating a palliative care/QOL advisory group or introduced ACS CAN state model legislation
Add one point if state introduced ACS CAN model legislation with two or more provisions
As of June 1, 2014
Palliative Care
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People facing serious illness want the types of services that
palliative care provides and they expect todays hospitals, cancer
centers and other care settings to deliver. The pillars of palliative
care involve:
Time to devote to intensive family meetings and patient/
family counseling
Expertise in managing complex physical and emotional
symptoms such as pain, shortness of breath, depression,
and nausea
Communication and support for resolving family/patient/
physician questions concerning goals of care
Coordination of care transitions across health care settings
The public recognizes the benets of this added layer of support
from a palliative care team focused on quality of life. To benet
from palliative care, patients and families must be able to access
these services in their local hospital or other care settings. In
addition, health professionals in training must learn from direct
experience at the bedside with high-quality palliative care teams.
ACS CAN supports policy initiatives to improve patient access to
palliative care through the following mechanisms:
1. Educate the public about palliative care. In partnership
with state departments of health and community
stakeholders, provide palliative care information online
and through other channels to help consumers and
clinicians understand palliative care and the benets
of integrating it with disease-directed treatment for all
seriously ill adults and kids.
2. Improve access to palliative care services. Encourage
policies requiring routine screening of patients for
palliative care needs and facilitating access to palliative
care services in all health care settings serving seriously
ill adults and kids (e.g., hospitals, cancer centers, nursing
homes, assisted living facilities, home care agencies).
3. Boost palliative care clinical skills. Foster training in
palliative care for all practicing health professionals and
students of medicine, nursing and other professions. This
would be done by aligning educational requirements
and professional practices with current evidence
demonstrating the importance of integrating palliative
care alongside disease-directed treatment.
4. Preserve access to pain therapies for people in pain.
Implement balanced policies that promote delivery of
integrated pain care for all people facing pain, including
preserving access to prescription medications and other
therapies, as well as improving workforce training in pain
assessment, management, responsible prescribing and use
of prescription monitoring programs.
ACS CAN has created model palliative care legislation that focuses
on public education and access to palliative care and urges
lawmakers to adopt this, or similar legislation, in their state.
Missed Opportunity:
During the 2014 legislative session, ACS CAN staff and volunteers
in Alabama advocated for model legislation that would have
created a state wide expert advisory council reporting to the
Department of Health and tasked with raising awareness of the
value of palliative care services.
The bill was one step short of passage when time ran out in the
session, but it is likely to be reintroduced in 2015, and ACS CAN
will continue to support its passage.
Success Story Connecticut and Rhode Island
ACS CANs model palliative care legislation establishes a multi-disciplinary advisory council made up of state palliative
care and health care experts and empowers state health departments to be a central point where the public, patients and
providers can access the latest information regarding palliative care. Connecticut and Rhode Island were early adopters
of this type of legislation in 2013 and are successfully implementing the laws. Both states created task forces to raise
awareness, availability and utilization of palliative care services.
Palliative Care
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The Challenge
Pain remains one of the most feared and burdensome symptoms for cancer patients and survivors,
but nearly all cancer pain can be relieved. The prevalence of pain and its inadequate treatment has
remained consistently high despite the recognition that pain relief is an integral part of comprehensive
palliative care for patients. Research shows pain is still a problem for nearly 60 percent of patients
with advanced disease or those undergoing active treatment, along with 30 percent of patients who
have completed treatment.
1
Still more troubling, medically underserved and socioeconomically
disadvantaged populations continue to face barriers to accessing pain treatment.
Cancer-related pain can interfere with the ability of patients to adhere to recommended treatments
and can devastate quality of life affecting work, appetite, sleep and time with family and friends.
Generally recognized as a mainstay of treatment for moderate to severe cancer pain, opioid
analgesics, such as OxyContin, Vicodin and other pain killers, pose particular policy challenges.
These medications provide much needed pain relief to patients, but their properties also make
them subject to misuse and abuse. In recent years there has been major emphasis on policies
aimed at curtailing misuse of opioids at both the federal and state levels. Combating illegal use
of prescription drugs is necessary, but it is also important to ensure that these well-intentioned
efforts do not simultaneously prevent patients suffering from pain from accessing appropriate
relief using legal medications. States face challenges to create and promote balanced public
policies that will make medications available to patients who need them, while also keeping those
medications away from those who intend to misuse them.
The Role of State Policies Governing Pain Management Issues
ACS CAN and several partner organizations commissioned a comprehensive study of state
policies around pain management issues, the results of which have been published in Achieving
Balance in Federal and State Pain Policy: A Progress Report Card, available at painpolicy.wisc.edu.
2

In the report, state pain policies are evaluated on 16 different criteria, and each state is assigned
an overall grade.
Nearly all cancer pain can be relieved.
Cancer Pain Control: Advancing Balanced State Policy
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Current Pain Policy in the States
Alabama
Arizona
Arkansas
California Colorado
Florida
Georgia
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
South
Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West
Virginia
Wisconsin
Wyoming
Hawaii
Alaska
How Do You Measure Up?
Received an A grade on the PPSG Pain Policy Report Card
Must either repeal restrictive or ambiguous policy requirements or adopt additional positive policy
Must adopt both additional positive policies and repeal restrictive or ambiguous policies
District of Columbia
Connecticut
Delaware
Maryland
Massachusetts
New Hampshire
New Jersey
Rhode Island
Source: Pain Policy Studies Group (PPSG) at the University of Wisconsin. For more information on this
report card, please visit: http://www.painpolicy.wisc.edu/sites/www.painpolicy.wisc.edu/files/prc2012.pdf
As of July 1, 2014
Success Story Tennessee
In the past 10 years, the improved availability of pain medications for cancer patients has helped reduce unnecessary suffering during
cancer treatment and at the end of life. But as we celebrate this progress, we need to constantly be vigilant to not allow these gains to
be eroded. A specic case in point occurred in Tennessee, where the 2014 legislative session saw an attempt to roll back the Intractable
Pain Act, a state law that reduces pain and suffering by protecting patients and the medical professionals who treat them. ACS CAN took
the lead in working to ensure that the needs of cancer patients were heard. In partnership with our close allies at the American Academy
of Pain Management, were able to defeat efforts to repeal the Intractable Pain Act, ensuring ongoing access to appropriate pain relief.
Cancer Pain Control: Advancing Balanced State Policy
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The Solution
State policies governing the practice of health care professionals, including the legitimate use of
pain medications, are critical to creating an environment where the risk of illicit drug use is balanced
with access to appropriate medications for patients suffering from pain. State governments must
play a strong role in ensuring that patients in need of pain management have access to it, specically
with regard to the use and distribution of pain medications. Most recent state policies focus solely
on preventing illicit drug abuse, and as a result they sometimes create undue burdens for clinicians
and patients that interfere with appropriate pain management. In the Progress Report Card, two
overarching recommendations provide guidance to states to consider as they develop pain policies
to better serve both clinicians and patients. These recommendations include:
Establish evaluation mechanisms for state pain policies. The exact review mechanism
may vary from state to state and might include task forces, commissions, advisory councils,
or summit meetings. Regardless of the mechanism, each state should systematically review
its pain policies for balance between providing patients access to pain medications and
efforts to reduce abuse.
Make a commitment to the implementation of pain policies. Studies have shown that
often practitioners are not fully aware of the policies that govern pain management, which
ultimately affects their ability to abide by these policies. Thus, every state should commit to
disseminating information about pain policies to clinicians and the public.
While good policies are necessary, written policies by themselves can be ineffective when
practitioners are unaware of them or are confused by conicting messages.
State governments must play a strong role in ensuring that
patients in need of pain management have access to it.
Cancer Pain Control: Advancing Balanced State Policy
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How Do You Measure Up?
1 American Cancer Society. Cancer Facts & Figures, 2014. Atlanta, GA: American Cancer Society, 2014.
2 Centers for Disease Control and Prevention. Youth Online: High School YRBS. 2013 Results. Available at http://www.cdc.gov/
healthyyouth/yrbs/index.htm
3 Campaign for Tobacco-Free Kids. A Broken Promise to Our Children: The 1998 State Tobacco Settlement 14 Years Later. February 2014.
4 Kushi LH, Doyle C, McCullough M, et al. American Cancer Society Guidelines on Nutrition and Physical Activity for Cancer
Prevention: Reducing the Risk of Cancer With Healthy Food Choices and Physical Activity. CA: A Cancer Journal for Clinicians
2012; 62:30-67.
5 American Cancer Society. Cancer Prevention & Early Detection Facts & Figures 2013. Atlanta: American Cancer Society; 2013.
6 American Cancer Society. Colorectal Cancer Facts & Figures 2014-2016. Atlanta: American Cancer Society; 2014.
7 Campaign for Tobacco Free Kids. Toll of Tobacco in the United States of America. Updated June 16, 2014. Available at http://www.
tobaccofreekids.org/research/factsheets/pdf/0072.pdf. Accessed June 11, 2014.
Tackling Tobacco Use
1 US Department of Health and Human Services. The Health Consequences of Smoking 50 Years of Progress: A Report of the Surgeon
General. Atlanta, GA: US Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for
Chronic Disease Prevention and Health Promotion, Ofce on Smoking and Health, 2014. Printed with corrections, January 2014.
2 Kann L, Kinchen S, Shanklin SL, et al. Youth Risk Behavior Surveillance United States, 2013. MMWR 2014; 63(4): p. 1-170.
3 Dutra LM and Glantz SA. Electronic Cigarette and Conventional Cigarette Use Among US Adolescents: A Cross-sectional Study.
JAMA Pediatrics 2014; Available at doi:10.1001/jamapediatrics.2013.5488.
Tobacco Excise Taxes
1 Chaloupka FJ. How Effective are Taxes in Reducing Tobacco Consumption? Available at http://tigger.uic.edu/~fjc/Presentations/
Papers/taxes_consump_rev. pdf.
2 Chaloupka FJ. The Impact of Proposed Cigarette Price Increases. Policy Analysis No. 9, Health Science Analysis Project, Advocacy
Institute, 1998. Available at http://tigger.uic.edu/~fjc/Presentations/Papers/hsap_policy9.pdf.
3 U.S. Government Accountability Ofce. Large Disparities in Rates for Smoking Products Trigger Signicant Market Shifts to Avoid
Higher Taxes, GAO-12-475, April 18, 2012, http://www.gao.gov/products/GAO-12-475.
Smoke-free Laws
1 U.S. Department of Health and Human Services (HHS). The Health Consequences of Involuntary Exposure to Tobacco Smoke: A
Report of the Surgeon General. Atlanta, GA: HHS, Centers for Disease Control and Prevention, National Center for Chronic Disease
Prevention and Health Promotion, Ofce on Smoking and Health, 2004.
2 U.S. Department of Health and Human Services (HHS). How Tobacco Smoke Causes Disease The Biology and Behavioral Basis for
Smoking-Attributable Disease. Atlanta, GA: HHS, Centers for Disease Control and Prevention, National Center for Chronic Disease
Prevention and Health Promotion, Ofce on Smoking and Health, 2010.
3 HHS. How Tobacco Smoke Causes Disease: A Report of the Surgeon General. Atlanta, GA: HHS, Centers for Disease Control and
Prevention, National Center for Chronic Disease Prevention and Health Promotion, Ofce on Smoking and Health, 2010.
4 Max W, Sung H-Y, and Shi Y. Deaths from Secondhand Smoke Exposure in the United States: Economic Implications. American
Journal of Public Health 2012; 102: 2173-2180.
5 American Nonsmokers Rights Foundation. Overview List How Many Smokefree Laws? April 1, 2014. Available at http://www.
no-smoke.org/pdf/ mediaordlist.pdf.
6 Ibid.
7 Centers for Disease Control and Prevention. State Smoke-Free Laws for Worksites, Restaurants and Bars United States, 2000-
2010. MMWR 2011; 60(15): 472-475.
8 American Nonsmokers Rights Foundation, 2014.
9 For research and additional information, see: ACS CAN. Secondhand Smoke and Casinos. Fact Sheet. February 2013. Available at
http://www.acscan.org/content/wp-content/uploads/2012/11/smokefree-casinos.pdf.
10 HHS, 2006.
11 Task Force on Community Preventive Services. Recommendations Regarding Interventions to Reduce Tobacco Use and Exposure
to Environmental Tobacco Smoke. American Journal of Preventive Medicine 2001;20(2S):10-5.
12 Eriksen M and Chaloupka F. The Economic Impact of Clean Indoor Air Laws. CA: A Cancer Journal for Clinicians 57(6): 367-378,
November 2007.
13 For additional research and information, see: ACS CAN. Smoke-free, Learn More. 2014. Available at http://acscan.org/tobacco/smoke-free/.
14 Institute of Medicine. Ending the Tobacco Problem: A Blueprint for the Nation. Washington, DC: National Academies Press, 2007.
15 Presidents Cancer Panel. U.S. Department of Health and Human Services, National Institutes of Health, National Cancer
Institute. Promoting Healthy Lifestyles: Policy, Program and Personal Recommendations for Reducing Cancer Risk. 2006-2007
Annual Report: Presidents Cancer Panel. August 2007.
Tobacco Cessation Services
1 Centers for Disease Control and Prevention. Quitting Smoking Among AdultsUnited States, 20012010. MMWR
2011;60(44):151319
2 Ibid.
3 Singleterry J, Jump Z, Lancet E, et al. State Medicaid Coverage for Tobacco Cessation Treatments and Barriers to Coverage United
States, 2008-2014. MMWR 2014; 63(12): 264-269.
4 This may not include coverage for phone counseling, which is also recommended as part of a comprehensive cessation benet.
5 Singleterry J, Jump Z, Lancet E, et al. State Medicaid Coverage for Tobacco Cessation Treatments and Barriers to Coverage United
States, 2008-2014. MMWR 2014; 63(12): 264-269.
6 Ibid.
7 U.S. Department of Labor, Department of Health & Human Services, and Department of Treasury. FAQs About Affordable Care Act
Implementation (Part XIX). May 2, 2014. Available at http://www.dol.gov/ebsa/faqs/faq-aca19.html. Accessed May 2, 2014.
8 American Lung Association. State of Tobacco Control 2014. January 2014.
Tobacco Control Program Funding
1 US Department of Health and Human Services. The Health Consequences of Smoking-50 Years of Progress. A Report of the Surgeon
General. Atlanta, GA: US Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for
Chronic Disease Prevention and Health Promotion, Ofce on Smoking and Health, 2014. Printed with corrections, January 2014.
2 Campaign for Tobacco-Free Kids. A Broken Promise to Our Children: The 1998 State Tobacco Settlement 14 Years Later. February 2014.
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References
12th Edition
45
3 Centers for Disease Control and Prevention. Best Practices for Comprehensive Tobacco
Control Programs, 2014. Atlanta, GA: US Department of Health and Human Services,
Centers for Disease Control and Prevention, National Center for Chronic Disease
Prevention and Health Promotion, Ofce on Smoking and Health, 201407.
Obesity, Nutrition, and Physical Activity
1 American Cancer Society. Cancer Facts & Figures, 2014. Atlanta, GA: American Cancer
Society, 2014.
2 Kushi LH, Doyle C, McCullough M, et al. American Cancer Society Guidelines on Nutrition
and Physical Activity for Cancer Prevention: Reducing the Risk of Cancer With Healthy
Food Choices and Physical Activity. CA: A Cancer Journal for Clinicians 2012; 62:30-67.
3 Ibid.
4 Finkelstein EA, Trogdon JG, Cohen JW, Dietz W. Annual Medical Spending Attributable
to Obesity: Payer- and Service-Specic Estimates. Health Affairs 2009; 28(5): w822-w831.
5 Flegal KM, Carroll MD, Kit BK, and Ogden CL. Prevalence of Obesity and Trends in the
Distribution of Body Mass Index Among US Adults, 1999-2010. Journal of the American
Medical Association 2012; 307(5).
6 Ogden C and Carroll M. NCHS Health E-Stat: Prevalence of Obesity Among Children
and Adolescents: United States, Trends 1963-1965 Through 2007-2008. Division of
Health and Examination Surveys, National Center for Health Statistics. Centers for
Disease Control and Prevention. June 4, 2010. Available at http://www. cD.C..gov/nchs/
data/hestat/obesity_child_07_08/obesity_child_07_08.htm.
7 Centers for Disease Control and Prevention. Adult Obesity Facts. Updated March 28,
2014. Available at http://www.cdc.gov/obesity/data/adult.html. Accessed May 7, 2014.
8 Centers for Disease Control and Prevention. Adult Participation in Aerobic and Muscle-
Strengthening Physical Activities United States, 2011. MMWR 2013; 62(17): 326-330.
9 Centers for Disease Control and Prevention. Youth Online: High School YRBS. 2011
Results. Available at http://apps.nccd.cD.C..gov/YouthOnline/App/Results. aspx?TT=&
OUT=&SID=HS&QID=QNPA0DAY&LID=&YID=&LID2=&YID2=&C OL=&ROW1=&RO
W2=&HT=&LCT=&FS=&FR=&FG=&FSL=&FRL=&FGL=&P V=&TST=&C1=&C2=&QP
=G&DP=&VA=CI&CS=Y&SYID=&EYID=&SC=&SO=. Accessed May 6, 2013.
10 Centers for Disease Control and Prevention. State Indicator Report on Fruits and
Vegetables, 2013. Available at http://www.cdc.gov/nutrition/downloads/State-
Indicator-Report-Fruits-Vegetables-2013.pdf. Accessed May 7, 2014.
11 Kushi et al, 2012.
12 Ibid.
13 Centers for Disease Control and Prevention. Recommended Community Strategies
and Measurements to Prevent Obesity in the United States. MMWR 2009; 58(7): 1-30.
14 Institute of Medicine and National Research Council, Local Government Actions to
Prevent Childhood Obesity. Washington, DC: National Academies Press, 2009.
15 US Department of Health and Human Services. 2008 Physical Activity Guidelines for
Americans. Available at http://www.health.gov/paguidelines/.
16 Institute of Medicine. Accelerating Progress in Obesity Prevention: Solving the Weight
of the Nation. Washington, DC: National Academies Press, 2012.
17 Institute of Medicine. Educating the Student Body: Taking Physical Activity and
Physical Education to School. Washington, DC: National Academies Press, 2013.
18 For more information on ACS CANs policy position on physical education and physical
activity in schools, please see: ACS CAN, American Diabetes Association (ADA), American
Heart Association (AHA). Physical Education in Schools Both Quality and Quantity
are Important. A Statement on Physical Education from ACS CAN, ADA, and AHA. 2013.
Available at http://www.acscan.org/content/wp-content/uploads/2013/08/PE-in-Schools-
Policy-Statement.pdf. Accessed May 7, 2014. Also see: ACS CAN, ADA, AHA. Fact Sheet:
Physical Education in Schools Both Quality and Quantity are Important. 2013. Available at
http://www.acscan.org/content/wp-content/uploads/2013/08/PE-in-Schools-Fact-Sheet-
from-ACS-ADA-AHA.pdf. Accessed May 7, 2014.
Indoor Tanning
1 American Cancer Society. Cancer Facts & Figures 2014. Atlanta: American Cancer
Society; 2014.
2 American Cancer Society. Cancer Facts & Figures 2014. Atlanta: American Cancer
Society; 2014.
3 Ghissassi, et al. A Review of Human Carcinogens Part D: Radiation. The Lancet
Oncology; 2009: 10.
4 US House of Representatives Committee on Energy and Commerce Minority Staff.
False and Misleading Information Provided to Teens by the Indoor Tanning Industry
Investigative Report. February 2012.
5 United States of America Federal Trade Commission. In the Matter of Indoor Tanning
Association, a corporation - Docket Number C-4290 Decision and Order. May 13, 2010.
Available at http://ftc.gov/os/caselist/0823159/100519tanningdo.pdf
6 Centers for Disease Control and Prevention. Youth Risk Behavior Surveillance-United
States, 2011. MMWR 2012;61(4):41.
7 Boniol B, Autier P, Boyle P, Gandini S. Cutaneous melanoma attributable to sunbed
use: systematic review and meta-analysis. British Medical Journal, 2012; 345:e4757.
Correction published December 2012; 345:e8503.
8 Wehner et al. Indoor tanning and non-melanoma skin cancer: systematic review and
meta-analysis. British Medical Journal. October 2012.
9 Guy, et al. State Indoor Tanning Laws and Adolescent Indoor Tanning. American
Journal of Public Health., February 2014.Online
Access to Care
1 Ward, E., Halpern, M., Schrag, N., Cokkinides, V., DeSantis, C., Bandi, P., Siegel, R.,
Stewart, A. and Jemal, A. (2008), Association of Insurance with Cancer Care Utilization
and Outcomes. CA: A Cancer Journal for Clinicians, 58: 931. doi: 10.3322/CA.2007.0011.
Additional data for young adults available in: Robbins, A. S., Lerro, C. C. and Barr, R. D.
(2014), Insurance status and distant-stage disease at diagnosis among adolescent and
young adult patients with cancer aged 15 to 39 years: National Cancer Data Base, 2004
through 2010. Cancer, 120: 12121219. doi: 10.1002/cncr.28568
2 American Cancer Society. Cancer Facts & Figures, 2014. Atlanta, GA: American Cancer
Society, 2014.
3 Streeter SB, Schwartzberg L, Husain N, et al. (2011) Patient and plan characteristics
affecting abandonment of oral oncolytic prescriptions. J Oncol Pract 7(suppl 3):46s51s.
4 Ibid.
5 Ibid.
6 Curtis, Rick and Ed Neuschler, Institute for Health Policy Solutions, June 2012.
7 Curtis, Rick and Ed Neuschler, Institute for Health Policy Solutions, June 2012.
8 US Department of Health and Human Services. Vital and Health Statistics. Series 10,
Number 260. February 2014.
9 US Department of Health and Human Services. Vital and Health Statistics. Series 10,
Number 260. February 2014.
10 McKinsey Center for US Health System Reform. Hospital networks: Congurations on
the exchanges and their impact on premiums. December 2013.
11 ACS CAN analysis of 681 silver plans available in the 34 federally-facilitated
marketplaces.
12 McKinsey Center for US Health System Reform. Hospital networks: Congurations on
the exchanges and their impact on premiums. December 2013.
13 A Closer Look at the Impact of State Decisions Not to Expand Medicaid on Coverage
for Uninsured Adults Kaiser Commission on Medicaid and the Uninsured. April 24,
2014. Table 1: Current Eligibility Among Uninsured Adults in Non-Expansion States
Who Would be Eligible for Medicaid if Their States Expanded
14 Glied, S. and Ma, S. How States Stand to Gain or Lose Federal Funds by Option In or
Out of the Medicaid Expansion. The Commonwealth Fund. December 2013. Exhibit 2.
Added up all non-expansion states, plus Indiana, Montana, and Tennessee.
15 Levy AR, Bruen BK, Ku L. Health Care Reform and Womens Insurance Coverage for
Breast and Cervical Cancer Screening. October 2012.
16 Congressional Budget Ofce. Payment of Penalties for Being Uninsured Under the
Affordable Care Act. September 2012.
17 Congressional Budget Ofce. Updated Estimates of the Effects of the Insurance Coverage
Provisions of the Affordable Care Act. April 2014.
Access to Colorectal Cancer Screening
1 American Cancer Society. Cancer Facts & Figures 2014. Atlanta: American Cancer
Society; 2014.
2 American Cancer Society. Colorectal Cancer Facts & Figures 2014-2016. Atlanta:
American Cancer Society; 2014.
3 American Cancer Society. Colorectal Cancer Facts & Figures 2014-2016. Atlanta:
American Cancer Society; 2014.
4 American Cancer Society. Colorectal Cancer Facts & Figures 2014-2016. Atlanta:
American Cancer Society; 2014.
Funding for Breast and Cervical Cancer Screening
1 American Cancer Society. Cancer Facts & Figures 2014. Atlanta: American Cancer
Society; 2014.
2 American Cancer Society. Cancer Facts & Figures 2014. Atlanta: American Cancer
Society; 2014.
3 American Cancer Society. Cancer Prevention & Early Detection Facts & Figures 2013.
Atlanta: American Cancer Society; 2013
4 Centers for Disease Control and Prevention. National Breast and Cervical Cancer Early
Detection Program (NBCCEDP) About the Program. Available http://www.cdc.gov/
cancer/nbccedp/about.htm. Accessed May 9, 2014.
Palliative Care
1 Morrison RS, Penrod JD, Cassel JB, et al. Cost savings associated with U.S. hospital
palliative care consultation programs. Arch Intern Med. 2008 Sep 8;168(16):178390.
2 Growth of Palliative Care in U.S. Hospitals, 2013 Snapshot, Center to Advance Palliative
Care, 2013.
3 Americas Care of Serious Illness, A State-by-State Report Card on Access to Palliative
Care in Our Nations Hospitals, Center to Advance Palliative Care (CAPC) and the
National Palliative Care Research Center (NPCRC).
4 Early Palliative Care for Patients with Metastatic NonSmall-Cell Lung Cancer, New
England Journal of Medicine, 2010 August 19, 363:733-742.
Cancer Pain Control: Advancing Balanced State Policy
1 Institute of Medicine, Relieving Pain in America: a blueprint for transforming
prevention, care, education, and research (National Academy of Sciences 2011).
2 Achieving Balance in State Pain Policy, A Progress Report Card (CY2013), Pain & Policy
Studies Group University of Wisconsin School of Medicine and Public Health Carbone
Cancer Center.
References
888-NOW-I-CAN
www.acscan.org