The federal health law gave a huge boost to insurance coverage for preventive care, mandating that nearly all health plans provide cancer screenings, checkups and, more controversially, contraceptives to people without an extra charge.
But those requirements won't help the 30 million or so people who are expected to remain uninsured despite the law. They will still lean on a patchwork of prevention services whose federal and state funding are anything but certain.
Among those who could still be without insurance are low-income people in states that aren't adopting the health law's expansion of Medicaid, immigrants in the country illegally and those here legally but not yet eligible for Medicaid.
Poor preventive care coverage hits women particularly hard. Women's reproductive care needs are greater than those of men, requiring regular visits for exams and contraceptives.
Women's health advocates say many women who want to ensure that their visits to health care clinics for birth control and other reproductive health services remain confidential frequently choose not to use insurance, even if they have it.
"The Affordable Care Act is wonderful in expanding coverage to millions of women, but it's very difficult to obtain confidential services if you're a dependent on anyone else's policy," says Kinsey Hasstedt at the Guttmacher Institute.
There are programs available that help uninsured and low-income people get the preventive care they need, but advocates worry that funding, which is always precarious, will be further cut because of the misperception that starting next year everyone will have insurance that covers preventive care. The health law requires that health plans provide preventive services recommended by the U.S. Preventive Services Task Force without any out-of-pocket cost to patients. The only exception is for grandfathered plans.
For example, the Centers for Disease Control and Prevention runs two cancer screening programs for uninsured and underinsured people with incomes up to 250 percent of the federal poverty level ($28,725 in 2013). The National Breast and Cervical Cancer Early Detection Program provides screening in all states and the District of Columbia. The Colorectal Cancer Control Program is smaller, operating in half the states.
A 2012 analysis published by researchers at George Washington University and the Lewin Group estimated that if every state expanded Medicaid under the federal law, 1.7 million low-income uninsured women would still be eligible for that breast cancer screening in 2014 and 4.5 million women would be eligible for cervical cancer screening. An additional 1.6 million men and women would be eligible for the colorectal cancer screening program, says Leighton Ku, a professor of health policy who co-authored the study.
Patient advocates are working to ensure the screening programs aren't cut back.
"We don't want to take steps backwards," says Citseko Staples Miller, senior specialist for state and local campaigns at the American Cancer Society's Cancer Action Network.