1)      Percent of Federal Poverty Level: No program offers services to women above 250% of Federal Poverty Level (FPL).  There are un- and under-insured women above this level who will be making choices about their health care spending that will not necessarily include preventive screening.

2)      Options for 'undocumented' women without social security numbers are restricted and include SAGE, SAGE colsposcopy program, FPSP and Title X but are limited to 60 days per year for the Medicaid Waver under 'presumptive eligibility.'

3)      Reimbursement Rates: For services offered through the Medicaid Waver, reimbursement rates - which are far below those of commercial health plans - may discourage providers' participation in this program.

4)      Limitation of grant programs: Title X (a federal program) and Family Planning Special Services Grants (state-funded family planning program) are grant-based, not fee for service programs.  That is, each of these programs has a limited amount of money to spend each year to offer women's reproductive services.  As the budgets for these programs become more restricted, less money will be spent on any outreach services, and clinical services will also be limited to fewer women

5)      Scope of services offered: The purpose of the SAGE program is to provide breast and cervical cancer screening for un and underinsured women, but this program does not include family planning methods and tests for sexually transmitted infections, services for which women over 40 still need and which may motivate them to seek reproductive health care.  In contrast, Title X, FPSP and the Medicaid Waver - which do not have the age limit of SAGE  - provide pap smears in the context of family planning.  There are underserved women under 40 who will need neither STI testing nor family planning, yet will still seek cervical cancer screening.  There may be some 'wiggle room' in the FPSP and Title X grants to provide services for such women, but the Medicaid Waver may be more restrictive. Some clinics participate in both SAGE and FPSP or Title X, and may be able to combine resources to offer complete care for women over 40.

6)      Options for immigrant women who are 'sponsored' are unclear.  Such women are not supposed to receive services through any federally funded program such as Medicaid or Medicare.  Whether this restriction applies as well to SAGE and Title X - also federally funded - is not clear.

7)      Foreign language translation services for women who do not speak English may be limited outside the metro area.  Transportation may be another challenge, especially outside the metro area.

8)      Colposcopy services: Many women who have abnormal Pap smears require colposcopy for further diagnosis.  The SAGE program for women 40 and older, and SAGE colpsocopy program for women under 40, are essentially the only option for free or low-cost colposcopies, and the number of clinics that participate in this option are limited.

9)      Cervical Cancer Treatment: While the vast majority of pap smears will show normal or precancerous results and can be further adjudicated by colposcopy, some Pap smears and colposcopies will show cervical cancer.  This raises a question about the ethics of offering free or low cost screening for a medical condition in underserved women for whom affordable treatment options are extremely limited.  Women specifically screened through the SAGE program (but not other programs) at 250% of FPL , without any insurance whatsoever may be eligible for another waver program - Medicaid for Breast and Cervical Cancer (MABC). Undocumented women may only be eligible for 60 day, meaning that health care providers must act expediently to provide services for such women. While this is a federal program, individual states set the eligibility requirements. For Minnesotans, eligibility requirements for this program were set by the MN legislature and can only be changed by the legislature. Hennepin county's Assured Care is an alternate option for residents only of that county.