“It’s Not Just Cost”: Barriers to Mammography Screening Access Among Low-income Women in the United States—A Scoping Review

Abstract

Despite the recognized importance of early detection, disparities in mammography access persist among low-income women in the United States. While financial barriers are often emphasized, less is known about how multiple barriers interact to shape access to screening. We conducted a scoping review following Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews guidelines to synthesize evidence on barriers to mammography access among low-income women in the United States. A systematic search of PubMed, CINAHL, and Google Scholar identified peer-reviewed studies published between 2010 and 2025, of which 47 met inclusion criteria. Extracted barriers were categorized into five domains: financial, structural, informational, cultural/social, and systemic. Barriers were multidimensional and frequently co-occurred across domains. Structural barriers, including transportation challenges and limited clinic availability, were the most reported, followed by financial and informational constraints. Cultural factors such as fear, stigma, and mistrust, along with systemic issues including provider bias and fragmented care coordination, further constrained access. Across studies, barriers rarely operated in isolation but instead reinforced one another, producing layered disadvantage that limited both screening uptake and follow-up care. These findings highlight the need for integrated, multi-level interventions that address structural, informational, and systemic barriers simultaneously. Expanding insurance coverage alone is insufficient; improving access will require strengthening patient navigation, enhancing care coordination, and embedding culturally responsive approaches within health systems.

INTRODUCTION

Breast cancer remains the most commonly diagnosed cancer among women in the United States and a leading cause of cancer-related death [1]. In 2025, approximately 319,750 females in the United States are expected to be diagnosed with invasive breast cancer, and an estimated 42,680 will die from the disease [2]. Mammography screening is a proven strategy to reduce breast cancer mortality through early detection, yet access to screening is far from equitable.

Despite national screening recommendations and publicly funded programs—including Medicaid and the National Breast and Cervical Cancer Early Detection Program (NBCCEDP)—low-income women continue to face disproportionately high rates of delayed screening and later-stage diagnosis. According to Centers for Disease Control and Prevention (CDC) and the National Center for Health Statistics (NCHS) data, in 2023, about 71.3% of women aged 50-74 with incomes under 200% of the federal poverty level reported having had a mammogram in the past two years—compared to about 83.0% of similarly aged women with incomes at or above 200% of the federal poverty level [3]. These disparities persist across racial and geographic lines, suggesting that cost alone cannot explain the gaps.

Previous studies have identified multiple contributing factors, including limited insurance coverage, logistical constraints, lack of culturally tailored communication, and deep-rooted medical mistrust [4-6]. A growing body of literature explores targeted interventions such as mobile mammography, patient navigation, and health education [7,8]. However, there has been less emphasis on synthesizing the broader ecosystem of barriers that persist even in the presence of such programs. Furthermore, many studies narrowly address single barriers in isolation, rather than examining how they converge to create compounded disadvantage.

This scoping review aims to address that gap. While prior studies have often examined barriers in isolation, this review synthesizes evidence across five intersecting domains. By mapping how these barriers interact across studies, the review highlights structural patterns that may help guide more integrated policy responses. This study uniquely maps five-domain intersections, synthesizes intervention-amenable gaps, and offers a policy-relevant typology for low-income U.S. women—adaptable to global contexts. Unlike prior reviews, we demonstrate a layered disadvantage that requires system redesign beyond insurance expansion alone.

By drawing on 47 peer-reviewed studies, we identify and categorize five recurring domains of barriers—structural, financial, cultural, systemic, and informational—that hinder mammography access among low-income women in the United States. Rather than evaluating intervention outcomes, our goal is to offer a clear, policy-relevant synthesis of persistent access failures, highlighting how these barriers operate in practice and where systemic reforms are most urgently needed.

MATERIALS AND METHODS

Scoping review framework

This scoping review followed the five-stage methodological framework proposed by to enhance conceptual clarity, transparency, and policy relevance [9-11]. These stages included: (1) identifying the research question, (2) identifying relevant studies, (3) selecting studies, (4) charting the data, and (5) collating, summarizing, and reporting the results. Reporting of the review followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews (PRISMA-ScR) guidelines to ensure transparency and completeness [12]. The review aimed to systematically map the breadth and nature of barriers to mammography access among low-income women in the United States, rather than assess the effectiveness or quality of specific interventions.

Search strategy

A structured search strategy was developed in consultation with an academic health sciences librarian to ensure comprehensiveness and alignment with Medical Subject Headings (MeSH) and relevant indexing conventions. Searches were conducted across three databases—PubMed (Medline), CINAHL, and Google Scholar—between January and March 2025. Search terms combined MeSH headings and free-text keywords across four conceptual domains: (1) mammography screening, (2) underserved or low-income populations, (3) barriers to access, and (4) studies conducted in the United States. Boolean operators (“AND”, “OR”) were used to optimize retrieval. The search was limited to English-language studies published between January 2010 and December 2025 to ensure contemporary policy relevance. Details on the search strategy including search strings are provided in Supplementary files.

Study selection

All identified records were imported into a shared Zotero group library for de-duplication and screened in two stages: title and abstract review, followed by full-text screening. Two reviewers (JM and CN) independently screened studies at both the title/abstract and full-text stages and independently coded included studies across barrier domains. Discrepancies were resolved through discussion and consensus, with input from a third reviewer (NJ) where needed. Because coding discrepancies were resolved through discussion and consensus before finalizing the dataset, a quantitative measure of inter-rater reliability was not calculated.

Studies were included if they focused on breast cancer screening (mammography) among women in the United States, examined barriers to access in low-income, uninsured, or underserved populations, and reported empirical findings—either observational or evaluative in nature. We excluded studies that focused solely on radiologic technique or screening efficacy without addressing access issues, as well as non-empirical formats such as editorials, commentaries, and conference abstracts. Only full-text articles published in peer-reviewed journals were considered. Our initial search retrieved 427 studies, of which 9 were duplicates. Of the remaining 418 studies, 339 were excluded because they were not related to the study question, and 32 were removed because no access / not on topic after further analysis. 47 studies met the inclusion criteria and were retained for final synthesis as shown in Figure 1.

Figure 1. PRISMA flow chart.

CINAHL, Cumulative Index to Nursing and Allied Health Literature; PRISMA, Preferred Reporting Items for Systematic Reviews and Meta-Analyses.

Data charting and synthesis

A structured data extraction form was developed to capture key information from each included study, including author/year, study location, population focus, study design, reported barriers, and any referenced interventions. The charting tool was piloted on a subset of studies and refined iteratively to accommodate nuanced or overlapping barrier types.

Extracted barriers were organized into five overarching domains—financial, structural, informational, cultural, and systemic—based on prior literature and recurring themes identified across the dataset. Because many studies reported barriers spanning multiple domains, each study was coded across all relevant barrier domains. This approach allowed us to capture the multidimensional and intersecting nature of barriers to mammography access. Domain-level classifications for each study are presented in Table S1, with detailed study characteristics provided in Table S2. Emerging pandemic-related disruptions—particularly those tied to coronavirus disease 2019 (COVID-19)—were captured within the structural and informational domains, where they often intensified existing barriers to access.

In line with established scoping review methodology, a formal risk of bias or quality appraisal was not conducted, as the primary aim of this review was to map the breadth and nature of available evidence rather than to assess the methodological quality of individual studies [9,11]. However, to ensure a baseline level of rigor, only peer-reviewed empirical studies were included.

The final synthesis focused on mapping the types, patterns, and intersections of reported barriers, rather than evaluating intervention effectiveness or quantifying outcomes. The complete charting matrix—including study characteristics, extracted findings, and assigned barrier domains—is presented in the Supplementary files.

RESULTS

To organize the findings, we categorized reported barriers into five overarching domains—financial, structural, informational, cultural, and systemic—grounded in prior conceptual frameworks, notably Gelberg et al.’s [13] Behavioral Model for Vulnerable Populations (predisposing/cultural factors, enabling resources like insurance/transportation, systemic need/context). Most studies reported barriers spanning multiple domains rather than a single category. Accordingly, studies were coded across all relevant domains, allowing for a more accurate representation of the multidimensional nature of access constraints. Although domains are presented separately for clarity, barriers frequently overlapped conceptually and were treated as interrelated rather than mutually exclusive. Table 1 provides an overview of barrier types, subgroups most affected, and selected references (see Table S1 for study-level domain coding and Table S2 for detailed study characteristics).

Table 1.

Overview of barrier types, subtypes, and population groups most affected

Barrier domain	Examples	Example of populations most affected	# of studies
Financial	Out-of-pocket costs, billing confusion, fear of follow-up costs, job or wage loss	Uninsured women, Medicaid enrollees, rural and hourly-wage populations	37
Structural	Travel distance, limited transportation, inflexible clinic hours, fragmented referral systems, mobile-unit discontinuity	Rural women, shift workers, women with limited English proficiency	47
Informational	Confusion about eligibility and coverage, inconsistent messaging, low health literacy, limited digital access	Immigrant women, low-literacy patients, LEP populations	36
Cultural and social	Fatalism, fear of diagnosis, modesty, stigma, mistrust of providers	African American women, Latina immigrants, Muslim and conservative cultural groups	31
Systemic	Provider bias, delayed referrals, coverage interruptions, poor care coordination	Black women, FQHC users, dual-eligible and uninsured patients	18

LEP, limited english proficiency; FQHC, federally qualified health center.

Financial barriers

Financial barriers were among the most frequently reported obstacles, appearing in 35 of the 47 included studies. These challenges extended well beyond lack of insurance coverage to encompass a spectrum of economic vulnerabilities—including anticipated out-of-pocket costs, fear of downstream expenses, and anxiety about hidden billing charges. Even when screening was advertised as free, many women hesitated to engage because prior encounters with billing confusion or surprise charges had eroded trust in the healthcare system [14-17]. Ponce et al. [18], added that even for insured women, insurance coverage did not always ensure equitable access due to narrow networks and hidden costs.

Studies consistently described women making rational calculations about whether they could afford the consequences of screening. Beyond copayments, participants weighed indirect and opportunity costs such as lost wages, transportation, and childcare expenses [7,19-21]. For hourly or shift workers, the prospect of taking unpaid time off—often for multiple appointments—made participation financially untenable [22,23]. Others feared the cascading financial fallout of a potential diagnosis, including the inability to pay for treatment, risk of job loss [7,8,24].

Several studies framed these financial fears as anticipatory harm rather than simple affordability concerns. Women’s reluctance to seek screening often reflected learned experiences with medical debt, opaque billing, and unpredictable insurance rules [25-27]. For many, uncertainty about follow-up costs translated into broader mistrust of institutions that promised “free” care but delivered new financial burdens. These anxieties were most acute among uninsured women, Medicaid enrollees navigating eligibility churn, and undocumented women facing exclusion from public coverage [5,14,28].

While mobile mammography programs were designed to reduce financial and geographic barriers, their reach was uneven. Studies found that limited awareness, confusion over eligibility, and concerns about potential hidden costs deterred utilization even among women in greatest need [8,29]. Across studies, affordability concerns were not solely logistical; they reflected broader anxieties around cost predictability, institutional trust, and economic precarity that shaped women’s willingness to engage with screening.

Structural barriers

Structural barriers—highlighted in 45 of the 47 included studies—were the most consistently cited impediments to screening. These barriers encompassed distance to imaging facilities, transportation limitations, inflexible clinic hours, long wait times, and fragmented systems of care. Together, these structural constraints limited the physical and logistical feasibility of accessing screening services, often interacting with financial and informational barriers to further restrict participation.

In rural settings, long travel distances and inconsistent deployment of mobile mammography units were common deterrents [30-32]. In urban and suburban areas, women frequently cited unreliable or costly public transit, inflexible work schedules, and caregiving demands that limited their ability to attend appointments [4,33,34]. Several studies noted that safety-net clinics rarely offered evening or weekend hours, effectively excluding hourly workers or those holding multiple jobs [25,35,36].

Even where mobile services were available, women often expressed confusion about follow-up procedures and referral pathways, reflecting a lack of integration between screening sites and primary-care providers in broader health system referral pathways [8,18,37]. This discontinuity discouraged utilization, particularly among those unfamiliar with navigating fragmented health systems.

Care-coordination challenges were especially pronounced within safety-net facilities. Federally Qualified Health Centers and public hospitals frequently lacked structured referral mechanisms, leaving patients to coordinate their own follow-up across multiple institutions [38,39]. Poor interoperability between electronic health-record systems further hindered communication between providers, often delaying follow-up after abnormal results [14,37]. For women with limited English proficiency or low digital literacy, these challenges were compounded by missed reminders, difficulty scheduling appointments online, and inadequate translation support—especially in areas with uneven clinic distribution or staffing shortages [25,32,39].

The COVID-19 pandemic magnified these structural vulnerabilities [22,34]. Clinic closures, reduced operating hours, and staff redeployments led to widespread disruptions in screening continuity. Women without reliable internet, regular primary-care relationships, or access to linguistically appropriate information were disproportionately affected, underscoring how quickly access collapses for marginalized groups when systems lack integration and resilience.

Informational barriers

Informational barriers—reported in 34 of the 47 included studies—spanned confusion about eligibility, cost, screening intervals, and program availability. These challenges were especially pronounced among immigrant women, first-generation patients, and individuals with limited English proficiency or low health literacy. While these barriers are categorized as informational, they often intersect with structural constraints (e.g., limited access to linguistically appropriate services) and cultural factors (e.g., mistrust), highlighting their cross-domain nature (Table S1).

Uncertainty about where and how to obtain mammograms was a recurring theme. Some women believed that physician referrals were mandatory, others were unaware of free or low-cost screening programs, and many did not know whether their insurance covered screening [39,40]. These gaps were magnified among immigrant and underserved populations, where limited familiarity with the U.S. health system and low health literacy compounded confusion [14,17]. Messaging inconsistencies across clinics, insurers, and public health campaigns further reinforced misunderstandings about eligibility and coverage [4].

For undocumented and mixed-status women, access may be further complicated by uncertainty about legal eligibility for no-cost programs and fear that personal information might be shared with immigration authorities. Translated materials were sometimes insufficient or poorly tailored, and in-person interpreters could not always bridge cultural or trust gaps [26]. Shame or embarrassment sometimes inhibited women from asking clarifying questions, particularly in rushed or impersonal clinical settings [41].

Several studies revealed widespread misconceptions about breast cancer and screening. Some participants believed mammography was only necessary if symptoms were present, while others questioned its efficacy or safety [22,26,42]. Conflicting screening guidelines across medical organizations added to this confusion, creating uncertainty about when and how often to obtain a mammogram [4,15].

Across studies, trust in the messenger proved critical. Women were more likely to disregard messages from automated systems or unfamiliar institutions, whereas peer educators, faith leaders, and language-concordant navigators were described as far more effective in building understanding and engagement [4,35,39].

The COVID-19 pandemic further exacerbated informational barriers [35]. Public health messaging during the pandemic often prioritized infection prevention and emergency care, inadvertently downplaying preventive services such as mammography. Women with limited English proficiency, low digital literacy, or poor internet access were particularly likely to miss or postpone screening appointments during this period, highlighting how communication inequities can rapidly widen existing access gaps.

Cultural and social barriers

Cultural and social barriers—reported in 29 of the 47 included studies—shaped women’s perceptions of breast cancer risk, comfort with screening, and interactions with providers. These barriers encompassed fatalistic beliefs, stigma, modesty concerns, gender norms, and deep mistrust of medical institutions.

Emotional and experiential factors, particularly fear and mistrust, emerged as key deterrents within this domain. Studies across African American, Latina, and Muslim women described anxiety related to pain, embarrassment, or receiving a cancer diagnosis [4,38,42]. Fatalistic beliefs—such as viewing cancer as inevitable, God’s will, beyond human control, or a death sentence—were especially prevalent among women who had prior negative healthcare experiences [22,24]. In some studies, spiritual or traditional healing practices were favored over biomedical screening, particularly where trust in the healthcare system was low [26,41].

For undocumented women, additional fears may stem from stigma and immigration-related concerns. Some avoid clinics altogether, while others disengage due to modesty norms or fear of being seen at service sites associated with public assistance. Embarrassment around disrobing for breast exams also emerged consistently, particularly among women from more conservative cultural or religious backgrounds [43].

Women lacking strong social support were more likely to internalize shame and avoid preventive care [6,22]. Some expressed reluctance to attend appointments alone, while others recalled poor outcomes among relatives or community members that reinforced fatalistic attitudes [6,22]. Gender norms also influenced screening behavior. Several studies noted that women often prioritized family needs over personal health or avoided screening to prevent causing worry to loved ones [24,26]. In contrast, quantitative evidence indicated that women with female primary care providers were more likely to receive mammograms, suggesting the importance of provider gender in facilitating preventive care [32].

Across studies, mistrust of healthcare institutions emerged as a product of experience rather than attitude. Participants recalled instances of disrespect, rushed encounters, or perceived indifference from providers, which amplified reluctance to return for screening [41,44]. Culturally concordant outreach strategies—such as faith-based programs, peer-led education, and community health worker engagement—were frequently cited as increasing comfort and trust, particularly among women who had faced language or cultural mismatches in prior care [7,14,29]. These findings, summarized in Figure 2, illustrate how cultural and social barriers frequently intersect with systemic and informational constraints.

Figure 2. Interlocking relationships across the domains.

ID, identification.

Systemic barriers

Systemic barriers—reported in 36 of the 47 included studies—reflected institutional and policy-level shortcomings in how care is financed, coordinated, and delivered across racial, ethnic, and socioeconomic lines. A nationally representative analysis by Narcisse et al. [45] found that women living below 400% of the federal poverty level, reporting medical financial hardship or anxiety about bills, lacking a usual source of care, or residing in rural areas were substantially less likely to receive guideline-concordant mammography, even after adjustment for other factors. These patterns underscore how weaknesses in enabling resources—such as primary-care attachment, benefit design, and the broader safety-net environment—operate as systemic constraints within Andersen’s Behavioral Model, limiting access to timely, coordinated, and respectful screening care.

Black and Latina women were particularly affected. Multiple studies documented delays in diagnosis and treatment even among women with similar income or insurance coverage as their white counterparts [22,26,46]. Some studies suggest that provider communication patterns, referral practices, and implicit bias may contribute to disparities in screening access. These systemic dynamics often underpin and amplify barriers in other domains, particularly structural fragmentation, informational gaps, and culturally rooted mistrust.

Within safety-net settings, patients were often expected to self-refer across disconnected services with minimal guidance [33,47]. Women with limited English proficiency or low digital literacy bore the brunt of these coordination gaps, particularly when referral tracking systems were unavailable or poorly interoperable [48,49]. Such operational shortcomings were not race-neutral; they mirrored resource disparities across clinics serving majority-minority populations.

Several studies emphasized that administrative complexity—such as unclear eligibility criteria, reimbursement delays, and coverage interruptions—reflected structural deficiencies in program design that discouraged participation, although few explicitly traced how these processes contributed to systemic delays [5,24,40].

Trust was frequently undermined by dismissive clinical encounters and insensitive communication, particularly when providers downplayed symptoms or failed to explain screening results clearly [17,22,41]. For many participants, these experiences—layered atop historical legacies of medical mistreatment—reinforced disengagement and fatalism, especially among Black women.

Taken together, systemic barriers extended far beyond gaps in insurance or referral logistics. They reflected deeply entrenched racial, linguistic, and economic inequities that interacted with financial, structural, informational, and cultural domains to sustain patterns of exclusion in breast-cancer screening access.

Conceptual mapping of reported barriers

Figure 2 presents a conceptual map illustrating the interconnections among the five barrier domains identified in this review. While domains are presented separately for analytical clarity, most studies reported overlapping barriers spanning multiple categories. Systemic barriers—such as administrative fragmentation, racism, and provider bias—were particularly pervasive, intersecting with and intensifying structural, financial, informational, and cultural obstacles. This visualization highlights the interconnected nature of access constraints among low-income women, highlighting how systemic barriers often amplify or intersect with other forms of disadvantage.

DISCUSSION

This scoping review synthesized findings from 47 studies to identify persistent barriers to mammography access among low-income women in the United States. Across five domains—financial, structural, informational, cultural, and systemic—barriers rarely existed in isolation. Instead, they co-occurred and intersected to produce layered disadvantage, particularly for women navigating multiple forms of marginalization. For example, a low-income woman living in a rural area may simultaneously face transportation challenges (structural), limited awareness of screening guidelines (informational), and concerns about out-of-pocket costs (financial), which together delay screening and reduce the likelihood of timely follow-up. Even when insurance or free screening programs were available, barriers such as transportation gaps, language discordance, stigma, and administrative fragmentation continued to deter engagement. Systemic forces—including racism, policy gaps, and fragmented safety-net infrastructure—were not merely contextual factors but active mechanisms shaping access across every domain.

These patterns can also be understood through the broader lens of the Social Determinants of Health, which emphasize how structural conditions—including economic stability, access to services, and social context—shape health behaviors and outcomes [50]. In this review, barriers to mammography access reflect not only individual-level constraints but also the cumulative effects of structural disadvantage embedded within healthcare systems and social environments. Taken together, these findings reinforce the view that access to preventive care is fundamentally shaped by intersecting social and institutional forces rather than isolated barriers.

These findings extend and contextualize earlier research. While Bea et al. [22], emphasized financial and psychosocial obstacles, this synthesis demonstrates that affordability is only one component of a broader, more complex access landscape. Across studies, institutional mistrust, informational asymmetry, and sociocultural stigma emerged as equally powerful determinants of screening behavior. These patterns align with and expand the Behavioral Model for Vulnerable Populations espoused by Gelberg et al. [13], illustrating how predisposing factors (e.g., mistrust, stigma), enabling resources (e.g., insurance, transportation), and systemic context (e.g., provider bias, policy design) interact to shape service use among underserved women. Future research may extend this framework to other preventive services, populations, and healthcare settings to better understand how multi-level barriers shape access across different contexts.

The COVID-19 pandemic further magnified these vulnerabilities. Although only a subset of studies directly examined pandemic-era barriers, these revealed how clinic closures, staff redeployments, and digital inequities disrupted preventive care. Women with limited internet access, low digital literacy, or weak primary-care ties were disproportionately affected. These disruptions did not create new inequities; they exposed and intensified existing fractures, underscoring the structural fragility of screening access for marginalized populations during times of crisis.

Policy implications

Findings underscore that improving screening uptake requires more than expanding insurance coverage. Across the 47 studies in this review, three policy priorities consistently emerged:

1) Invest in navigation and continuity infrastructure

Patient navigation, language-concordant outreach, and integrated mobile screening were repeatedly associated with higher completion of mammography and follow-up among low-income and racially marginalized women, especially when embedded within safety-net systems and linked to clear referral pathways. These approaches were most effective when they were supported through sustained financing mechanisms, such as Medicaid reimbursement for navigation services, and integrated into routine care pathways rather than implemented as short-term interventions.

2) Embed equity in system design

Studies highlighted that overlapping disadvantages—such as poverty, immigration status, rural residence, and racism—shape how women encounter the screening system. Reducing administrative churn, simplifying documentation requirements, and redesigning workflows to support respectful communication and continuity of care were described as central to rebuilding institutional trust. This includes redesigning care delivery to incorporate language-concordant services, culturally tailored communication strategies, and continuity mechanisms that ensure patients are supported from screening through diagnosis and follow-up. Training and accountability mechanisms to address implicit and explicit bias within clinical encounters were also emphasized as necessary system-level tools, rather than optional add-ons.

3) Coordinate policy levers across programs

Evidence from multiple settings showed that fragmented rules across Medicaid, safety-net hospitals, and public health programs create gaps at every step from outreach to diagnosis. Aligning eligibility, reimbursement, and data-sharing policies across these programs—particularly through coordinated federal and state policy efforts—was consistently described as a prerequisite for reducing screening and diagnostic delays.

Limitations

This review has several limitations. As a scoping review, it does not estimate effect sizes or quantify associations. Reliance on published, peer-reviewed literature may exclude community-led data, gray literature, and insights from grassroots organizations or local program evaluations—potentially limiting generalizability to non-academic or highly localized contexts. In addition, definitions of low-income and underserved varied across studies, complicating precise comparison. Despite these limitations, this synthesis provides a comprehensive, policy-relevant map of barriers grounded in diverse empirical evidence.

CONCLUSION

Mammography access for low-income women in the United States is shaped by a web of intersecting barriers that reflect both individual-level vulnerabilities and entrenched systemic inequities. As this review demonstrates, these barriers rarely operate in isolation; rather, they co-occur and reinforce one another across financial, structural, informational, cultural, and systemic domains, producing layered disadvantage that constrains timely access to screening and follow-up care.

Addressing these disparities requires moving beyond single-focus interventions toward integrated, system-level responses that reflect the lived realities of underserved populations. Expanding insurance coverage alone is insufficient. Meaningful progress will depend on strengthening care coordination, investing in patient navigation, embedding culturally responsive communication, and aligning policies across safety-net programs to reduce fragmentation.

A durable and equitable response will require sustained commitment to redesigning systems of care—ensuring that preventive services are not only available, but accessible, navigable, and responsive to the needs of those most affected by inequity.

SUPPLEMENTARY MATERIALS

Supplementary materials can be found via https://doi.org/10.15430/JCP.26.013.