The Affordable Care Act's Free Preventive Care Mandates and HPV Vaccinations: An Early Look at a Troubled Area

Background: The Patient Protection and Affordable Care Act (ACA) of 2010 mandates free access to recommended preventive care for all individuals, except those enrolled in pre-ACA (grandfathered) health insurance plans. This free care includes all vaccinations recommended by the Advisory Committee on Immunization Practices (ACIP). The elimination of patient cost-sharing for recommended care arguably better aligns patient financial incentives with clinical goals, i.e., value-based insurance design (VBID), than does requiring patients to pay for high value care. Human papilloma virus (HPV) vaccines in particular are believed to reduce the risk of cervical and other cancers, but uptake of this new vaccine has been slow. ACIP recommended vaccination for females age 11-12 years old (yo) starting in 2007, with catch-up vaccination for females 13-26 yo. For males, ACIP guidelines suggested use starting in 2010, and recommended routine vaccination in 2011. We examined patterns of HPV vaccination starting in 2007 through 2011, the first year after the ACA mandate.

Methods:Using 2007-11 MarketScan data, we empirically estimated plan-level cost-sharing amounts for HPV vaccinations (vaccine, administration, visits) in each year. We then used logistic regression models with a random subject effect to assess the association between current year cost-sharing and vaccine initiation, i.e., first HPV vaccine receipt, or vaccine completion, i.e., receipt of all three vaccines in the series, for continuously enrolled subjects age 7 to 26 yo. We adjusted for geographic region, payer type, physician specialty, patient age in the year of vaccine introduction, and comorbidity scores (DxCGs).

Results: There were 974,456 female subjects who were eligible for the HPV vaccine (32% received any vaccination and 17% completed their vaccination series), and 970,744 eligible male subjects (3% initiated and <1% competed their vaccination). Among all subjects, mean cost-sharing amounts for complete vaccination dropped from $24 (2007) to $9 (2011); the percent with free vaccinations increased from 56% (2007) to 88% (2011). The cumulative percentage of all subjects receiving any vaccination increased over time, e.g., from 18% (2007) to 45% (2011) among 13yo females, but vaccine initiations among 11-12yo females dropped over time even among those with free vaccinations, e.g., from 15% (2007) to 11% (2011) among 11-12 yo female subjects. After adjustment, each $10 increase in vaccination cost-sharing (single dose) was associated with fewer complete vaccinations (OR=0.923 for females; 95%CI:0.919-0.926; OR=0.954 for males; 95%CI: 0.927-0.983). Other factors associated with vaccination completion included region (e.g., OR=0.578 among females in the West versus Northeast; 95%CI: 0.568-0.588), and having a visit with a pediatrician (e.g., OR=2.479  among females, compared with visits with other types of physicians; 95%CI: 2.451-2.507).

Conclusions:There are two notable findings. First, cumulative HPV vaccination levels are increasing slightly, but fewer female patients are initiating vaccination at the recommended age. Second, the elimination of cost-sharing is modestly associated with greater vaccination.

Implications:Additional efforts beyond the current ACA VBID mandates may be necessary to increase use of this cancer vaccine.