We're still waiting to see how exactly the Trump administration will replace Obamacare, but one thing already appears certain: Sexual health is unlikely to be a big priority, with plans to defund Planned Parenthood and ditch no-cost birth control already in motion.
Given the increasing influence of anti-vaxxers on the GOP's agenda, it's not out of the question to imagine that coverage of the HPV shot could be at risk—despite the fact that it can help prevent cancer, and has been proven to lead to less risky sexual behavior.
And up until now, the ACA and the HPV vaccine have paired well together. A 2015 study found that Obamacare had a generally positive impact on getting people vaccinated: It's estimated that 1.1 million women initiated the series of treatments, and another 854,000 completed them. (Ideally, boys and girls get two doses at age 11 or 12, and it protects them against the nine strains of HPV that cause certain cancers—cervical, anal, penile and genital warts.)
There's also emerging evidence that the vaccine is reducing rates of HPV, according to a 2016 study, which found a 64 percent drop among women ages 14 to 19 and a 34 percent decrease in women ages 20 to 24. Not enough time has passed to say whether or not the shots are actually preventing cervical cancer, but a Harvard study projected that women who get them may be able to go from getting a Pap every three years to every 10, since their risk of getting cervical cancer is quite low.
Part of the reason that the ACA could have upped HPV vaccine rates is that the mandate covered the shots. They're the most expensive of the CDC recommended vaccines—costing up to $190 a pop. Factor in the additional expense of the doctor's visit, and a series of two can easily cost $500 or more if you need three shots, so it's not exactly a bargain. That's one reason research has found that not having insurance coverage, combined with high costs, are two common reasons why people don't get the vaccine. One meta-analysis of 29 studies even found that lack of health insurance, rather than income, was one of the most important reasons women opted out.
But cost isn't everything. Statistics show that more girls and boys are receiving the shots than in the past, with 71 percent of girls and 61 percent of boys ages 13 to 17 completing the series. That's good, though it's not nearly as many as are getting the Tdap (tetanus, diphtheria, pertussis) or meningococcal vaccines, whose total uptake rates are 86 percent and 81 percent, respectively, according to the CDC.
One reason for the lower rates could be a parent or caregiver's hesitation or lack of knowledge about who needs the vaccine. Since the shots target a virus that is only transmitted through sexual contact, it's not totally surprising that some parents might have reservations. A 2016 report from the National Vaccine Advisory Committee found that parents have qualms about the HPV vaccine that are perhaps not relevant to other immunizations: a fear that their kid would want to start having sex, a belief that their kid is too young to get the vaccine, worries about potential harmful side effects, and claims that their youngster isn't at risk for HPV.
But the reasons don't stop there. "People skipped the vaccine [because] they didn't think they needed it, they didn't think they were at risk," says Kimberly Levinson, associate director of gynecologic oncology at Johns Hopkins, and co-author of the new research which will be presented in March. "We need to get to the bottom of what that actually means for each individual, because this is a vaccine that can help prevent cancer."
For young adults who generally make their own health decisions, skipping the vaccine—the CDC says that women and men up to age 26 can get it—can be more complex. The ACA expanded coverage and access to health care but, from what we know so far, this didn't mean that millions of eager patients were rushing to the doctor to catch up on all the poking and prodding that they missed out on while they were uninsured or underinsured. Why? Because there are a number of other "costs" associated with health care—fear of doctors, convenience (yes, we're lazy), and beliefs about efficacy and risk—that might turn someone away from a visit.
"Just because you are covered, doesn't mean you will take advantage of all that your insurer is going to offer," says Kosali Simon, a health economist at the University of Indiana Bloomington, who recently published a study on how the ACA impacted preventive care and health behaviors. She found that under Obamacare, specifically the Medicaid expansion, there was a small improvement in health behaviors: a 5 percent increase in the number of preventive care services that people received, people surveyed were 7 percent more likely to have a personal doctor, and 5 percent more likely to receive an HIV test. "The economic view on health care isn't as optimistic as the public health view," says Simon. "It is very hard to change people's behavior, even if there are big incentives."
Another study found that, at least early on in the ACA, there wasn't a big jump in women using preventive services. Birth control prescription rates increased about 3 percent, birth control counseling increased and STI testing/treatment went up less than 1 percent, and HIV screening increased 1 percent. More women reported paying through insurance, but out-of-pocket costs didn't decrease after the ACA went into effect. Of course, it's better than nothing, but it's definitely not the Earth-shattering change that policy makers might have been hoping for.
Unfortunately, giving people access doesn't always translate into uptake. "Policy can make things cheaper or free, more accessible, and really convenient, but it won't cover all of the other factors that come into play when people make health decisions," Simon says.
But there is one person who could help change that: Your physician. "Doctors do a lot of education," Levinson says. "They can address questions while also addressing their own individual barriers as to why they are not getting the vaccine." The National Vaccine Advisory report from above found that most of the hesitant parents surveyed would allow their child to get the vaccine if their doctor recommended it.
Simon's study found that surveyed participants were 7 percent more likely to report having a personal doctor. Though they might not actually go, it's still important to give people access and agency in making health decisions. "Insurance is not the only part of the puzzle when it comes to the HPV vaccine but it can be a huge limiting factor," Levinson says. "Public health campaigns can be as loud as they want, but if people don't have access, that could be something that supersedes our education attempts."
So messing with the ACA won't necessarily mean that there will be a huge drop-off in HPV vaccination rates, nor a huge uptick in HPV or cancer—clearly, literal cost isn't everything when it comes to this vaccine. But it could mean taking away thousands of important conversations between patients and doctors, as well as thousands of clarifications and educational opportunities. Because if your doctor tells you a shot can reduce your or your kid's risk of cancer, you might just change your mind.