HPV and paying for vaccines

The Journal of American Medical Association (JAMA) has a new article on the relative risks of sexually transmitted infections (STI) for women who either were or were not vaccinated against HPV. The short story is that vaccination is very effective against preventing cancer and has absolutely no impact on the probability that young women will have more sex or at least more risky sex that leads to more STI’s.

Good news!

The vaccine works and it does not have a side effect that worries people.

I want to talk a little about financing vaccines. Right now, preventative care, including vaccines, is no cost sharing under the ACA. Under the AHCA, who knows what it would be. Vaccines distribute benefits to two groups of people. The first group is the person who receives the vaccine. They get a far lower chance of getting sick. That is extremely beneficial. The second group are the people who are not vaccinated but who avoid getting sick because the transmission vector ran into a brick wall of vaccinated people. This only matters where the disease spreads person to person; it does not matter for diseases like rabies or tetanus.

In the HPV context, that means the young women who are overwhelmingly likely to be HPV vaccinated receive the direct benefit but their lovers and their lovers’ other lovers receive indirect protection. It is a partially a public good. Basic economics argue that public goods that are privately financed will be under provisioned.

The ACA tries to get around this public good problem by mandating that insurers pay for vaccines as a preventative measure. The goal is to reduce the personal expense barrier to getting a partial public good, a vaccine, so that the population is healthier over the long run. It mandates that insurers pay.

The ACA does not mandate that insurers push vaccines hard. With the exception of flu shots, there are very few vaccines that give full benefits that can be internalized by the insurer via lower claims cost within the expected length of stay on a single policy. This is true in all markets. It is especially true for HPV where the health benefits are years after administration. Insurers will pay the claims but they won’t actively chase people to get vaccinated.

If the AHCA passes and if a state chooses to gut essential health benefits, vaccination rates will fall and the population will get sicker over the long run.

Finance is not the only barrier to vaccination. But it is a barrier.






26 replies
  1. 1
    Patricia Kayden says:

    If the AHCA passes and if a state chooses to gut essential health benefits, vaccination rates will fall and the population will get sicker over the long run.

    This needs to be tweeted and retweeted a million times. This is just one of the many ways Trump Care will damage this country.

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  2. 2
    Cheryl Rofer says:

    I recall being lined up in school for various vaccines. Polio for sure, and I think smallpox. Those must have been paid for by tax dollars, no? That would have been under the thinking that vaccination is a public good. I think you can still get some vaccinations free at public health offices, but they are usually tucked away in an obscure corner of some government building or shopping mall, and the vaccinations are not widely advertised.

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  3. 3
    zeecube says:

    It is also important to get your teenage sons vaccinated with HPV vaccine too.

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  4. 4
    JCJ says:

    The short story is that vaccination is very effective against preventing cancer and has absolutely no impact on the probability that young women will have more sex or at least more risky sex that leads to more STI’s.

    I have often wondered how this ever became a line of reasoning – is there really anyone who abstained from sex for fear of HPV? So after vaccination a person will go around banging anyone or anything? In the last month I have met three new patients with HPV related cancer, one in the tonsil and two in the base of tongue. These are men in their fifties who are otherwise healthy. They are likely to be cured (radiation and chemotherapy), but that is tough treatment.

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  5. 5
    Karen says:

    @zeecube: why would you vaccinate males against cervical cancer? it isn’t contagious

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  6. 6
    LongHairedWeirdo says:

    @JCJ: No, the attacks on HPV vaccine were probably two-fold:
    1) Republicans didn’t want to pay for it – make it mandatory and the state will have to pick up the tab and
    2) Republicans like to say EEEEEVIL liberals want to tell your daughters it’s okay to have sex someday – so it’s a nice bit of divisive propaganda “See, we defend traditional values like making sure sex has possibly deadly consequences, while liberals want to encourage licentiousness!”

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  7. 7
    LongHairedWeirdo says:

    @Karen: HPV is contagious. If a guy never gets it, he can’t spread it.

    I’m not sure if doctors would advise it, but it strikes me as a good way of providing herd immunity.

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  8. 8
    Nicole says:

    @zeecube: Truth. This mom of a six-year-old boy is making sure he gets vaccinated against it when the time comes. I know he can’t get cervical cancer himself, but I would just as soon him not be responsible for anyone else developing it.

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  9. 9
    Karen says:

    When this vaccination first came out doctors were told NOT to give it to males that the side effects could be life threatening; later the doctors who received money from drug company said that the number of males injured wasn’t as large group as claims. Now it is be recommended.
    When my children were little, getting vaccinated almost killed them; my calm doctor went on rant. He believed that vaccinations should be one at a time and spread out, that there should be a way of testing to see if there were adverse reactions. This was over 30 years ago, back; then he said that nothing good will come from the vaccination schedules being set up by drug companies not independent doctors who received no money from said drug companies. The number of vaccinations required for my children was minute compared to what is not recommended; also vaccinations are given in “groups” so if your child ends up in ER there is no way of telling just what put them there.

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  10. 10
    Villago Delenda Est says:

    BUT THE SLUTS MUST BE PUNISHED WITH CANCER!

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  11. 11
    Edith says:

    @Karen: HPV is also responsible for an increasing percentage of oral cancers, especially in men, as the popularity of oral sex has increased. It’s never been tested for prevention of oral cancer, which is why it’s not an official recommendation, but public health officials have communicated less formally that they think it’s a good idea

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  12. 12
    opiejeanne says:

    Casual sex! The horror!

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  13. 13
    JCJ says:

    @Karen:

    The vaccine is to prevent cervical cancer by preventing Human Papilloma Virus infection. Certain subtypes of this virus can cause cervical cancer. These viruses can also cause anal cancer and oropharyngeal cancer. If you question the value of preventing oropharyngeal cancer then I would suggest going to a nearby cancer center and seeing the patients who are at the end of a course of radiation for one of these cancers. Interestingly there is research being done to decrease the radiation doses used in an effort to limit long term toxicity. The ECOG E1308 study was a phase II trial that enrolled 90 patients nationwide. Patients were treated with induction chemotherapy then treated with radiation and chemotherapy. I personally enrolled two patients on this trial and my associates enrolled four others. Phase III trials are being planned / are underway to further evaluate radiation dose de-escalation. This is important to try to limit long term problems with decreased salivary function, pharyngeal stenosis, and dental problems. Of course, better yet would be to prevent the cancers in the first place.

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  14. 14
    liberal says:

    @JCJ: Completely agree, though I would assume the vast majority of cases are due to smoking, not HPV. Maybe I’m wrong in that.

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  15. 15
    Mnemosyne says:

    @liberal:

    IANA doctor, but apparently smoking can be a contributing factor to an oral HPV cancer (or vice versa — they’re not quite sure which factor is the actual trigger for the cancer to start).

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  16. 16
    Nicole says:

    @Karen: And my kid has had all of his vaccinations on schedule, including the newfangled ones like chicken pox that weren’t around 30 years ago AND gets his flu vaccine every year and he is absolutely fine. The plural of anecdote is not data.

    I wish the chicken pox vaccine had existed when I was little. Getting chicken pox at 15 was a whole sack of no fun.

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  17. 17
    JCJ says:

    @Mnemosyne: Correct. Also the prognosis is affected – HPV related cancers in non smokers has the best prognosis while non-HPV related cancers in smokers has the worst with HPV positive tumors in smokers being in between.

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  18. 18
    Central Planning says:

    All my kids got/will get the HPV vaccine, and I have 4 boys and 1 girl.

    And frankly, the HPV vaccine doesn’t cause any more promiscuity than the availability of condoms. I think that’s just projection.

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  19. 19

    @Nicole: He can get oral, throat and tongue cancers from HPV if he A) likes girls and B) is a considerate lover when he gets older

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  20. 20
    JCJ says:

    @David Anderson:

    He can get these cancers if he likes boys as well.

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  21. 21
    Karen says:

    @JCJ: I have seen cancer wards, have had cancer; the virus alone is not enough it needs other factors

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  22. 22
    Karen says:

    @JCJ: @JCJ: if the fear of aids did nothing to slow down unsafe sex I doubt that anything will

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  23. 23
    Karen says:

    @Nicole: when I turned certain age I was told I had to get shingles vaccination; I was going to wellness doctor and asked for information. seems, in some cases if you have never had chicken pox you are at risk for the vaccination giving you chicken pox, a certain percentage of people who receive the vaccination become carriers and have given chicken pox to grandchildren. I had just finished having tests that finally showed the nerve damage I was suffering was due to shingles, the chances, in my case of increased never damage was high.

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  24. 24
    David Anderson says:

    @JCJ: very true. Mean culpa

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  25. 25
    wmd says:

    @Karen: Guys do get cancer from HPV. In fact it is responsible for a massive increase in the number of cases of squamous cell carcinoma of the head and neck since the 1970s.

    I’m currently being treated for oropharyngal squamous cell carcinoma at Stanford and have done a huge amount of reading on the topic since my initial diagnosis in April. I’m a non smoker and non heavy drinker, so I’ve got a good prognosis. That said, the radiation and chemotherapy I’m getting is not fun.

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  26. 26
    wmd says:

    @Karen: Fundamentally the problem is one of iimmune response. My immune system can’t detect HPV mediated blocking of E6/E7 proteins that cause cell death in epithelial cells, so those cells became tumors. I had a good conversation with one of the surgical residents about this and it helped clarify how HPV becomes carcinoma in cases like mine.

    I’ve asked for tissue samples to be banked for further research – in particular to assess genetic factors in both the pathogen and my personal genome that increase risk. I’m lucky – Stanford is at the forefront of research on this cancer and I get to contribute to understanding of the disease as I am cured.

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