Marilyn Keefe is Vice President for Public Policy at the National Family Planning and Reproductive Health Association (NFPRHA).
The promise of dramatically lessening—and someday, eliminating cervical cancer completely is a goal we can all get behind. Right? Well, maybe in the long run but not too quickly—and not this week. What should be a slam dunk on the public health front has, at least temporarily, gotten sidetracked because of an overly aggressive marketing campaign by Merck which has fueled charges by right wing groups like the Family Research Council that parental rights are being violated and that giving adolescent girls the HPV vaccine will somehow lead them away from abstinence and down the path of sexual depravity. Assuming, of course, that we accept the dubious proposition that HPV—that little known virus—plays a significant role in a teenager's decision to engage in or abstain from sexual activity. Research shows it does not.
From a practical standpoint, some of the biggest issues surrounding the HPV vaccine are getting lost in controversy, including an inadequate vaccine delivery infrastructure, the high cost, and a continued lack of understanding among much of the public about the connection between HPV and cervical cancer.
The cost issues are paramount. Merck did reach an agreement with the Centers for Disease Control (CDC) to provide the vaccine to the woefully underfunded Vaccines for Children program (VFC),a federal program that covers the cost of vaccines for uninsured and Medicaid-eligible children under the age of 19, at a reduced price. But that cost—$288 through the VFC—threatens to break the bank of many health care systems and providers. The company also has established a patient assistance program to cover vaccine for some lower income women in the 19-26 year old group. But the costs and administrative hoops for providers make it a cumbersome and still expensive option at best. Providers attempting to access the patient assistance program are required to pay the up front cost for the first dose of the vaccine ($120)—a significant barrier—although replacement doses are free. Furthermore, the program is unavailable to many government-funded providers—even if they don't get government funds for the purpose of providing the vaccine. This means that many of the already sexually active women who see the ubiquitous "One Less" commercials and arrive at publicly funded family planning clinics hoping to avail themselves of this breakthrough vaccine won't have access.
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The situation in the private sector is still problematic as well. While many insurance companies are paying for the vaccine, coverage is far from complete. Doctors are expected to pay the high up front cost on the hope of later reimbursement, which may or may not cover the cost of the vaccine, the storage, and its administration, making many unwilling to even stock the product. This problem was driven home by the experience of an employee of NFPRHA who began her odyssey by calling the insurance company to confirm that the vaccine was covered. The "yes" from our insurer was just the beginning of her saga. She next called her doctor's office for the appointment and was told her doctor didn't stock the vaccine. Strike one. She then called a second gynecologist and was told that this doctor, too, didn't stock the vaccine, but that the doctor could give her a prescription for the vaccine that could then be administered by the doctor. However, this created a Catch-22, for beyond the obvious issues with trying to get a vaccine from a pharmacy, she had a bigger problem—even if she could get it from the pharmacy, her insurance would not cover the pharmacy-to-patient-to-doctor-back-to-patient route; it had to go directly from doctor to patient, with no middle man in between. Strike 2. Tired of blindly calling doctor's offices to see whether they had the vaccine, our intrepid staffer then contacted the local health department. Surely they could tell her where she could go to get the vaccine? Strike 3. They had no idea. Finally, after another round of phone calls and searching on the internet, she was able to get the first dose of the vaccine—at the local Planned Parenthood, which her insurance company said it would cover. She got her first dose of the vaccine… followed by a statement from the insurance company saying they would not reimburse most of the cost because the vaccine was not administered by a doctor. And the battle continues…
Many women will not be as "lucky" or as persistent as our staffer was. There are nearly 17 million uninsured women in the United States, a number that grows daily. Many women—especially in the 19-26 year old aged group, don't have any type of insurance—public or private. At $360 for the vaccine, it is certain to be out of reach, even if they can even find a health care provider who offers it. Title X, the nation's family planning program, provides high-quality reproductive health care to nearly 5 million women each year, the majority of whom are low-income and disproportionately women of color, populations that are most at risk of developing cervical cancer. Title X-funded family planning clinics, which provide 2.6 million Pap tests each year and often provide low-income and uninsured women with their only source of health care, represent the best hope for girls and women ages 13-26 to receive the vaccine. Yet most of these clinics, which have been starved of federal funds for years, don't have the resources to offer the vaccine to their patients.
An estimated 80 percent of women will have contracted HPV by age 50. It is therefore critical that all eligible women have access to the vaccine. If some of the money spent to lobby legislatures to endorse mandatory vaccination for adolescents was spent on services to the women most in need, and to better educate the public about the benefits of the vaccine and its relationship to cervical cancer, we would all be better off.