HPV Vaccine Underused Despite ACA Access

The Centers for Disease Control and Prevention (CDC) announced on July 24, 2014 that the number of teenagers and preteens who are vaccinated against human papilloma virus (HPV) remains unacceptably low, even though the vaccine is covered as a preventive service and its value has been established. The CDC urges health care practitioners to make strong recommendations to parents that both boys and girls be vaccinated against HPV when they discuss meningococcal and tetanus, diphtheria and pertussis (TDAP) vaccines, which also are administered to adolescents and preadolescents. The CDC estimates that 57 percent of adolescent girls and 35 percent of adolescent boys have received at least one dose of the vaccine. About 38 percent of adolescent girls have received all three doses, up from one-third in 2012.

What is HPV?

HPV is the most common sexually transmitted virus. About 14 million people in the United States are infected with HPV each year. According to the CDC, 80 percent of women have been infected with HPV by age 50. HPV often has no symptoms. In addition to causing genital warts in both males and females, HPV infection causes cervical, vaginal, and vulvar cancers in women, penile cancer in men, and cancers of the anus and the oropharynx, which includes the back of the throat, base of the tongue and tonsils, in both sexes. About 20,000 women and 12,000 men develop HPV-related cancer each year.

The HPV Vaccines

There are two vaccines that offer protection against HPV-related cancers. Each must be given in three doses, the second two months after the first and the third four months later (six months after the first). According to the CDC, both HPV vaccines have been studied extensively and found to be safe. After the administration of 67 million doses, the CDC has received about 25,000 reports of adverse events—health occurrences that may or may not be related to the vaccination—and 8 percent were considered serious. There may be an increased risk of fainting, according to one study. Other commonly reported side effects include headache, fever, dizziness, nausea, and redness or swelling in the area of the vaccination.

Practitioners’ Recommendations

The CDC’s 2013 national survey found that preteens and teens were much more likely to receive the HPV vaccine when their health care practitioners recommended it to the parents. Among parents who had their daughters vaccinated, 74 percent said their daughters’ physicians had recommended it. In contrast, 52 percent of parents who did not have their daughters vaccinated said the physicians had recommended it. The physician recommendations may be even more effective for boys; 72 percent of parents whose sons were vaccinated against HPV received a doctor’s recommendation to do so, while only 26 percent of those who did not vaccinate their sons had been advised to do so.

Coverage Gap

Adolescents between the ages of 13 and 17 years were most likely to have received the TDAP vaccination (86 percent) and were very likely to have received at least the first of two doses of meningococcal vaccine (77.8 percent). 2013 was the first year that the number of teens who received the second dose of meningococcal vaccine was tracked; the CDC found that 29.6 percent of teens who received the first dose by age 16 received the second dose in 2013.

The CDC notes that the Patient Protection and Affordable Care Act (ACA) (P.L. 111-148) has increased access to preventive services, including HPV vaccination, making it easier and less expensive than ever for parents to have their children vaccinated.

Federal Exchange Still Buzzing with Activity After Open Enrollment Ends

HealthCare.gov has handled nearly 1 million transactions since the close of the open enrollment period, according to government data obtained by ProPublica under the Freedom of Information Act. Special enrollment periods allow people to buy or switch plans after qualifying life events, such as marriage or divorce, having a baby or adopting a child, or losing other health coverage.

While the numbers released don’t shed any light on how many of those transactions resulted in paid premiums, the information is surprising for some.

“That’s higher than I would have expected,” said Larry Levitt, the Kaiser Family Foundation’s senior vice president for special initiatives, to ProPublica. “There are a lot of people who qualify for special enrollment, but my assumption has been that few of them would actually sign up.”

However, ProPublica reported that, based on the estimate of an insurance industry official, less than half of the transactions are new enrollments. Though 960,000 transactions were counted, these numbers include new members, changes in enrollment status, and disenrollment. These transactions are all grouped under the umbrella of “834″ transactions. According to ProPublica, when an existing member changes his or her policy, two 834s are created–one for ending the old plan and another for starting a new one. Thus, the number of actual new enrollments is hard to discern.

ProPublica discerned some other details of the first open enrollment period based on the data:

  • The slowest day was October 18, when there were no 834 transactions;
  • The next slowest day was the first day of open enrollment, October 1, with only 6 transactions;
  • The busiest day was March 31, the original deadline for enrollments, with more than 202,000 transactions; and
  • Eighty-six percent of individuals who signed up for coverage were eligible for premium tax subsidies from the federal government.

The next open enrollment period runs November 15, 2014 to February 15, 2015.

Unlocking Opportunities for Inmates, ACA May Be the Key to Better Health

Over 10 million individuals enter the jail system in the United States each year. Statistically speaking, jail inmates are disproportionately male, people of color and poor.  An article by Maura Ewing, published recently in The Nation, noted that “this population suffers from higher rates of many health problems, including chronic and infectious disease, injuries, mental illness and substance abuse. And people are often at their sickest when detained. Eighty percent of detained individuals with a chronic medical condition have not received treatment in the community prior to arrest.”

Ewing noted that jails can be considered an “emergency room” of sorts, in that individuals often are very sick and require immediate treatment. Once individuals become inmates, they may have access to health care that they would never have had before. As these individuals receive treatment and get healthy during their incarceration, many people are realizing that jails offer an opportunity to identify and treat people who might not otherwise seek or have access to healthcare.

The problem, though, is that the treatment inmates receive in jail ends once they are released. According to The Nation, “health records are hard to transfer in and out, leaving patients who have received care prior to arriving in jail with siloed histories, creating inefficient, costly and potentially inconsistent treatment.” Currently, there are very few processes in place to  follow-up care once someone is released.  And the brief average jail stay of approximately three months is not enough time to get the individual on the road to recovery. With 96 percent of these individuals returning to their home communities, the need for continuity of care is stark.

Ewing points out in her article that the Patient Protection and Affordable Care Act (ACA) (P.L. 111-148) provides a unique opportunity to address this problem. Before the ACA was enacted, 90 percent of those released from prison or jail each year were uninsured. Like many others, former inmates tended to use the ER. However, Ewing contends, “with the ACA’s Medicaid expansion in full swing in twenty-six states and Washington DC, 5.3 million people who are or have been incarcerated are newly eligible for Medicaid. The opportunity for continuity in treatment is palpable, and across the country, a movement is brewing among forward-looking jail administrators and healthcare providers to bridge this gap.”


CMS Warns: Stop Using Federal Marketplace to Process all Medicaid Applications

Tennessee’s Medicaid agency (TennCare) essentially stopped processing Medicaid applications for children and nondisabled adults when the modified adjusted gross income (MAGI) eligibility standards became effective. Nine months after open enrollment began for the newly eligible adult group, TennCare cannot take or process applications under the standards required by law. It has relied on the Federally Facilitated Marketplace (FFM) to perform these functions for all MAGI-based Medicaid applications since the requirements of the Patient Protection and Affordable Care Act (ACA) (P.L. 111-148) became effective on October 1, 2013. On June 27, 2014, CMS sent a letter to Darin Gordon, director of TennCare, the state’s program, giving the state ten business days to submit a plan to comply with the law.

The State’s Obligations

Under Soc. Sec. Act sec. 1943, all states were required to streamline their Medicaid eligibility determination systems to share information with the Health Insurance Exchange and to enroll individuals whom the Exchange identified as eligible. The statute and related regulations set seven requirements for state eligibility determination systems. Specifically, the state system must be able to:

  • Accept a single, streamlined application;
  • Convert the 2013 income eligibility standards to the modified adjusted gross income; (MAGI) rules required by Soc. Sec. Act sec. 1902(e)(14);
  • Communicate the state’s eligibility standards to the FFM as needed;
  • Process applications based on the MAGI rules;
  • Transfer application files to and from the FFM as needed;
  • Respond to inquiries from the FFM on current coverage through Medicaid and the children’s health insurance plan (CHIP); and
  • Verify eligibility information using electronic sources.

According to the letter, Tennessee has met only one of those requirements, the ability to transfer application files.

Temporary Mitigations

States were required to use the MAGI standards for children and their parents beginning October 1, 2013. Many states were not able to update their systems by that deadline, and CMS required them to develop mitigation strategies to be used until the updates were complete. Tennessee was permitted to rely on the FFM, www.healthcare.gov, for these purposes through December 31, 2013, but it remains in place. The state also placed kiosks in its Medicaid offices so that residents could apply for Medicaid at those locations. However, it has not provided any help to applicants who are using the kiosks.

Effects on Tennessee Residents

The Tennessean reports that at least one woman could not access prenatal care because of delays and mistaken determinations of ineligibility. Her baby was born six weeks early and spent time in neonatal intensive care. Eventually, she was found eligible, and Medicaid paid the bill.

Presumptive Eligibility Problem

The ACA also required states to allow hospitals to make presumptive determinations of Medicaid eligibility. Tennessee has not met that requirement, either. The CMS letter mentioned that compliance with this requirement also could serve as a mitigation strategy until the system updates were complete.

The Agency’s Statements

According to the Tennessean, Darin Gordon, the TennCare director, said that the agency has enrolled 95,000 individuals in Medicaid since January 1, 2014, the highest number since the program started. He attributed some of the delays to the changes in the federal requirements for the project and others to its contractor, Northrup Grumman. Gordon said that the company has not achieved most of the deliverables under its $35 million contract, so it has been paid only $5 million so far. He also said that the agency was becoming “skeptical” about the contractor’s ability to predict when it could meet benchmarks, and that the agency was hiring another contractor to audit Northrup Grumman’s performance and project delivery dates.