1. 1 ACCESSING HPV VACCINE: Preliminary Progress Alexandra Stewart, JD Department of Health Policy Contact: stewarta@gwu.edu June 2, 2007

2. 2 FEDERAL FUNDING: –Ensured access to vaccines through VFC and 317 –Ensured access to vaccines through Medicaid, SCHIP PRIVATE MARKET FUNDING: –Increased access to vaccines through private health insurance coverage STATE STATUTES: –Increased access to vaccines through school entry requirements ACIP* Recommendations Trigger 3 Avenues to Access * Advisory Committee of Immunization Practices

3. 3 VACCINES FOR CHILDREN (VFC) Free vaccines to age19 who are: Uninsured, underinsured, Medicaid eligible, American Indian, Alaska native MEDICAID EARLY, PERIODIC SCREENING, DIAGNOSIS & TREATMENT(EPSDT) STATE CHILDREN’S HEALTH INSURANCE PROGRAM (SCHIP) Covers ACIP-recommended vaccines for children in families with incomes that are too high for Medicaid, but have no insurance. States set age limitations for program eligibility. SECTION 317 Awards grants to state, local, & territorial public health agencies for program operations and vaccine purchases. Limited funds available for vaccine purchase PUBLIC HEALTH CLINICS Some states provide free or low-cost vaccines to the uninsured (children or adults) Public Funding of Vaccines

4. 4 MEDICAID COVERAGE of HPV VACCINE for AGES 21-26 AGES COVERAGE OBLIGATION COVERAGE STANDARD FINANCING 0 through 18Required (EPSDT) ACIPVaccines for Children 19 and 20RequiredACIPDesignated Match 21 through 26OptionalDiscretionaryDesignated Match After age 21, enrollee must establish adult eligibility. Each state has different criterion based on income, parental status, disability, gender Source: GWU/SPHHS Medicaid Coverage and HPV Vaccine for Adult Beneficiaries – April 2007

5. 5 Medicaid Coverage of HPV Vaccine for ages 21-26 WA OR ID MT ND WY SD MN WI MI ILIN OH PA NY ME CA NV UT CO NE KS IA MO KY WV VA NC TX NM AZ OK AR LA TN SC GA FL AL MS NJ RI CT VT MA NH AK HI DE MD DC Source: GWU/SPHHS Medicaid Coverage and HPV Vaccine for Adult Beneficiaries – April 2007 Covered (n = 22) Not Covered (n = 22) Unknown (n = 7)

6. 6 States that Provide Free/Low Cost HPV Vaccine (n=9) WA OR ID MT ND WY SD MN WI MI ILIN OH PA NY ME CA NV UT CO NE KS IA MO KY WV VA NC TX NM AZ OK AR LA TN SC GA FL AL MS NJ RI CT VT MA NH AK HI DE MD DC Source: GWU/SPHHS Review of Standing Orders – February 2007 As of 05/24/07

7. 7 STATES THAT PROVIDE FREE/LOW COST HPV VACCINE (n = 9) STATEELIGIBLE POPULATION ARKANSASFemales ages 9 through 18 MICHIGANFemales ages 9 through 26 MISSOURI5,000 females ages 9 through 26 NEVADAFemales ages 9 through 26 ADULTS: $140/dose CHILDREN: $20/dose NEW HAMPSHIREFemales under age 19 OREGONFemales ages 9 through 12 who are uninsured or underinsured ELIGIBLE SITES: FQHC or health dept FEES: Waivable administration fee SOUTH DAKOTAFemales ages 11 through 18. If patient turns 19 after Dose 1, may continue series. ELIGIBLE SITES: Various WASHINGTONFemales ages 9 through 18 94,000 doses available for 31,000 FEES: Administration feed up to $15.60, plus office visit charge WISCONSINPriority: Females ages 11 & 12. Others: Contact provider or health department FUNDING SOURCES: 317 Program Grants, VFC, Medicaid, State Funds Source: GWU/SPHHS/DHP/05/07

8. 8 State mandates convert recommendations into legally enforceable obligations Power to mandate: 10 th Amendment “police power” Most effective strategy to ensure full access to vaccines Laws are variable: Medical standard may fail to require ACIP Opt-out language Lack of enforcement of existing law ½ of nation is considering requiring HPV vaccine 1 state (VA) requires the vaccine for girls entering 6 th grade District of Columbia: Awaiting Mayoral and Congressional approval School Immunization Requirements

9. 9 Mandating HPV Vaccine for School Entry WA OR ID MT ND WY SDWI MI IL OH PA NY ME CA NV UT CO NE KS IA MOVA NC TX NM AZ OK AR LA TN SC FL AL MS NJ RI CT VT MA NH AK HI DE MD DC Source: WomeninGovernment.org/prevention As of 05/07/07 MO KY WV MN IN HPV Vaccine School Requirement Introduced (n = 23) HPV Vaccine School Requirement Enacted (n = 2) Executive Order blocked by legislature (n = 1) GA

10. 10 Proposed Legislation to Require Private Insurance Coverage of HPV Vaccine (n = 16) WA OR ID MT ND WY SD MN WI MI ILIN OH NY ME CA NV UT CO NE KS IA MO KY WV VA TX NM AZ OKAR LA TN SC GA FL AL MS NJ RI CT VT MA AK HI DE MD DC Source: Womeningovernment.org/prevention As of 05/07/07 NH PA NC INTRODUCED: Compulsory Insurance Coverage of HPV Vaccine

11. 11 Federal policy recommendations from 6/06 support broad access to HPV vaccine FEDERAL PROGRAMS: Adopted federal recommendations: VFC, Medicaid, SCHIP, 317 STATE ACTIVITY: PUBLIC HEALTH PROGRAMS: Less than ¼ participate in special HPV vaccine campaigns SCHOOL MANDATES: 1/2 of states have addressed mandating HPV vaccine, only 1 state has legislation in place HEALTH INSURANCE COVERAGE: 1/3 of states are considering mandating coverage for HPV vaccine Summary: Access to HPV Vaccine