2.A8 Medicaid expansion was associated with an increase in the likelihood of parent-reported HPV vaccine uptake for poorer teens, teens whose mothers did not have college degrees, and non-. Evidence from Washington, DC's HPV vaccine requirement, I study how switching from a one-time opt-out form to an annual opt-out requirement improved vaccine uptake.
Introduction
In this paper, I provide the first causal assessment of how the 2014 school HPV vaccine requirement in Washington, DC affected vaccine coverage. For adolescent girls, I find an 11 percentage point increase in HPV vaccine initiation and a 20 percentage point increase in vaccine completion.
Policy Background & Existing Literature
Policy Background
During the same month that DC's 2009 mandate went into effect, Gardasil was approved for teenage boys and young men (FDA 2009). At this point, the policy was also modified so that parents who choose not to vaccinate their children are required to opt out annually (American Academy of Pediatrics DC Chapter 2015; Ko et al. 2020).
Vaccine Mandates
However, recent outbreaks of vaccine-preventable diseases have increased interest in exemptions that allow individuals to remain unvaccinated (Olive et al. 2018), with authors finding that vaccination declines when it is easier to obtain an exemption (Blank et al. 2013; Nyathi et al. 2019; Richmine, Dor and Moghtaderi 2019). Similarly, Lawler (2020) found that meningococcal vaccine recommendations increased vaccine uptake by the target population by 133 percent compared to the baseline average.
HPV Vaccination
For adolescent boys, they used 2008-2013 as the pre-period and 2014-2017 as the post-period, and the authors reported a statistically significant 94 percent increase in vaccination. Finally, the authors did not adjust their standard errors to account for the fact that there was only one unit treated in each analysis.
Data & Methodology
Data: National Immunization Survey-Teen
I show in Figure 2 that DC and the rest of the United States had similar rates of HPV vaccination before 2014. In 2013, 26 percent of DC teens completed the HPV vaccine (22nd highest in the nation), which was identical to the average vaccination rate in the rest of the country.
Methodology: Difference-in-Differences with Randomization
Vector B includes indicators for Washington, DC's 2009 HPV vaccine requirement, regardless of whether the vaccine is approved by the FDA and/or recommended by the ACIP for the adolescent. VACCist= GROUPist × (α + β∙1{s=DC}∙1{t ≥ 2014} + X'istγ + B'st δ + θs + τt ) + εist (2) Interpreting β as the causal effect of DC 's school HPV vaccine requirement for vaccination, I have to assume that vaccine coverage would have developed similarly to the rest of the US if it hadn't been for the mandate.
Methodology: Synthetic Control Analysis
For an easier comparison, I use 2013 as a reference year - the year before the mandate. I then construct a “Synthetic DC” from a subset of control conditions that best approximates HPV vaccination rates in pre-period DCs.
Results
- Vaccine Completion
- Vaccine Initiation
- Vaccine Intentions & Physician Recommendations
- Robustness to Synthetic Control Strategy
I also show that the estimate is robust to opting out in 2013 (column 4), when some teenagers may have started vaccination in anticipation of the 2014 requirement, and that the estimate is robust to controlling only for state and year fixed effects (column 5). Consistent with prior estimates, I show in Figure 3 that the school requirement was associated with a 20% increase in the likelihood of vaccine introduction (Panel C).
Implied Reductions in Cancer and Health Care Costs
Firstly, I am only considering cervical and oropharyngeal cancer, while the HPV vaccine also protects against cancer of the anus, penis, vulva and vagina. In 2018, 70 percent of girls and 67 percent of boys had received at least one injection of the HPV vaccine.
Discussion
For one, the HPV vaccine initiation rate in the US in 2018 was higher than Washington, DC's initiation rate immediately before the policy change (68 percent vs. 62 percent). I also show that while teenage girls and boys experienced similar increases in the probability of vaccine completion, the point estimate for HPV vaccine initiation was greater for boys than for girls.
In panels (A) and (C), the independent variable of interest is the indicator for school-based HPV vaccine requirements in Washington, DC, for 2014. The independent variable of interest is the indicator for school-based HPV vaccine requirements in 2014 in Washington, DC.
Appendix A: Additional Figures & Tables
In panel (A), the independent variable of interest is an indicator of Washington, DC's 2014 HPV vaccine school requirement. The independent variable of interest is an indicator of Washington DC's 2014 HPV vaccine school mandate and estimated using Equation (1). The independent variable of interest is an indicator of Washington DC's 2014 HPV vaccine school mandate.
Appendix B: DC Grant Expenditures
In support of the first option, I find that Medicaid expansion was associated with a 1-2 percentage point increase in the likelihood that teenagers have health insurance. I still find a 4-5 percentage point decrease in the probability that probable unauthorized immigrants had health insurance (column 5). Note: The dependent variable in columns (1) and (4) is an indicator of whether the child has regulated (private or public) health insurance.
Insurance Coverage, Provider Contact, and Take-Up of the HPV Vaccine
Introduction
1 A version of this chapter has appeared in the press as “Insurance Coverage, Contact with Providers, and Use of the HPV Vaccine.” In this article, I provide new evidence that the Affordable Care Act's Medicaid expansion increases the likelihood that teens will receive the HPV vaccine. I show that teens in Medicaid expansion states were more likely to have had a recent checkup and that their parents reported greater knowledge about the HPV vaccine.
Existing Literature and Policy Background
- Policy Background and Vaccination Research
- Medicaid Expansion and “Welcome Mat” Effects
The rest of this paper proceeds as follows: Section 2 discusses the history of the HPV vaccine and existing knowledge about vaccination policies. Existing work suggests that educating patients about the HPV vaccine is a successful strategy to increase vaccine uptake. Similarly, Churchill (2020) found that school HPV vaccine requirements in Washington, DC increased the likelihood of adolescent (girls) HPV vaccination initiation by 20 (12) percentage points.
Data+Methodology
- Data
- Methodology
Similarly, I show in Table 1 that Medicaid expansion states had a higher HPV vaccine initiation rate compared to nonexpansion states over the sample period (0.51 vs. 0.45).5 This difference was not present before Medicaid expansion. I use an event study framework to examine whether pre-Medicaid expansion trends in HPV vaccination may bias my estimates in the post-expansion periods. This specification also allows me to test whether the relationship between Medicaid expansion and HPV vaccine initiation has varied over time.
Results
- HPV Vaccination
- Potential Mechanisms: Health Insurance Coverage
- Potential Mechanisms: Provider Contact
In both cases, I continue to conclude that Medicaid expansion was associated with a 3 percentage point increase in vaccine uptake. Nevertheless, in Table 5 I show that Medicaid expansion was associated with a 2 percentage point increase in HPV vaccination (column 1). First, I find that Medicaid expansion was associated with a 2 percentage point increase in the odds that a teen had a checkup in the past year (column 1).
Note: The dependent variable is an indicator of whether the child's immunization provider reports that the child had received at least one dose of the HPV vaccine. Note: The dependent variable in column (1) is an indicator of whether the parent reports that the child has had a check-up within the last year, and in column (2) an indicator of whether the child has been recommended the HPV vaccine. Note: The dependent variable is an indicator of having received at least one dose of the HPV vaccine.
Appendix
Note: The dependent variable is an indicator of whether the child was covered by any health insurance. I now explore how these mandates may have affected unauthorized immigrants' potential access to health insurance. Note: The dependent variable is an indicator of being a policyholder for employer-sponsored health insurance.
E-Verify Mandates and Unauthorized Immigrants’ Health Insurance Coverage
Introduction
In this paper, I show that state-level E-Verify mandates reduced the likelihood that probable unauthorized immigrants had health insurance, a relationship driven by a reduction in the likelihood of employer-sponsored insurance. Interestingly, the effect for likely unauthorized immigrants was limited to the immediate post-implementation period. I have shown that this pattern can be explained by the selective emigration of otherwise unemployed and consequently uninsured presumably unauthorized immigrants.
Existing Literature
- E-Verify and Employment
- Immigrants and Health Insurance
There is mixed evidence on the relationship between E-Verify mandates and the labor market outcomes of unauthorized immigrants. Looking at a broader group of states, Orrenius and Zavodny (2016) found that universal E-Verify mandates reduced the number of likely unauthorized immigrants in the country. There is also evidence that some unauthorized immigrants forgo medical visits due to fear of interaction with law enforcement officials (Núñez and Heyman 2007; Heyman et al. 2009).
Data, Measures, and Methods
- Data and Measures
- Potential Channels
- Empirical Strategy
Building on this finding, Dillender (2017) showed that immigrants with better English skills are more likely to have employer-sponsored health insurance. In 2008—the year of E-Verify's first universal mandate—87 percent of employees were offered employer-sponsored health insurance (Vistnes et al. 2012). Additionally, E-Verify mandates may shift unauthorized immigrants from full-time to part-time work, making part-time workers less likely to qualify for employer-sponsored health insurance (Farber and Levy 2000).
Results
- E-Verify Mandates and Health Insurance
- Falsification Test and Sensitivity of Likely Unauthorized
- Spillovers onto US Citizens
Perhaps surprisingly, I also find evidence that public E-Verify mandates reduced the likelihood that likely unauthorized immigrants were employed at larger firms (column 6 row 2). Similarly, Orrenius and Zavodny (2016) found that universal E-Verify mandates led to a reduction in the number of new and recent probable unauthorized immigrants living in a state. I find that universal mandates are associated with a 4.5 percentage point reduction in the probability of employment for likely unauthorized men (column 1 row 1) and a 4 percentage point reduction for likely unauthorized women (column 2 row 1).
Discussion
Note: The dependent variable in column (1) is an indicator for whether the individual had any health insurance coverage (private insurance, Medicaid, or Medicare). Note: The dependent variable in Panel (A) is an indicator of whether the individual is employed, while the dependent variable in Panel (B) is an indicator of being the policyholder for employer-sponsored health insurance. Note: The dependent variable is an indicator of whether the individual is covered by private health insurance.
Appendix
Note: The dependent variable in column (1) is an indicator of being employed, while the dependent variable in column (2) is an indicator of being a holder of an employer-sponsored health insurance policy. The dependent variable in column (2) is an indicator of having any health insurance coverage (private insurance, Medicaid, or Medicare). The dependent variable in column (3) is a proxy for private insurance coverage, while the dependent variable in column (4) is a proxy for public insurance (Medicaid or Medicare).
E-Verify mandates and child health insurance coverage
E-Verify mandates and health insurance coverage of US adult
