Impact of the Affordable Care Act on human papillomavirus vaccination initiation among lesbian, bisexual, and heterosexual U.S. women

Health Serv Res. 2020 Feb;55(1):18-25. doi: 10.1111/1475-6773.13231. Epub 2019 Nov 10.


Objective: To examine the effect of the 2010 Affordable Care Act (ACA) extended dependent coverage and no cost-sharing provisions on human papillomavirus (HPV) vaccination in relation to sexual orientation identity among U.S. women.

Data sources: 2006-2010 and 2011-2015 National Survey of Family Growth.

Study design: We used an interrupted time series design and multivariable Poisson regression to assess differences in HPV vaccination initiation before (2007-2010) and after (2011-2015) the 2010 ACA provisions among heterosexual, bisexual, and lesbian U.S. women aged 15-25 years (N = 7033), adjusting for temporal trends and demographic factors.

Data collection: Computer-assisted personal interview and audio computer-assisted self-interview questionnaires.

Principal findings: The adjusted prevalence of HPV vaccination initiation was significantly higher among lesbian and bisexual women after compared to before the 2010 ACA-at 19.1 (95% confidence interval [CI]: 5.4, 32.9) and 15.7 (95% CI: 4.4, 27.1) percentage points in 2015 compared to 2007-2010, respectively. We observed no association between the 2010 ACA provisions and HPV vaccination initiation among heterosexual women after adjusting for temporal trends and demographic factors.

Conclusions: The 2010 ACA provisions may have improved HPV vaccination initiation among lesbian and bisexual women. Policies and programs that increase access to health insurance and provide HPV vaccines at no cost to patients may facilitate HPV vaccine uptake in these marginalized populations.

Keywords: Affordable Care Act; health inequities; human papillomavirus vaccination; sexual orientation; women.

Publication types

  • Comparative Study
  • Research Support, Non-U.S. Gov't

MeSH terms

  • Adolescent
  • Adult
  • Female
  • Heterosexuality / psychology*
  • Heterosexuality / statistics & numerical data
  • Humans
  • Papillomavirus Infections / prevention & control*
  • Papillomavirus Vaccines / economics*
  • Patient Acceptance of Health Care / psychology*
  • Patient Acceptance of Health Care / statistics & numerical data
  • Patient Protection and Affordable Care Act / economics*
  • Patient Protection and Affordable Care Act / statistics & numerical data
  • Sexual and Gender Minorities / psychology*
  • Sexual and Gender Minorities / statistics & numerical data
  • United States
  • Vaccination / psychology*
  • Vaccination / statistics & numerical data
  • Young Adult


  • Papillomavirus Vaccines