Immunization and Moral Hazard: The HPV Vaccine and Uptake of Cancer Screening

Abstract

Immunization can lead to moral hazard by reducing the cost of risky behaviors and reducing preventive efforts. In this study, we examine the effect of HPV (human papillomavirus) vaccination on participation in the Pap test, which is a diagnostic screening test to detect HPV and non-HPV-related cancerous processes. The HPV vaccination is explicitly recommended for women up to age 26 years who were not previously vaccinated. Pap tests are strongly recommended for women between 21 and 65 years old even after having the HPV vaccine. To study the effect of HPV vaccination on Pap test uptake, we construct a fuzzy regression discontinuity design, centered on the vaccination threshold age. The results suggest that moral hazard was not the dominant effect. The estimates show that women who have been vaccinated, if anything, are actually more likely to have a Pap test, possibly due to increased awareness of its benefits at the time of vaccination.

Keywords

moral hazard Pap test HPV vaccination

Get full access to this article

View all access options for this article.

References

American Cancer Society. (2014). HPV vaccines. http://www.cancer.org/cancer/cancercauses/othercarcinogens/infectiousagents/hpv/humanpapillomavirusandhpvvaccinesfaq/hpv-faq-vaccine-and-pap-testing

Angrist

J. D.

Pischke

J. S.

(2009). Mostly harmless econometrics: An empiricist’s companion. Princeton, NJ: Princeton University Press.

Anhang Price

Koshiol

Kobrin

Tiro

J. A

. (2011). Knowledge and intention to participate in cervical cancer screening after the human papillomavirus vaccine. Vaccine, 29, 4238-4243.

Budd

A. C.

Brotherton

J. M. L.

Gertig

D. M.

Chau

Drennan

Saville

(2014). Cervical screening rates for women vaccinated against human papillomavirus. Medical Journal of Australia, 14, 279-282.

Calonico

Cattaneo

M. D.

Titiunik

(2014). Robust nonparametric confidence intervals for regression-discontinuity designs. Econometrica, 82, 2295-2326.

Centers for Disease Control and Prevention. (2010). FDA licensure of quadrivalent human papillomavirus vaccine (HPV4, Gardasil) for use in males and guidance from the Advisory Committee on Immunization Practices (ACIP). MMWR. Morbidity and Mortality Weekly Report, 59(20), 630-632. https://www.cdc.gov/mmwr/preview/mmwrhtml/mm5920a5.htm

Centers for Disease Control and Prevention. (2013). Cervical cancer statistics. http://www.cdc.gov/cancer/cervical/statistics/

Centers for Disease Control and Prevention. (2014). What should I know about screening. http://www.cdc.gov/cancer/cervical/basic_info/screening.htm

Centers for Disease Control and Prevention. (2015). Human papillomavirus (HPV) information for young women. http://www.cdc.gov/std/hpv/stdfact-hpv-vaccine-young-women.htm

10.

Cook

E. E.

Venkataramani

S. A.

Kim

J. J.

Tamimi

R. M.

Holmes

M. D.

(2018). Legislation to increase uptake of HPV vaccination and adolescent sexual behaviors. Pediatrics, 142(3), e20180458.

11.

Dave

Kaestner

(2009). Health insurance and ex ante moral hazard: Evidence from Medicare. International Journal of Health Care Finance and Economics, 9, 367-390.

12.

Ehrlich

Becker

G. S.

(1972). Market insurance, self-insurance, and self-protection. Journal of Political Economy, 80, 623-648.

13.

Ferris

D. G.

Waller

Dickinson

McCracken

Goebel

(2012). Impact of Pap test compliance and cervical cancer screening intervals on human papillomavirus vaccine acceptance. Journal of Lower Genital Tract Disease, 16, 39-44.

14.

Franco

E. L.

Cuzick

Hildesheim

de Sanjosé

(2006). Chapter 20: Issues in planning cervical cancer screening in the era of HPV vaccination. Vaccine, 24, 171-177.

15.

Gelman

Imbens

(2014). Why high-order polynomials should not be used in regression discontinuity designs (Working Paper No. 20405). Cambridge, MA: National Bureau of Economic Research. http://www.nber.org/papers/w20405

16.

Greene

W. H.

(2007). Econometric analysis (6th ed.). Upper Saddle River, NJ: Prentice Hall.

17.

Hill

(2014). Medical innovation and moral hazard: The effect of HPV vaccine on risky sexual behavior. https://far.human.cornell.edu/FAR/uploads/webcv/aeh78_webcv.pdf

18.

Howe

H. L.

Ries

L. A. G.

Cokkinides

Ahmed

Jemal

. . . Edwards

B. K.

(2006). Annual report to the nation on the status of cancer, 1975-2003, featuring cancer among U.S. Hispanic/Latino populations. Cancer, 107, 1711-1742.

19.

Imbens

G. W.

Kalyanaraman

(2012). Optimal bandwidth choice for the regression discontinuity estimator. Review of Economic Studies, 79, 933-959.

20.

Imbens

G. W.

Lemieux

(2008). Regression discontinuity designs: A guide to practice. Journal of Econometrics, 142, 615-635.

21.

Imbens

Wooldridge

(2007a). What’s new in economterics? Control function and related models (Summer Institute 2007). Cambridge, MA: National Bureau of Economic Research.

22.

Imbens

Wooldridge

(2007b). What’s new in economterics? Regression discontinuity designs (Summer Institute 2007). Cambridge, MA: National Bureau of Economic Research.

23.

Klick

Stratmann

(2007). Diabetes treatments and moral hazard. Journal of Law and Economics, 50, 519-538.

24.

Lee

D. S.

Lemieux

(2010). Regression discontinuity designs in economics. Journal of Economic Literature, 48, 281-355.

25.

Margolis

Hockenberry

J. M.

Grossman

Chou

S-Y.

(2014). Moral hazard and less invasive medical treatment for Coronary Artery Disease: The case of cigarette smoking (NBER Working Paper No. 20373). Cambridge, MA: National Bureau of Economic Research. http://www.nber.org/papers/w20373

26.

Markowitz

L. E.

Dunne

E. F.

Saraiya

Lawson

H. W.

Chesson

Unger

E. R.

(2007). Quadrivalent human papillomavirus vaccine: Recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR. Recommendations and Reports, 56, RR-2.

27.

National Cancer Institute. (2014). Pap and HPV testing. Bethesda, MD: Author. http://www.cancer.gov/types/cervical/pap-hpv-testing-fact-sheet

28.

National Conference of State Legislatures. (2018). HPV vaccine: State legislation and statutes. http://www.ncsl.org/research/health/hpv-vaccine-state-legislation-and-statutes.aspx

29.

Peltzman

(2011). Offsetting behavior, medical breakthroughs, and breakdowns. Journal of Human Capital, 5, 302-341.

30.

Roblin

D. W.

Chang

Roblin

D. W.

Ritzwoller

D. P.

Carroll

N. M.

Daley

M. F.

Rees

D. I.

(2014). The influence of deductible health plans on receipt of the human papillomavirus vaccine series. Journal of Adolescent Health, 54, 275-281.

31.

Saslow

Castle

P. E.

Cox

J. T.

Davey

D. D.

Einstein

M. H.

Ferris

D. G.

. . . Garcia

(2007). American Cancer Society guideline for human papillomavirus (HPV) vaccine use to prevent cervical cancer and its precursors. CA: A Cancer Journal for Clinicians, 57, 7-28.

32.

Saslow

Runowicz

C. D.

Solomon

Moscicki

A.-B.

Smith

R. A.

Eyre

H. J.

Cohen

(2002). American Cancer Society Guideline for the early detection of cervical neoplasia and cancer. CA: A Cancer Journal for Clinicians, 52, 342-362.

33.

Simon

Soni

Cawley

(2017). The impact of health insurance on preventive care and health behaviors: Evidence from the first two years of the ACA Medicaid expansions. Journal of Policy Analysis and Management, 36, 390-417.

34.

Skinner

S. R.

Garland

S. M.

Stanley

M. A.

Pitts

Quinn

M. A.

(2008). Human papillomavirus vaccination for the prevention of cervical neoplasia: Is it appropriate to vaccinate women older than 26? Medical Journal of Australia, 188, 238-242.

35.

Van Der Klaauw

. (2008). Regression-discontinuity analysis: A survey of recent developments in economics. LABOUR, 22, 219-245.

36.

Yaniv

Rosin

Tobol

(2009). Junk-food, home cooking, physical activity and obesity: The effect of the fat tax and the thin subsidy. Journal of Public Economics, 93, 823-830.