Use of cervical cancer preventive services among US women aged 21–29: an assessment of the 2010 Affordable Care Act rollout through 2018



The 2010 Affordable Care Act (ACA) provided millions of people with health insurance coverage and facilitated routine cancer screening by requiring insurers to cover preventive services without cost-sharing. Despite greater access to affordable cancer screening, Pap testing has declined over time. The aim of this study is to assess participation in Pap test and HPV vaccination, and adherence to guidelines as outlined by the American Cancer Society (ACS) from the 2010 ACA provision eliminating cost-sharing for preventive services.


Using multi-year responses from the Behavioral Risk Factor Surveillance System, we examined the association between the ACA and participation in and adherence to Pap testing and HPV vaccination behaviors as set by the ACS. The sample included women aged 21–29 who completed the survey between 2008 and 2018 (every other year) and who live in 24 US States (N = 37,893).


Results showed significant decreases in Pap testing rates but increases in the uptake of the HPV vaccine series for all age groups and across all demographics. Post-ACA year significantly predicted increases in HPV + Pap co-testing participation and adherence. Women with health insurance coverage were more likely to engage in both behaviors.


Findings raise concerns around declines in the proportion of women receiving and adhering to Pap testing guidelines. A need exists for research to examine the role of increases in HPV vaccination uptake on decreases in Pap testing. Moreover, effective strategies should target increases in cervical cancer screening uptake among women vaccinated against HPV.

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Fig. 1

Data availability

The annual survey data can be obtained from the Center of Disease Control’s Behavioral Risk Factor Surveillance System’s website found through the following link:


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This work was supported by National Cancer Institute Grant T32CA078447 for all authors.

Author information




All authors contributed to the study conception and design. Drs. COG (corresponding author) and RAC completed preparation of the materials prior to data analysis. Dr. COG performed all analyses. The first draft of the manuscript was written by Drs. COG, RAC, and AL. All authors substantially provided their feedback and commented on all previous versions of the manuscript. All authors read and approved the final manuscript.

Corresponding author

Correspondence to Carlos O. Garrido.

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The authors declare no potential conflicts of interest or competing interests.

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The data presented on this article represent publicly available, retrospectively collected survey responses that were de-identified. The Internal Review Board of the University of Arizona confirmed that no ethics approval is required.

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Not applicable in this research that is based on publicly available, retrospective data.

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Garrido, C.O., Coşkun, R.A., Lent, A.B. et al. Use of cervical cancer preventive services among US women aged 21–29: an assessment of the 2010 Affordable Care Act rollout through 2018. Cancer Causes Control (2020).

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  • Affordable care act
  • Cost-sharing
  • Human papilloma virus
  • Cervical cancer
  • Cancer screening