When Coverage Ends, Prevention Can Too: Medicaid Disenrollment and HPV Cancer Risk in the Southeast

By: Citseko Staples Miller, Kristy Piccinini, PhD, and Shanshan Wang, MSPH

HPV vaccination prevents at least 90% of six types of HPV cancer, but vaccination depends on access, and access often depends on health insurance coverage. Following the end of the COVID-19 public health emergency, states resumed Medicaid eligibility checks and began disenrolling people from the program—a process known as “unwinding.” The St. Jude HPV Cancer Prevention Program, in collaboration with FTI Consulting, examined how unwinding affected HPV vaccination coverage and future cancer risk in 12 Southeastern states and one jurisdiction* who are part of the HPV Vaccination Roundtable of the Southeast and have significant rural populations.

Our analysis assessed the impact of unwinding on HPV vaccination and future health and economic outcomes for the affected children and young adults. We estimated how many individuals lost Medicaid coverage, how many HPV vaccine doses were likely missed as a result, and how those missed doses could translate into future cancer cases, deaths, and economic costs.

The scale of coverage loss was significant. Between 2023 and 2024, an estimated 3.6 million children and young adults were disenrolled from Medicaid, and about 530,000 became or remained uninsured. Program disenrollment ranged from 1% in Kentucky to 23% in South Carolina.

Coverage matters for vaccination. Using data from the National Immunization Survey (NIS)-Teen and the National Health Interview Survey (NHIS), we found that children enrolled in Medicaid had higher HPV vaccine initiation rates than uninsured children across all age and sex groups examined. The disparity was even greater for series completion, reaching 19 percentage points among females and 9 percentage points among males. Because of unwinding-related coverage losses, we estimate that approximately 26,086 initial doses and 55,748 series completion doses were missed across the region. Although safety-net programs like Vaccines for Children provide vaccines for uninsured children, Medicaid coverage losses interrupt routine care and opportunities to complete vaccination.

Rural communities face an even greater burden. Rural HPV vaccination rates already lag urban rates by 10 to 13 percentage points. In every state we analyzed, rural adolescents ages 13–17 were more likely than their urban counterparts to lose coverage. In seven states (Alabama, Arkansas, Florida, Georgia, South Carolina, Tennessee and West Virginia), more than 20% of rural children lost coverage. While urban areas had more missed vaccinations overall, rural areas were projected to see larger increases in preventable cancers per 100,000 people in several states, such as Alabama (8.7 rural versus 7.4 urban) and Florida (8.8 versus 7.2). Lower starting vaccination rates, higher disenrollment, and a greater per-person economic burden combine to make rural communities the highest-risk group for long-term consequences.

These findings matter now and in the future because HPV cancers develop over decades, so missed vaccinations today translate into preventable cancers years from now. Across the 12 states and one jurisdiction studied, we project an additional 447 HPV cancer cases and 122 additional HPV cancer deaths. Florida and Georgia carry the largest absolute burden because of their population size and status as non-Medicaid expansion states. The total economic impact is estimated at $196 million, and more than 93% comes from lost lives and lost productivity rather than medical bills.

State policy choice also influenced outcomes. Kentucky’s continuous enrollment policy is projected to result in virtually no unwinding-related HPV cancer deaths and an estimated economic burden of $437,000. In contrast, Florida’s approach is associated with 33 projected deaths and a $53.1 million burden.

Taken together, these findings demonstrate that Medicaid coverage decisions are also cancer prevention decisions. For policymakers, public health leaders, and community partners, the analysis identifies a clear priority: supporting rural families in states with the highest levels of disenrollment to prevent avoidable cancers and reduce long-term economic costs.

*The following states and jurisdictions were included in our research: Alabama, Arkansas, District of Columbia, Florida, Georgia, Kentucky, Louisiana, Mississippi, North Carolina, South Carolina, Tennessee, Virginia, and West Virginia.

About the authors