funded health savings account). To ensure vaccination coverage for children under private insurance arrangements, most states have mandates for childhood immunizations. The regulations may also prohibit cost-sharing in the form of deductibles or coinsurance for those services (American Academy of Pediatrics, 2008). State mandates for recommended adult vaccinations are less common. Employers that use national health plans are exempted from the state mandates because their health-benefit plans operate under the federal Employee Retirement Security Act which pre-empts state laws that govern these plans.

Gaps and Barriers

Coverage for hepatitis B vaccination and other ACIP-recommended vaccinations is greater for children and youths than for adults. Federal and state funding for hepatitis B vaccination and other vaccinations provides a safety net for the poorest children and youths, but no such program, such as an adult version of the VFC program, exists for uninsured or underinsured adults. Public Health Section 317 provides a potential vehicle for filling that void, but funding has been increased only modestly since 2003 (Rodewald, 2008), and only recently has adult hepatitis B vaccination become a target for some of the Section 317 funds. CDC has reported to Congress that it would take about $1.6 billion—or 3 times the amount of current Section 317 funding—to fill gaps in coverage and support to states to provide a rigorous national vaccination program for children, adolescents, and adults, including $335 million for payments to providers for all vaccine administration (CDC, 2009d). In that report, CDC included only $49 million for hepatitis B vaccine purchase for 675,000 high-risk adults in a total high-risk population of 4.5 million people who visit STD-HIV and drug-treatment centers—a 15% uptake. If uptake at those venues reached 74% for the first dose, as was observed at a San Diego STD clinic that combined free vaccination with counseling (CDC, 2002), the cost for hepatitis B vaccine purchase alone would approach $80 million.

Except for Medicaid’s Early Periodic Screening, Diagnosis, and Treatment entitlement, public-health insurance often contains cost-sharing, which may create a barrier to vaccination for some people. Adults covered by Medicaid and Medicare and those being phased out of CHIP coverage must share the costs of hepatitis B vaccination. Families of non-Medicaid VFC-covered children may be responsible for the administration portion of the vaccination cost.

Private health insurance has gaps for vaccination coverage because it does not universally cover all ACIP-recommended vaccinations for children and adults. Furthermore, most privately insured persons are required to pay to receive vaccinations. More than two-thirds of privately insured persons

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