Preliminary Considerations Regarding Federal Investments in Vaccine Purchase and Immunization Services: Interim Report on Immunization Finance Policies and Practices (1999)

to make significant reductions for Section 317 FA funds in the period FY 1996–1998.⁹ By the end of the decade new money for FA grants declined to $117 million per year for awards for 1998 and 1999 (a 55 percent decrease). In 1998, the two forms of immunization assistance (DA and FA funds) were roughly comparable.

During this period of reductions in Section 317 FA awards, state expenditure rates have gradually increased, suggesting that the states have improved their capacity to use federal funds for immunization services. Expenditure rates during 1997 and 1998 are in the range of 86 percent and 96 percent, respectively; total carryover of funds is currently estimated at less than $10 million for 1998 Section 317 FA awards. CDC and state officials now report that the current level of federal funds for Section 317 infrastructure support FA funds (requested at $117 million for FY 2000) is no longer sufficient to support their needs.¹⁰

New management and administrative services require time to be put into place, particularly when consensus needs to be developed about how parents, providers, payers, and health departments should share responsibility for ensuring that children receive appropriate health care.¹¹ State efforts to foster public awareness of the importance of immunization coverage are particularly challenged in the current environment with the addition of new vaccines to the childhood immunization schedule, the addition of new population groups (adolescents and adults) to the immunization system, public concerns about vaccine safety, and diminished public perception of the importance of timely immunization coverage in the absence of disease outbreaks (Orenstein et al., in press).

Although vaccine coverage rates are currently high, recent federal budget cutbacks have caused states to reduce the scale of their immunization assessment, outreach, performance monitoring, program linkages, and information management efforts.¹² Their flexibility to detect and respond quickly to sudden disease outbreaks is threatened. Their ability to continue outreach to underserved communities and to build linkages with community-based programs such as local WIC programs is diminished. New financing sources may eventually emerge to provide a stable platform for essential services that benefit and protect the health of the community, but at present state and local health agencies are experiencing significant instability in immunization efforts during times of transition and change in the health care system.

Changes in the organization of health care services for disadvantaged families appear to have significant impact on the structure of the vaccine delivery system in many underserved communities, but this impact is uneven and its effect on actual immunization coverage rates remains uncertain. Several shifts are occurring simultaneously: (1) Responsibility for primary care services (including immunization) for disadvantaged families is migrating from publicly funded health programs to other care settings, including private managed care arrangements; (2) An enhanced governmental role in national immunization policy and practice is evolving through federal and state collaboration; (3) Medicaid is enrolling larger numbers of children than ever before (especially in the period 1990–1995);

and (4) The new state Children's Health Insurance Program (CHIP) is emerging in a health plan niche between Medicaid and private insurance (IOM, 1998). The confluence of these changes may eventually sustain and improve immunization rates by increasing access to private health care providers but it is premature to determine how CHIP enrollments will influence immunization coverage rates among disadvantaged families.

As an insurance program, CHIP does not provide for surveillance, population and vaccine monitoring, professional training, or public education efforts that are commonly funded through infrastructure efforts and benefit the community as a whole. CHIP plans are supposed to conform to federal Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) requirements that include the provision of the required immunizations for children. State plans are expected to provide data that hold them accountable for supporting the performance of these services. But CHIP is not expected to monitor levels of vaccine use among the state population as a whole, nor does it have the mandate to provide surveillance for vaccine-related phenomena. Section 317 funds have traditionally supported these efforts in addition to providing direct vaccine purchase and administration services. What remains uncertain, at this time, is the public cost of and need for the population-wide assessment, data surveillance, and education services as states shift increasingly larger shares of the responsibility for direct health services from the public sector to private health care plans. This topic will be a critical component for consideration in the IOM committee's final report.

Certain factors deserve consideration at this time:

• Larger numbers of uninsured children are eligible for health care coverage under CHIP but enrollment remains low. Although CHIP makes childhood immunization a basic benefit, the extent to which the program has penetrated the 0–2 age population is unknown at this time. Service utilization patterns have not yet been established or evaluated for new birth cohorts that could provide information about the extent to which these plans are able to meet the immunization needs of eligible families with young children.

• Although a few states are monitoring immunization rates for the commercial and the Medicaid managed care programs (e.g., New Jersey, Connecticut, and Massachusetts), no regional or national datasets exist that can reveal the extent to which such individuals enrolled in managed care plans receive one or more immunization services from out-of-network publicly funded providers.

• Public health clinics may often provide an important source of immunization services for young children when a family's insurance status is uncertain, interrupted, or limited in coverage.

• VFC-eligible families may no longer qualify for vaccine discounts under some non-Medicaid CHIP programs.¹³ Therefore, the relationship of managed care payment status to access to vaccine services in private medical offices deserves special consideration, particularly if individuals or families who once relied upon VFC in private health care centers are now referred to public health clinics.

• Many CHIP plans do not offer continuous service eligibility. If significant numbers of enrollees shift among Medicaid, CHIP, uninsured status, and pri-