CALLING THE SHOTS

Immunization Finance Policies and Practices

Committee on Immunization Finance Policies and Practices

Division of Health Care Services and

Division of Health Promotion and Disease Prevention

INSTITUTE OF MEDICINE

NATIONAL ACADEMY PRESS
Washington, D.C.



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Calling the Shots: Immunization Finance Policies and Practices CALLING THE SHOTS Immunization Finance Policies and Practices Committee on Immunization Finance Policies and Practices Division of Health Care Services and Division of Health Promotion and Disease Prevention INSTITUTE OF MEDICINE NATIONAL ACADEMY PRESS Washington, D.C.

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Calling the Shots: Immunization Finance Policies and Practices NATIONAL ACADEMY PRESS 2101 Constitution Avenue, N.W. Washington, D.C. 20418 NOTICE: The project that is the subject of this report was approved by the Governing Board of the National Research Council, whose members are drawn from the councils of the National Academy of Sciences, the National Academy of Engineering, and the Institute of Medicine. The members of the committee responsible for the report were chosen for their special competences and with regard for appropriate balance. Support for this project was provided by the Centers for Disease Control and Prevention (Award No. 200199900023). The views presented are those of the Institute of Medicine’s Committee on Immunization Finance Policies and Practices and are not necessarily those of the funding organization. Library of Congress Cataloging-in-Publication Data Calling the shots: immunization finance policies and practices/Committee on Immunization Finance Policies and Practices, Division of Health Care Services and Division of Health Promotion and Disease Prevention, Institute of Medicine, p. cm. Includes bibliographical references and index. ISBN 0-309-07029-5 1. Immunization—Government policy—United States. 2. Immunization of children—Government policy—United States. 3. Immunization—United States—Finance. 4. Immunization—United States—Planning. 5. Medicine, Preventive—United States. I. Committee on Immunization Finance Policies and Practices (U.S.). II. Institute of Medicine (U.S.). Division of Health Care Services. III. Institute of Medicine (U.S.). Division of Health Promotion and Disease Prevention. RA638 .C35 2000 614.4´7´0973—dc21 00–046277 The full text of this report is available on line at www.nap.edu. Additional information about this report and America’s vaccine safety net is available online at www.nationalacademies.org/includes/shots.htm. For more information about the Institute of Medicine, visit the IOM home page at www.iom.edu. Copyright 2000 by the National Academy of Sciences. All rights reserved. Printed in the United States of America The serpent has been a symbol of long life, healing, and knowledge among almost all cultures and religions since the beginning of recorded history. The serpent adopted as a logotype by the Institute of Medicine is a relief carving from ancient Greece, now held by the Staatliche Museen in Berlin.

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Calling the Shots: Immunization Finance Policies and Practices “Knowing is not enough; we must apply. Willing is not enough; we must do.” —Goethe INSTITUTE OF MEDICINE Shaping the Future for Health

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Calling the Shots: Immunization Finance Policies and Practices THE NATIONAL ACADEMIES National Academy of Sciences National Academy of Engineering Institute of Medicine National Research Council The National Academy of Sciences is a private, nonprofit, self-perpetuating society of distinguished scholars engaged in scientific and engineering research, dedicated to the furtherance of science and technology and to their use for the general welfare. Upon the authority of the charter granted to it by the Congress in 1863, the Academy has a mandate that requires it to advise the federal government on scientific and technical matters. Dr. Bruce M.Alberts is president of the National Academy of Sciences. The National Academy of Engineering was established in 1964, under the charter of the National Academy of Sciences, as a parallel organization of outstanding engineers. It is autonomous in its administration and in the selection of its members, sharing with the National Academy of Sciences the responsibility for advising the federal government. The National Academy of Engineering also sponsors engineering programs aimed at meeting national needs, encourages education and research, and recognizes the superior achievements of engineers. Dr. William A.Wulf is president of the National Academy of Engineering. The Institute of Medicine was established in 1970 by the National Academy of Sciences to secure the services of eminent members of appropriate professions in the examination of policy matters pertaining to the health of the public. The Institute acts under the responsibility given to the National Academy of Sciences by its congressional charter to be an adviser to the federal government and, upon its own initiative, to identify issues of medical care, research, and education. Dr. Kenneth I.Shine is president of the Institute of Medicine. The National Research Council was organized by the National Academy of Sciences in 1916 to associate the broad community of science and technology with the Academy’s purposes of furthering knowledge and advising the federal government. Functioning in accordance with general policies determined by the Academy, the Council has become the principal operating agency of both the National Academy of Sciences and the National Academy of Engineering in providing services to the government, the public, and the scientific and engineering communities. The Council is administered jointly by both Academies and the Institute of Medicine. Dr. Bruce M.Alberts and Dr. William A.Wulf are chairman and vice chairman, respectively, of the National Research Council.

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Calling the Shots: Immunization Finance Policies and Practices COMMITTEE ON IMMUNIZATION FINANCE POLICIES AND PRACTICES BERNARD GUYER, M.D., M.P.H. (Chair), Professor and Chair, Department of Population and Family Health Sciences, Johns Hopkins School of Hygiene and Public Health DAVID R.SMITH, M.D. (Vice Chair), President, Texas Tech University Health Sciences Center, Lubbock E.RUSSELL ALEXANDER, M.D., Professor Emeritus, Department of Epidemiology, University of Washington GORDON BERLIN, M.A., Senior Vice President, Manpower Demonstration Research Corporation, New York City STEVE BLACK, M.D., Codirector, Vaccine Study Center, Kaiser Permanente, Oakland, CA SHEILA BURKE, M.P.A., R.N., F.A.A.N., Executive Dean, John F. Kennedy School of Government, Harvard University BARBARA DeBUONO, M.D., M.P.H., Health Care Consultant, New York City GORDON H.DeFRIESE, Ph.D., Professor of Social Medicine, Epidemiology, Health Policy, and Administration, University of North Carolina at Chapel Hill R.GORDON DOUGLAS, JR., M.D., Former President, Merck Vaccines (retired), Princeton, NJ WALTER FAGGETT, M.D., Pediatric Consultant, Medlink Hospital, Washington, DC SAMUEL L.KATZ, M.D., Wilburt C.Davison Professor Emeritus, Department of Pediatrics, Duke University Medical Center SARA ROSENBAUM, J.D., Hirsh Professor, Health Law and Policy, Center for Health Services Research and Policy, School of Public Health and Health Services, George Washington University Medical Center CATHY SCHOEN, M.A., Vice President, Research and Evaluation, The Commonwealth Fund, New York City JANE E.SISK, Ph.D., Professor of Health Policy, Department of Health Policy, Mount Sinai School of Medicine BARBARA WOLFE, Ph.D., Director of the Institute for Research on Poverty and Professor of Economics, University of Wisconsin-Madison

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Calling the Shots: Immunization Finance Policies and Practices Project Staff ROSEMARY CHALK, Study Director SUZANNE MILLER, Research Assistant WILHELMINE MILLER, Ph.D., Senior Program Officer HEATHER SCHOFIELD, Senior Project Assistant Division Staff JANET CORRIGAN, Ph.D., Division Director, Health Care Services ROSE MARIE MARTINEZ, Sc.D., Division Director, Health Promotion and Disease Prevention KATHLEEN STRATTON, Ph.D., Senior Program Officer, Health Promotion and Disease Prevention TRACY McKAY, Senior Program Assistant, Health Care Services Consultants SARAH J.CLARK, M.P.H., Department of Pediatrics, University of Michigan Medical Center ANNE E.COWAN, M.P.H., Department of Pediatrics, University of Michigan Medical Center GERRY FAIRBROTHER, Ph.D., Associate Professor of Epidemiology and Social Medicine, Montefiore Medical Center, New York City AMY FINE, M.P.H., Consultant, Washington, DC ROBIN FLINT, M.P.H., Consultant, Santa Monica, CA GARY FREED, M.D., M.P.H., Department of Pediatrics, University of Michigan Medical Center ROY HOGAN, M.P.A., Consultant, Austin, TX KAY JOHNSON, Ed.M., Johnson Group Consultant, Inc., Hinesburg, VT HANNS KUTTNER, School of Public Policy Studies, University of Chicago EAMON MAGEE, Consultant, Kensington, MD HEATHER McPHILLIPS, M.D., M.P.H., Department of Pediatrics, University of Washington VICTOR MILLER, M.P.P., Consultant, Washington, DC GREGORY A.POLAND, M.D., F.A.C.P., Chief, Mayo Vaccine Research Group, Mayo Clinic and Foundation, Rochester, MN BARBARA RICHARDS, M.P.P., Consultant, Washington, DC KATHY STROUP, Consultant, Riverside, CA

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Calling the Shots: Immunization Finance Policies and Practices INDEPENDENT REPORT REVIEWERS This report has been reviewed by individuals chosen for their diverse perspectives and technical expertise, in accordance with procedures approved by the National Research Council’s Report Review Committee. The purpose of this independent review is to provide candid and critical comments that will assist the authors and the Institute of Medicine in making the published report as sound as possible and to ensure that the report meets institutional standards for objectivity, evidence, and responsiveness to the study charge. The content of the review comments and draft manuscript remain confidential to protect the integrity of the deliberative process. We wish to thank the following individuals for their participation in the review of this report: STEVEN F.BOEDIGHEIMER, M.M., Deputy Secretary, Delaware Health and Social Services, New Castle, Delaware FITZHUGH MULLAN, M.D., Project HOPE and Contributing Editor, Health Affairs, Bethesda, Maryland PATRICIA NOLAN, M.D., M.P.H., Director of Health, Department of Health, State of Rhode Island and the Providence Plantations, Providence ANTHONY ROBBINS, M.D., Chairperson, Department of Family Medicine and Community Health, Tufts University School of Medicine WILLIAM SCHAFFNER, M.D., Professor and Chairman, Department of Preventive Medicine, Vanderbilt University School of Medicine NATALIE SMITH, Chief, Immunization Department, California State Health Department, Berkeley NEAL A.VANSELOW, M.D., Rio Verde, Arizona VIRGINIA V.WELDON, M.D., Consultant, St. Louis, Missouri DAVID WOOD, M.D., Corporate Director of Clinical Outcomes Management, Shriners Hospital, Tampa, Florida The individuals listed above have provided many constructive comments and suggestions, but responsibility for the final content of this report rests solely with the authoring committee and the Institute of Medicine.

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Calling the Shots: Immunization Finance Policies and Practices Preface The U.S. immunization system is a national treasure that is too often taken for granted. Through an intricate maze of public- and private-sector activity, vaccines are delivered to thousands of children, adolescents, and adults each day. The process by which each of us achieves up-to-date immunization status for ourselves and our children differs in large part by the circumstances of birth. Geographic and economic differences in these circumstances can contribute to disparities in access to vaccines and lead to reduced levels of immunization coverage within a general population. Such disparities are not as important, for the purpose of immunization coverage, if they occur within populations that largely achieve complete immunization status. If such disparities are concentrated with certain groups, however, outbreaks of infectious disease that have tragic consequences can occur. Today we are involved in a national experiment with health care reform. The delivery of immunizations for disadvantaged populations, which once occurred primarily through public health clinics, has shifted in large part to the private sector. This shift has occurred swiftly and unevenly over the past decade, stimulated by changes in Medicaid policies and practices, the creation of new governmental programs such as Vaccines for Children (VFC), and the adoption of a new federal-state partnership known as the State Children’s Health Insurance Program (SCHIP). These changes have occurred against a backdrop of traditional public health practices that served disadvantaged families for many decades in each state.

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Calling the Shots: Immunization Finance Policies and Practices The privatization of primary health care services for the nation’s disadvantaged children has caused many individuals to question the scope and scale of federal assistance for state immunization programs. Childhood immunization coverage levels are currently high, and outbreaks of vaccine-preventable infectious disease are low. Adult immunization coverage rates are low, and programs designed to improve coverage levels are rare at the federal or state level. Given these conditions, is the federal government spending too much or too little to support immunization programs within each state? What role should state governments play in this area? And how important are the data collection, assessment, and outreach efforts of public health agencies if most immunization services are being delivered in the private sector? In this context, the U.S. Senate Appropriations Committee and the Centers for Disease Control and Prevention (CDC) asked the Institute of Medicine to examine the roles and responsibilities of the state and federal governments in supporting immunization programs and services. The Committee on Immunization Finance Policies and Practices was formed to conduct this study. The committee was asked to give attention to a specific program administered by CDC, known as Section 317, that makes annual awards to the states to help them purchase vaccines and support infrastructure efforts. The committee was asked to consider the history of this program, as well as its relationship to newer federal health initiatives such as VFC and SCHIP. In conducting this study, the 15-member committee met five times during the period February 1999 through January 2000. We commissioned a state survey and eight case studies to inform our deliberations, and we hosted a workshop on issues related to pockets of need, held in September 1999 in Washington, D.C.* Several committee members, consultants, and staff participated in site visits conducted during the period September 1999 through January 2000 in four areas: Detroit, Michigan; Houston, Texas; Newark, New Jersey; and Los Angeles and San Diego, California. We received testimony from a distinguished group of federal, state, and local health officials; representatives of state organizations; congressional staff; and researchers engaged in studies of the national immunization system. The committee benefited from a series of reports and briefings provided by the staff of the National Immunization Program within CDC, which is responsible for administering the Section 317 grants and the VFC program. CDC staff attended many of the committee meetings and par- *   Selected materials from the case studies, state survey, and background papers commissioned by the committee will appear in a special supplemental issue of the American Journal of Preventive Medicine, Vol. 19, No. 3S, in October 2000.

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Calling the Shots: Immunization Finance Policies and Practices ticipated in the September workshop. We are grateful to each of these officials for their thoughtful contributions and expertise over the course of the study: Angie Bauer, Kristin Brusuelas, Jose Cordero, Russell Havlak, Glen Koops, Joel Kuritsky, Martin Landry, Edward Maes, Dean Mason, James Mize, William Nichols, Dennis O’Mara, Walter A.Orenstein, Lance Rodewald, Jeanne M.Santoli, Abigail Shefer, Allyson Shoe, and Nicole Smith. State health officials also contributed perspectives and information in meetings and conversations with committee members, staff, and consultants. We are especially grateful to the immunization project directors, program managers, and other health officials in each of the states who made themselves available for lengthy phone interviews as part of the project’s state survey and case studies. We would particularly like to thank the following individuals for their efforts: Christine Grant, New Jersey Department of Health and Human Services; David Johnson, Michigan Department of Community Health; Brad Prescott, Texas Department of Health; Natalie Smith, Immunization Branch, California Department of Health; and Donald Williamson, Alabama Department of Public Health. Several federal officials assisted in arranging meetings with key agency personnel who provided background information relevant to the study, and we are grateful for their assistance: Patricia MacTaggart, Health Care Financing Administration; Doris Barnette and Rita Goodman, Health Resources and Services Administration; and Barbara Hallman, U.S. Department of Agriculture. Data collection and analysis and the development of the final study report required an extensive staff effort. Study Director Rosemary Chalk organized our discussions and prepared several drafts of the study report to guide our analysis and recommendations. Senior Program Officer Wilhelmine Miller was responsible for overseeing the development of the case studies and preparation of the site visit reports and provided much of the analysis for Chapter 3 of this report. Two senior program assistants provided valuable assistance over the course of the study. Suzanne Miller prepared materials for Chapter 2, coauthored two papers on adult immunization and the role of immunization registries, and contributed to the production of the numerous charts and figures in this report. Heather Schofield ably administered the myriad activities associated with each meeting, briefing book, workshop, and site visit, and also prepared our public access files over the course of the study. Other staff made important contributions during the initial or final stages of data collection: Division Director Janet Corrigan prepared the initial project proposal, Senior Program Officer Jane Durch prepared descriptive materials and an analysis of the carryover problem in the Section 317 grant awards, Research Assistant Stacey Patmore conducted initial bibliographic searches on behalf of the committee, and Senior Program Assistant Tracy McKay completed

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Calling the Shots: Immunization Finance Policies and Practices final edits of the report and assisted with bringing the manuscript into production. We also thank our editors Rona Briere, Kristin Motley, and Mike Edington; Sally Stanfield and Estelle Miller from the National Academy Press; and Stayce Bush from the reprographics unit, whose efforts all made significant contributions to the organization and presentation of the committee’s views. The committee was extremely fortunate in obtaining the services of a talented and dedicated group of consultants who prepared background papers and case studies to guide and inform the committee’s deliberations: Gerry Fairbrother, Amy Fine, Robin Flint, Roy Hogan, Kay Johnson, Hanns Kuttner, Eamon Magee, Heather McPhillips, Victor Miller, Greg Poland, Barbara Richards, and Kathy Stroup. Gary Freed, Sarah Clark, and Anne Cowan in the Division of General Pediatrics, University of Michigan, prepared the state survey that provided much of the data supporting our analysis of state immunization policies and practices. Other individuals, including Harris Berman from Tufts Health Plan; Steven Boedigheimer from the Delaware Health and Social Services; Victoria Freeman from the University of North Carolina at Chapel Hill; Alan Hinman from the Task Force for Child Survival and Development; Vince Hutchins from the National Center for Education in Maternal and Child Health; Kala Ladenheim of the National Conference of State Legislatures; Donald Mattison from the March of Dimes; and William Roper from the University of North Carolina offered useful suggestions and perspectives at critical times in the development of the report. We also benefited from the expertise of staff from professional organizations that are concerned with immunization and the vitality of the nation’s public health system. These include Karen Hendricks, American Academy of Pediatrics; Craig Carlson, American Association of Health Plans; Catherine Hess, Association of Maternal and Child Health Programs; Claire Hannan, Association of State and Territorial Health Officers; Tom Musco, Health Insurance Association of America; Cynthia Phillips, National Association of City and County Health Officers; and Doug Greenaway, National Association of Women, Infants, and Children (WIC) Directors. Additional materials regarding state roles in public health were provided by Joan Henneberry of the National Governors’ Association and Mary Smith from the National Conference of State Legislatures. We thank each of these individuals and organizations for their assistance and advice over the course of this study. Bernard Guyer, M.D., M.P.H., Chair David R.Smith, M.D., Vice Chair Committee on Immunization Finance Policies and Practices

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Calling the Shots: Immunization Finance Policies and Practices Contents     EXECUTIVE SUMMARY   1 1   INTRODUCTION   18     Background,   18     Charge to the Committee,   32     Study Context: The National Immunization Partnership,   34     Six Roles of the National Immunization System,   43     Study Approach,   50     Organization of the Report,   52 2   CHANGE AND COMPLEXITY IN THE NATIONAL IMMUNIZATION SYSTEM   54     Key Changes,   55     Increasing Complexity,   61     Successes and Persistent Problems,   66 3   FINANCING VACCINE PURCHASE AND DELIVERY   71     Private Insurance Coverage of Immunization,   74     Medicaid, Vaccines for Children, and State Children’s Health Insurance Program,   77     Medicare,   86     Section 317 Vaccine Purchase Grants,   89     State Vaccine Purchase,   92

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Calling the Shots: Immunization Finance Policies and Practices     Issues in Vaccine Purchase,   97     Summing Up,   99 4   BUILDING, MONITORING, AND SUSTAINING IMMUNIZATION CAPACITY   103     Infectious Disease Prevention and Control,   105     Surveillance of Vaccine Coverage and Safety,   108     Efforts to Improve and Sustain High Vaccine Coverage Rates,   128     Summing Up,   139 5   IMMUNIZATION FINANCE POLICIES AND PRACTICES   142     Private-Sector Roles and Responsibilities,   144     Local Health Department Roles and Responsibilities,   152     State Roles and Responsibilities,   156     Federal Roles and Responsibilities,   175     Summing Up,   188 6   SUMMARY FINDINGS, CONCLUSIONS, AND RECOMMENDATIONS   193     Six Questions and Six Answers,   194     Conclusions,   220     Summary Recommendations,   223     REFERENCES   228     APPENDIXES   243     A Public Health Services Act, Section 317,   245     B Immunization Time-Line,   250     C List of Contributors,   253     D Overview of State Survey,   261     E Overview of Case Studies and Site Visits,   263     F Annual Section 317 Awards to States, 1995–1999,   271     G State Immunization Requirements for School Children,   282     H Committee and Staff Biographies,   287     INDEX   295

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Calling the Shots: Immunization Finance Policies and Practices Boxes, Tables, and Figures BOXES 1–1   Funding of State Activities Under Section 317 Grant Program,   27 1–2   Section 317 Grant Guidance,   28 1–3   The Measles Epidemic, 1989–1991,   35 1–4   Immunization Infrastructure: The Michigan Example,   42 3–1   Examples of Residual Needs That Require State Vaccine Purchase,   73 3–2   New Jersey: Carving the Vaccine Administration Fee Out of Capitation Rates,   85 3–3   Calculating the Size of the Adult Population That Relies on State-Purchased Vaccines,   89 3–4   Calculating the Size of the Child Population That Relies on State-Purchased Vaccines,   94 4–1   Alaskan Measles Outbreak in 1998,   106 5–1   Small-Area Analysis for Detroit and Newark,   148 5–2   Rochester Private-Public Partnership Approach,   151 5–3   Sample of State and Local Immunization Coverage Surveys,   160 5–4   Total Section 317 Funds Awarded to Support Registries as of July 1, 1999,   184 6–1   Conclusions and Recommendations,   195

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Calling the Shots: Immunization Finance Policies and Practices TABLES ES-1   Recommended Finance Levels for the National Immunization System,   12 1–1   Comparison of 20th-century Baseline and Current Morbidity, Vaccine-Preventable Diseases,   19 1–2   Vaccination Coverage Levels Among Children Aged 19–35 Months, by Selected Vaccines (1995–1999),   20 1–3   Universally Recommended Vaccinations,   25 1–4   Total Federal Immunization Funding, FY 1999,   26 1–5   Estimated Vaccination Coverage of 4:3:1:3 Among Children 19–35 Months of Age by Selected Geographic Areas—United States, National Immunization Survey, 1995–1999,   30 2–1   Vaccines in Widespread Use, 1985–2020,   58 3–1   U.S. Population Health Insurance Coverage, 1998,   75 3–2   Coverage of Pediatric Immunizations by Health Benefit Plans Offered by Employers,   76 3–3   Medicaid and Vaccines for Children (VFC) Program, FY 1994–1999,   80 3–4   State Children’s Health Insurance Programs, 2000,   81 3–5   Federal Immunization Coverage Policies for Children Under Medicaid, Vaccines for Children (VFC), and State Children’s Health Insurance Programs (SCHIP),   84 3–6   Influenza and Pneumococcal Immunization Rates,   88 3–7   Vaccine Supply Policy, January 2000,   96 4–1   Vaccine Injury Compensation Program Petitions Filed, Adjudications, and Awards,   127 5–1   Main Uses of Section 317 Infrastructure Grant Funds in High-Funding Years (1994–1996),   158 5–2   Annual Awards and Expenditures of Section 317 Direct Assistance (DA) Vaccine Purchase Funds,   164 5–3   Estimated Vaccination Coverage with 4:3:1:3 Series Among Children 19–35 Months of Age by Provider Type, Census Division, and State— United States, National Immunization Survey (NIS), 1998,   167 5–4   State Responses to Section 317 Funding Cuts,   170 5–5   Annual Awards and Expenditures of Section 317 Financial Assistance (FA) Immunization Program Funds,   178 5–6   Composition of CDC Immunization Appropriations, 1995–1999, Amounts and Shares,   186

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Calling the Shots: Immunization Finance Policies and Practices FIGURES ES-1   Six roles of the national immunization system,   7 1–1   Recommended childhood immunization schedule—United States, January-December 2000,   22 1–2   Amount of new funding awarded as Section 317 Direct Assistance (DA) and Financial Assistance (FA), 1990–1999,   39 1–3   Amount of total annual awards of Section 317 Funds, Direct Assistance (DA) and Financial Assistance (FA), 1990–1999,   40 1–4   Federal agencies that support immunization services and programs,   44 1–5   Immunization core functions,   45 1–6   Six roles of the national immunization system,   46 1–7   Six roles of the national immunization system, broken down by role,   48 2–1   Changes in the childhood vaccination schedule, 1975–2000,   56 2–2   Immunization coverage levels with the 4:3:1:3 series, by state,   68 3–1   Children receiving VFC vaccines by eligibility category, calendar year 2000,   80 3–2   U.S. children’s insurance coverage for immunizations,   82 3–3   Section 317 Direct Assistance and Financial Assistance expenditures by grantees, 1990–1998,   92 3–4   Total Section 317 Direct Assistance awards, expenditures, and balances, 1990–1999,   93 4–1   Enrollment of children aged 0 through 5 in immunization registries, by state,   118 4–2   Provider enrollment and participation in immunization registries, by state,   120 5–1   Federal and state funding for immunization programs per child in 2000, by grantee,   162 5–2   Section 317 grant operations funding history, 1995–2001,   169 5–3   Immunization activities by funding source,   181 6–1   Level of grantee contribution by number of states, calendar year 2000,   197 6–2   Level of grantee contributions by program component,   198

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Calling the Shots: Immunization Finance Policies and Practices CALLING THE SHOTS

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