Calling the Shots Immunization Finance Policies and Practices (2000) / Chapter Skim
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Summary Findings, Conclusions, and Recommendations
Summary Findings, Conclusions, and Recommendations
Pages 193-227
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From page 193... ...
3. What are current and future funding requirements for immunization activities, and how can those requirements be met through a combination of state funding, federal Section 317 immunization grant funding, and funding available through the State Children's Health Insurance Program (SCHIP)
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· Conduct populationwide surveillance of immunization coverage levels, including the identification of significant disparities, gaps, and vaccine safety concerns. · Sustain and improve immunization coverage levels within child and adult populations, especially in vulnerable communities.
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These newer programs have absorbed many of the costs of vaccine purchases and office visits previously covered by Section 317 or Medicaid. Even with the expansion of public and private health plans, however, pockets of need remain in which individuals are susceptible to vaccine-preventable diseases.
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State budgets for vaccine purchase and immunization programs vary widely depending on the size of the state, the state's poverty level, per capita investments in public health, and the state's ability to carry out coordinated efforts that can use internal funds and cost savings efficiently. Of the total $340 million expenditures reported by the states, including state, local, other federal, and private funding (see Figures 6-1 and 6-2)
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198 o o N O lo.
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. Federal grants to the states under Section 317 provide the core funding for state immunization programs, most of which is passed on to local health departments to support outreach, data collection, and program oversight efforts.
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used their vaccine purchase savings to increase their reimbursement fees to Medicaid providers for administration of immunizations. Some states expanded the eligibility criteria for Medicaid programs, or used the VFC savings to purchase additional vaccines for school health programs or other groups not covered by VFC, such as the underinsured (insured children whose health plans do not cover immunizations)
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From page 201... ...
VFC eligibility requirements excluded many thousands of children (e.g., those enrolled in health plans that did not include immunization coverage) whom many states felt obligated to serve through a universal purchase program or an enhanced vaccine purchase policy, and (2)
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Following the 1989-1991 measles outbreak, CDC launched a national initiative designed to strengthen state immunization programs and provide resources for a broad array of direct services, outreach, and expanded access programs. The CDC budget for state infrastructure grants almost tripled between FY 1993 and 1994, growing rapidly from $45 million in new funds (FY 1993)
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From page 203... ...
· Statewide hiring freezes and other administrative policies prohibited immunization programs from hiring full-time permanent staff. · CDC grants were commonly allocated in a piecemeal way, including multiple grants within a budget cycle and the distribution of funds late in the fiscal year.
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· State officials have expressed concern that continued outreach efforts may be futile if services are not available within public health clinics to provide up-to-date vaccinations for individuals who are incompletely immunized and are not covered for such services. Question 3: What are the current and future funding requirements for immunization activities, and how can those requirements be met through a combination of statefunding,federal Section 317 immunization grantfunding, andfunding available through S CHIP?
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Future changes to the adult immunization schedule are likely to increase these costs. As changes occur in the vaccine schedule, the pool of federal and state funds allocated for vaccine purchase will need to expand to allow the
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Therefore, CDC and state health officials need to work closely and expeditiously with HCFA, state Medicaid directors, and state SCHIP program officers, as well as professional associations of health care providers, to address three objectives: · To ensure that the states have a pool of Section 317 funds that is sufficient to meet routine vaccine needs, as well as unexpected outbreaks. · To be certain that disparities do not emerge in public and private health plans in access to recommended vaccines.
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From page 207... ...
Based on an examination of total state expenditure histories, the committee estimates that the states require a total of about $500 million in annual infrastructure funds to sustain a national immunization system that can achieve current national health goals; respond to future developments in the areas of vaccine science, information technology, and health care delivery systems; improve the sensitivity of surveillance measures so they can identify important gaps in immunization coverage levels; and extend immunization programs to the adult population. This amount was derived from two sources: it combines (1)
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From page 208... ...
of the total federal grant awards for infrastructure should also be set aside so that CDC will have discretionary funds available to respond to unexpected outbreaks, gaps in immunization coverage, or other exceptional circumstances within the states. Four Basic Principles for a Federal Grant Formula Allocating federal immunization grants to the states requires consideration of several factors: need, capacity, performance, and the determination of a base-level grant award.
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From page 209... ...
The capacity of the state's public health insurance system (including Medicaid and SCHIP) to cover immunizations and encourage the delivery of immunizations in each child's medical home will influence the size of residual needs, reducing or expanding the population that will seek immunization services directly from safety net health centers.
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From page 210... ...
These two measures per capita wealth and state health care capacity merit explicit consideration in the allocation of federal funds, including Section 317 grants. High marks for either indicator suggest that the state has the revenue to support the cost of vaccine purchase or is already investing substantially in immunization services for disadvantaged populations, reducing the demands on the public immunization infrastructure.
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From page 211... ...
A match requirement will give state legislatures, state health finance agencies, and state governors' offices incentives to monitor the performance of private health care plans that operate within their borders and to determine whether plans that use state funds have the capacity to keep their clients up to date on the immunization schedule. Greater oversight of the immunization budgets of public health agencies will reveal the extent to which such budgets support safety net services to meet residual needs, as well as critical surveillance and assessment functions that benefit the general population.
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From page 212... ...
The committee believes broader exposure of the immunization grants program will strengthen federal and state collaboration. Although the legislative reform process may introduce undesirable or radical changes in the program's scope, purpose, or funding approach that could create uncertainty and confusion and disrupt programmatic efforts, at least in the short term, a state match requirement is not likely to have this effect provided the rationale for the match is sound and justified.
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From page 213... ...
The direct approach involves direct payments to public health programs for immunization services, whereas the indirect approach involves greater reliance on performance assessment, incentives, and regulatory initiatives, since other agencies, including public and private health plans, are responsible for immunization services. States that cover greater numbers of children through SCHIP and serve a significant portion of their uninsured and Medicaid children with VFC through private providers may require fewer federal and state funds for Section 317 vaccine (because they receive larger amounts of federal and state funds for Medicaid and SCHIP payments)
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The calculation process requires an extensive dialogue with federal and state health agencies, state legislatures, state governors, and the U.S. Congress.
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Poverty remains a daunting obstacle to efforts to improve immunization coverage within any specific population. The size of a state's population that resides in poverty and the extent to which this population is distributed or clustered within the state are important factors to consider in evaluating the size of the public health infrastructure and immunization program needed within the state.
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What is known for certain is that highly disadvantaged populations seek services more frequently from multiple providers in multiple health care settings. Such populations frequently cycle among different health plans, including public and private health care finance arrangements, and are often uninsured for lengthy periods.
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Immunization coverage rates for adults are well below those achieved for childhood immunizations, although some progress in immunization was made in immunizing the adult population over age 65 during the l990s. The Healthy People 2000 objective for influenza coverage levels was met for the noninstitutionalized elderly (individuals aged 65 and older)
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, with a median of 53.3 percent (lanes et al., 1999~. Although differences in coverage rates among children of different ethnic groups have been significantly reduced, troublesome disparities remain in adult immunization coverage levels (see Table 3-6~.
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Approximately 50,000 adult Americans still die each year from diseases for which both safe and effective vaccines exist, and yet as noted, only 2 percent of Section 317 funds have been dedicated to adult immunization (Poland and Miller, 2000~. What is missing is a coordinated and comprehensive federal, state, and local strategy to improve adult immunization coverage levels.
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From page 220... ...
But three other areas require attention in renewing the national immunization partnership: improving the quality of immunization surveillance efforts and vaccine safety programs, strengthening efforts to sustain and improve immunization coverage rates, and using primary care and public health resources efficiently. The instability of funding for state immunization programs discourages the development of strategic responses designed to foster disease prevention, improve immunization coverage levels for specific populations, and ensure vaccine safety.
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From page 221... ...
At the same time, the implementation of immunization policy must be flexible enough to respond to special circumstances that occur at the state and local levels. A comprehensive strategy that clarifies the roles and responsibilities of federal and state agencies as well as private-sector providers and health plans within the national immunization system is needed to sustain an important intergovernmental partnership in the midst of change and complexity.
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From page 222... ...
To carry out these roles, state health agencies require a national immunization policy that provides them with adequate resources, stability, and flexibility. Conclusion 4: Private health care plans and providers have the capacity to do more in implementing immunization surveillance and preventive programs within their health practices, but such efforts require additional assistance, oversight, and incentives.
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From page 223... ...
Health plan providers should also be prepared to assess immunization coverage rates among their enrollees by using measures that can contribute to accurate community health profiles at the state and local levels. These efforts require independent oversight, however, to ensure that all groups are included in such assessments and that the measures used accurately reflect the immunization profile of those not currently enrolled in public and private health plans.
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From page 224... ...
The improvement of adult immunization rates will require more than increased vaccine purchases. A comprehensive and coordinated adult immunization program needs to be initiated within each state, with leadership at the national, state, and local levels, to encourage the participation of private and public health care providers in offering immunizations to adults under the guidelines established in the ACIP schedule.
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From page 225... ...
The additional state contribution is necessary to reduce current disparities in state spending practices and to address future infrastructure needs in such areas as records management, development of appropriate performance measures and immunization registries, and outreach and education for adult vaccines. This increased budget could strengthen the state roles in immunization, with a special emphasis on infectious disease prevention and control, surveillance of vaccine coverage rates and safety, and programs to sustain and improve immunization coverage rates.
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From page 226... ...
About half of the states currently invest in immunization programs in addition to their vaccine purchases; the remaining half do not support infrastructure costs on a routine basis. To reduce this disparity, the proposed formula for distributing federal funds should include a state match requirement such as 75 federal/ 25 state similar to that in place for other federal programs, such as Medicaid grants, Title V MCH grants, and block grants for the prevention and treatment of substance abuse.
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From page 227... ...
. Such measures can also facilitate efforts by state and federal health officials to assess the quality of primary care health services within privatesector health plans, so that public health agencies can direct appropriate resources to areas in which private-sector plans do not have sufficient capacity to meet health care needs.
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