state adopted a “first-dollar” coverage law in 1999, which requires health plans and insurers under state jurisdiction to cover immunizations without requiring copayments or prior fulfillment of plan deductibles. The legislature is considering several immunization issues with budgetary implications, including the cost of purchasing additional vaccines and policies for the state’s immunization registry. An evaluation of the operation of the Texas Department of Health (Bomer, 2001) has proposed that statutory changes be made to shift from an “opt-in” to an “opt-out” system for the immunization registry (that is, inclusion of a child in the registry unless parents request exclusion) and to give all immunization providers access to the registry. These steps are likely to help in efforts to improve the state’s immunization coverage rates but also raise concerns in the legislature about privacy and parental rights. Nevertheless, Representative Delisi sees support for these proposals, as well as for using the registry to support a statewide immunization recall and reminder campaign. She concluded by urging a stronger collaboration between the public health system and primary care providers to meet the state’s immunization needs.

A LOCAL PERSPECTIVE

Local health departments play an important role in implementing certain elements of the state’s immunization program. They often operate clinics to provide vaccinations to children and adults in the community. With the advent of VFC, however, they have also taken on responsibility for recruiting private providers to participate in the program and for assessing immunization rates in public clinics and private provider practices. Jorge Magaña, director of the El Paso City-County Health and Environmental District, discussed his experience in El Paso with these changing roles and responsibilities.

Dr. Magaña noted several challenges in serving the El Paso area. The population includes many new immigrants who are often highly mobile and have limited education. Children frequently need catch-up immunizations, and many families have fears about the vaccines. Dr. Magaña noted that physicians have been leaving El Paso, and the area is underserved compared with other parts of the state. In 2001, 104 El Paso providers, primarily pediatricians and family physicians, participated in VFC, down from 128 providers in 1998. In addition, a prenatal care program in health department clinics that had helped link new mothers with immunization services has been transferred to local hospitals and is less likely to serve the uninsured.

Before 1994, the local health district provided most immunization services in El Paso, and the coverage rate for the 4:3:1 series had reached



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