During the 1990s, immunization programs in California and elsewhere were also affected by the introduction of VFC and SCHIP and the growth of Medicaid managed care programs, which helped shift the delivery of most immunization services to private providers. However, VFC increased the availability of publicly purchased vaccine. The case study showed that Los Angeles and San Diego differ in terms of how publicly purchased vaccine is used. In Los Angeles, about 60 percent of the children who receive such vaccine do so through Medicaid and only about 7 percent are uninsured. In San Diego, 40 percent of the children receiving publicly purchased vaccine are on Medicaid and 52 percent are uninsured. As Dr. Natalie Smith noted, children enrolled in the Healthy Families Program are not eligible for vaccine obtained through VFC. This creates an added burden for providers participating in the Healthy Families Program because they must order and track that vaccine separately from the VFC vaccine. Moreover, provider payments for immunization services are relatively low because they were set based on an expectation of other funding for vaccine purchase.
The IOM case studies for the California counties and other states showed the problems that unpredictable federal funding posed for state and local efforts to plan and undertake certain activities for their immunization programs. They also demonstrated that while health departments were playing a smaller role in the direct delivery of immunization ser-