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~n~ro~ue~ion n tune 2000, the Institute of Medicine (IOM) released a report resulting from an 18-month study of the national immunization finance system in the United States (Institute of Medicine, 2000a). The IOM study was originally requested by the Senate Appropriations Committee of the U.S. Congress, which had expressed concerns about the sudden shifts in fed- eral immunization budgets and uncertainties about the nature of the fed- eral and state partnership in supporting immunization efforts. The IOM report, titled Calling the Shots, offered a conceptual frame- work for immunization programs to clarify the types of roles that re- quired support in the public health system. In developing this report, the study committee drew upon research literature from multiple disciplines; eight case studies (Fairbrother et al., 2000)l;a national survey of state- level immunization programs (Freed et al., 2000~; site visits to the cities of Detroit, Newark, Houston, San Diego, and Los Angeles; and a national workshop in September 2000 that focused on issues related to addressing the immunization problems of pockets of need within the United States. The committee also commissioned background papers on topics such as adult immunization, registries, measuring immunization coverage (Fairbrother et al., 2000), and federal immunization policy Johnson et al., 1Each case study is available electronically via the website of The National Academies Press at 3

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4 SETTING THE COURSE 2000~. Selected portions of these materials were published in a supple- mental issue of the American Journal of Preventive Medicine in October 2000. The findings of the IOM report noted that although childhood immu- nization levels are high, federal, state, and private-sector investments in vaccine purchases and immunization programs are lagging behind emerg- ing opportunities to reduce the risks of vaccine-preventable disease. Fur- thermore, three key trends have produced significant instability in the national immunization system: 1. Rapid acceleration in the science of vaccine research and produc- tion; 2. Increasing complexity of the health care services environment of the United States (represented by trends such as the emergence of man- aged care as the primary health care providers for low-income popula- tions); and 3. Recent reductions in federal immunization grants to the states, which followed on the heels of dramatic increases in the early 1990s. In response to these trends, the IOM report recommended that the federal and state governments increase their investments in the public health infrastructure for immunization. The study committee recom- mended that a total of $1.5 billion be allocated in federal and state re- sources over 5 years, an annual increase of $175 million over current spending levels. The committee also recommended that Congress replace the current Section 317 discretionary grants to the states with a formula approach to provide a base level of support for all states as well as addi- tional amounts related to each state's need, capacity, and performance. Following the publication of Calling the Shots, IOM convened three regional workshops to review the findings and recommendations of the report and to identify areas of consensus as well as unresolved concerns that require future attention by public and private officials in strengthen- ing the national immunization system. The IOM immunization workshop series and summary reports of each meeting are designed to achieve the following goals: Foster awareness of the conclusions and recommendations of Call- ing the Shots; Strengthen interactions among public- and private-sector health officials to build consensus about immunization infrastructure initiatives, measurement approaches, and financing plans; and Identify unresolved public health and health finance issues and concerns at the regional, state, and local levels that require further atten- tion from public and private policymakers.

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INTRODUCTION 5 The first of the three regional workshops, held in tune 2001 at the University of Illinois School of Public Health in Chicago, examined state- wide concerns in Illinois and Michigan and the challenges facing the cities of Chicago and Detroit in sustaining efforts to improve immunization rates (IOM, 2002a). A second workshop was held in October 2001 at the Texas Medical Association in Austin, Texas. Discussions at that meeting highlighted concerns of private providers throughout the state and op- portunities for greater public-private collaboration in financing vaccine purchase and service delivery (IOM, 2002b). The third regional workshop was held in lanuary 2002 at the University of California at Los Angeles (UCLA), with a special focus on public health partnership efforts in Los Angeles and San Diego Counties (IOM, 2003~. The meeting, which was organized by IOM in collaboration with the School of Public Health at UCLA and the Los Angeles County Health Department, featured presen- tations by state and local health officials; health care providers; represen- tatives of health plans and corporate health care purchasers; faculty from UCLA and the University of California at San Diego; community leaders; and Centers for Disease Control and Prevention (CDC) staff. This report of the Washington, DC workshop summarizes the find- ings of the IOM study Calling the Shots, reviews the status of implementa- tion of the IOM report recommendations at the federal and state levels, and highlights continuing challenges in immunization finance for the na- tion as a whole and for individual state and local health departments. Participants in the workshop included members of the original study committee and the workshop program committee; consultants and other contributors to Calling the Shots; state and local health directors; represen- tatives of national health care and public health organizations, health plan associations, and business groups; health care providers; congres- sional staff; and staff from the CDC National Immunization Program and other federal agencies concerned with immunization. (See Appendixes A, B. and C for the workshop agenda, a list of participants, and addresses of Internet websites that pertain to the IOM report and the workshop discus- sions.)