Bureau, the community and migrant health centers of the Bureau of Primary Health Care, and the Vaccine Injury Compensation Program. Other DHHS agencies involved in immunization activities include the Indian Health Service, the Health Care Financing Administration (Medicaid), and the Administration for Children and Families (Child Care Block Grant and Aid to Families with Dependent Children [AFDC]). The Department of Agriculture (Special Supplemental Food Program for Women, Infants, and Children [WIC] and the Cooperative Extension Service) and the Department of Housing and Urban Development also contribute to these efforts.

State responsibilities and participation in immunization-related activities vary. Common roles include establishing immunization requirements for day-care and school entry, setting Medicaid reimbursement levels, and distributing publicly purchased vaccines. Most states purchase vaccines for their public health clinics at a federally negotiated contract price for bulk quantities. Grants from CDC provide some of the funds that states use for these purchases. Twelve states purchase vaccines at the contract price for all of their participating providers. In most states, however, individual providers must purchase vaccines at higher catalog prices.

Beginning in October 1994, under the Vaccines for Children Program of the Childhood Immunization Initiative, the federal government will purchase vaccines to immunize children who are (1) eligible for Medicaid (even if not enrolled in the Medicaid program), (2) without health insurance, (3) insured but have no coverage for immunization and obtain immunizations at federally qualified health centers or rural health clinics, or (4) Native Americans. States will distribute the vaccine to participating providers without charge. Although the vaccines will be free, providers will be permitted to charge limited fees for administering them. States are expected to apply CDC funds previously spent on vaccine purchase to improving the infrastructure for delivering immunization services.

Anticipated Features with Health Care Reform

In the longer term, immunization services and efforts to improve the primary care environment in which they should be delivered will be shaped by the health care reform measures that are finally implemented. Although the details of those measures remain to be settled, the committee agreed that certain features with implications for immunization are likely to appear in any comprehensive reform legislation. A uniform benefits package will include immunizations for children, and financial barriers to primary care services will be removed for children covered by the system. Workshop participants noted, however, that experiences in HMOs and communities such as Rochester, New York, where the availability of care is already assured, have shown that removing financial barriers to services does not ensure that families use them,



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