new undertakings. The committee was particularly concerned that oversight and implementation of state IAPs be coordinated with the increased federal purchase of vaccines by the federal government under the Vaccines for Children Program. States will face the need to manage large-scale distribution of the federally purchased vaccines. In Washington State, for example, 67 percent of children under 1 year old will be eligible to receive federally purchased vaccines. Walter Orenstein emphasized CDC's desire to move away from auditing and outcomes assessment to providing collaborative assistance to states, communities, and providers.


Efforts to protect the health of children through immunization cannot always proceed along unambiguous paths. In several areas, competing interests need to be recognized and managed by officials with public health responsibilities. Several concerns surfaced during workshop discussions, and others were apparent to the committee.

Financial constraints at state and local levels and steady or declining funds from federal sources have made it difficult for health departments to meet the increasing demand for public immunization services caused by referrals from private providers (Schulte et al., 1991). Some assistance should come from an increase of $83 million in federal funding through IAPs in fiscal year 1994 and, beginning in October 1994, expanded purchase of vaccines by the federal government for Medicaid-eligible and uninsured children, including those cared for by private providers.

In addition to children who are uninsured or covered by Medicaid, many children with health insurance are immunized in public clinics because their insurance does not provide “first-dollar” coverage for immunizations.4 Alan Kohrt, a Pennsylvania pediatrician instrumental in passage of state legislation mandating insurance coverage for immunizations, explained that such legislation does not resolve the problem. The many employers that self-insure remain exempt from state requirements under the provisions of the 1974 federal Employee Retirement Insurance Security Act (ERISA).

An emerging concern for some local health departments is what their responsibilities will be in delivering personal health services, such as immunizations, as Medicaid moves families into capitated and managed care programs that are expected to provide immunizations as part of overall primary


Health insurance plans with first-dollar coverage pay for immunizations regardless of the amount of a family's other health care expenditures. Plans without first-dollar coverage pay for immunizations only after a family has incurred a specified level of health care costs (the plan's deductible).

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