National initiatives that provide immunization coverage for larger numbers of disadvantaged families under private and public health insurance plans require state public health responsibilities to shift from direct service delivery to oversight roles concerned with assessment, assurance, and policy development. Yet certain residual immunization needs will remain that will necessitate reliable access to vaccines within the public health sector. States need flexibility and resources to adapt to these shifts, which occur unevenly across and within state borders.

Conclusion 3: Federal and state governments each have important roles in supporting not only vaccine purchase, but also infrastructure efforts that can achieve and sustain national immunization goals.

The federal government should be the senior finance partner for the national immunization system because of the central importance of vaccines in contributing to the nation’s health, and because disease outbreaks in one region can threaten the health of another without respect for political borders. However, the federal role is to supplement and support states, not replace them, in their day-to-day efforts to assure that every child and adult is properly immunized. State legislatures and governments should be expected to sustain an immunization infrastructure that reflects each state’s need, capacity, and performance. Because states are the ultimate stewards of public health, they are responsible for delivering services to those whose immunization needs are not met by the private sector. Performance monitoring, including the development of immunization registries, is important to assure that vulnerable groups have access to adequate primary health care and that public resources are used efficiently in meeting residual needs where necessary.

Conclusion 4: Private health care plans and providers have the capacity to do more in implementing immunization surveillance and preventive programs within their health practices, but such efforts require additional assistance, oversight, and incentives. At the same time, comprehensive insurance and high-quality primary care services do not replace the need for public health infrastructure.

The committee believes health plans should not have the option of providing selective coverage for vaccines once they have been recommended for widespread use, as is currently the practice in most states. For example, all health plans (public and private) that offer primary care benefits for children and adults should bear the costs of integrating all vaccines recommended for widespread use into their basic health care package. Federal mandates for insurance coverage may be necessary to



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