At the same time that states were encouraged to use their public clinics to expand access and foster outreach, however, the VFC program and Medicaid reforms created a counteremphasis by promoting immunizations for children in their private medical homes and encouraging greater reliance on managed care organizations to serve populations that once relied on public health clinics. In the majority of states, VFC has made strides in this area, assisted by the increasing penetration of managed care plans, the proliferation of Medicaid managed care plans, and the implementation of SCHIP. Of the 46 states that reported this information in response to the survey conducted for the present study, 40 had experienced decreases in the proportion of children receiving vaccines in the public sector, and some of these decreases were substantial (Freed et al., 1999).

Still, the need for public-sector immunization services has not disappeared. As discussed earlier, most children receive their services from private providers, but the trend toward private-sector immunization delivery is uneven (see Table 5–3). Indeed, the number of doses of vaccine provided in the public sector did not decrease appreciably during the 1990s even though the overall numbers of clients were reduced, a fact that can be attributed to the increase in the number of recommended doses for newborns and adolescents (Freed et al., 1999). Residual needs for vaccine remain in most public clinics, reflecting the realities of serving vulnerable children and adults who have urgent needs and are unable to take advantage of other health care resources. Furthermore, the clientele of public health clinics has changed; the current clientele requires more effort to maintain and improve immunization status because they are often more transient, more socially isolated within their community, and more likely to have contact with multiple health care providers in the public and private sectors.

Furthermore, recent trends in poverty measures suggest that the needs of those who depend on public programs may become more complex. While the overall proportion of children living below the poverty line has declined somewhat during recent years, the number of children in extreme poverty may be increasing (Center on Budget and Policy Priorities, 1999). These trends suggest that although fewer children may be eligible for federal and state assistance programs, those who are eligible may face more barriers, and require greater assistance, than was previously the norm. Anecdotal reports from clinical sites have confirmed this observation (Szilagyi, 1999).

State health officers in various regions of the United States have reported that managed care providers sometimes refer their patients to public clinics for vaccine services because such immunizations can then be provided without cost to the managed care plan (and the plan’s assess-



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