• Congress has directed CDC to help states target pockets of need so that federal funds can be focused on disadvantaged communities (U.S. House of Representatives, 1989; U.S. Senate, 1992, 1995, 1998).

  • Congress has supported the use of incentive grants to reward states that achieve high rates of immunization coverage (U.S. Senate, 1993, 1994, 1995, 1998).

  • Congress has guided the development of vaccine safety concerns through the creation of a federal injury compensation plan financed by a special excise tax on vaccine sales.

  • Congress has urged CDC to provide leadership in improving adult immunization coverage rates (U.S. House of Representatives, 1992).

  • Congress has urged CDC to develop the worldwide polio eradication program, drawing on carryover funds in the state infrastructure grants to support the program’s early development (U.S. House of Representatives, 1996).

Congress has not addressed the issues of state data collection or the assurance and assessment roles of public health agencies in the oversight of private-sector performance, which now represent significant aspects of immunization infrastructure. These latter areas raise fundamental concerns about the extent to which federal agencies should support and guide state practice through financial assistance and other incentives, including penalties and reporting requirements. These areas also reveal challenges that emerge when federal and state agencies attempt to guide or change professional practices within the private health care sector. Recently, legislation has been introduced that seeks to require comprehensive health insurance coverage for childhood immunization.9 But such initiatives must address the complex regulatory structure for group and individual health insurance coverage within the private sector and face the traditional political resistance to federal mandates for the private health insurance system.

Federal Finance Practices

As discussed earlier, significant increases in the federal immunization grant awards to the states occurred in the early 1990s, followed by rapid decreases in the latter part of the decade (see Figures 1–2 and 1–3 in Chapter 1). In 1990 and 1991, infrastructure grants (called Financial Assistance [FA] grants) and state expenditures were about one-fourth the level of those for vaccine purchase (called Direct Assistance [DA] grants) (see Tables 5–2 and 5–5). At mid-decade, FA levels increased substantially, rising to twice the levels for DA. New money for FA grant awards increased more than seven-fold from a total of $37 million awarded for 1990

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