leaders were urged to participate in negotiating the state’s contracts for Medicaid managed care (NVAC, 1999a).

Despite these mandates, state and local immunization programs have few resources to dedicate to program coordination and leadership initiatives. As noted earlier, collaborative and partnership efforts were often the first activities to be reduced within the states when budget cutbacks occurred. The elimination of staff positions within the states, as described earlier, also resulted in multiple task assignments for remaining personnel that reduced their ability to take on new roles. While states have received additional federal assistance in the forms of SCHIP funds and VFC, the application of these resources to state immunization program needs has been constrained by the strict eligibility guidelines and limits to spending for program administration (including the costs of setting up outreach and record-keeping systems) (see Figure 5–3). These guidelines and restrictions leave little margin for collaborative program development in areas of mutual interest and common goals.

Use of Incentive Grants. In an effort to improve state performance in reaching national immunization goals, the Senate Appropriations Committee instructed CDC in 1993 (for FY 1994) to set aside approximately $32 million annually from the state infrastructure awards for incentive grants (U.S. Senate, 1993). These funds are distributed to the grantees according to their levels of immunization coverage, as reported by the NIS. Once the size of the base award has been determined for each state in response to its original request, states with higher coverage rates receive “bonus” awards from the incentive funds to reward their achievement.

In the mid-1990s, when infrastructure grants amounted to more than $300 million annually, incentive grants constituted less than 10 percent of that total. In recent years, as the total funding for infrastructure grants has diminished, the $33 million set-aside has become an increasing source of concern. Incentive grants now represent about 24 percent of the total grant awards, and grantees with low immunization coverage rates have indicated that they are being “punished” by lower total awards when they require additional assistance to meet urgent local needs.

The Carryover Problem. As noted earlier, in the aftermath of the rapid and unplanned buildup of state infrastructure grants in the early 1990s, significant amounts of carryover emerged within the state immunization budgets (see Table 5–5 and Figure 5–2). Although the states had acquired extensive experience over several decades in working with federal agencies to purchase vaccines, the large increases in infrastructure support were targeted to areas that required new personnel and new efforts (such as outreach, record assessment, performance measures, and the develop-

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