• Assure the purchase of recommended vaccines for the total population of U.S. children and adults, with a particular emphasis on the protection of vulnerable groups.

  • Assure access to such vaccines within the public sector when private health care services are not adequate to meet local needs.

  • Control and prevent infectious disease.

  • Conduct population wide surveillance of immunization coverage levels, including the identification of significant disparities, gaps, and vaccine safety concerns.

  • Sustain and improve immunization coverage levels within child and adult populations, especially in vulnerable communities.

  • Use primary care and public health resources efficiently in achieving national immunization goals.

The last of these roles provides overarching support for the other five, and was the focus of the committee’s charge. In conducting the study, we gave particular attention to the responsibilities of federal and state health agencies and the burden of effort required to support each of the above roles in an integrated manner. In this chapter, we apply the findings presented in Chapters 2 through 5 to answer the six questions under the committee’s charge. We then present the overall conclusions and recommendations resulting from the study, as summarized in Box 6–1.

SIX QUESTIONS AND SIX ANSWERS

Question 1. What was the extent of overall spending by all sources for immunizations in the United States during the 1990s? (Supported by Findings 3–1 through 3–6 in Chapter 3.)

The most common sources of spending for immunization in the United States during the 1990s were federal funds, state funds, private insurance reimbursements, and other private funds (e.g., foundation support for the development of registries and local outreach efforts). The federal government was and remains the primary source of assistance for both vaccine purchases and immunization programs.

Federal funding for immunization services (including vaccine purchases, infrastructure, and other grants), estimated from congressional budgets, grew from about $500 million in 1990 to more than $1 billion in 1999, an increase that reflects the expanded federal role in purchasing vaccines for disadvantaged children (see Table 1–4 in Chapter 1). Principal federal investments include the Vaccines for Children (VFC) program, Section 317 grant awards, and Medicaid reimbursements to the states for vaccine administration services. Medicare reimbursements for adult vac-



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