must provide tallies of doses administered for larger numbers of vaccines and providers, as well as estimates of VFC participants served in increasingly diverse health settings. The requirements are particularly burdensome in universal purchase programs (which were designed to reduce paperwork in determining patient or provider eligibility for state-financed vaccines). The implementation of SCHIP has added a new client base that further complicates determinations of VFC eligibility. Children who were once VFC-eligible because they were not insured now do not qualify in states that have adopted stand-alone SCHIP programs, since only Medicaid expansion programs qualify for VFC. Uncertainties about the extent to which VFC eligibility should be expanded to the entire SCHIP population have prompted requests for guidance from the Health Care Financing Administration (HCFA) (Richardson, 1999; Richardson and Orenstein, 1999), as well as legislation introduced in the Congress in September 1999 (U.S. House of Representatives, 1999a; U.S. Senate, 1999).

Infrastructure Grants. Section 317 grants to the states for infrastructure were highly unstable during the 1990s (see Figures 1–2 and 1–3 in Chapter 1). Following the 1989–1991 measles outbreak, CDC launched a national initiative designed to strengthen state immunization programs and provide resources for a broad array of direct services, outreach, and expanded access programs. The CDC budget for state infrastructure grants almost tripled between FY 1993 and 1994, growing rapidly from $45 million in new funds (FY 1993) to more than $128 million (FY 1994) (information provided by CDC). States were permitted to carry forward unobligated funds and transfer vaccine purchase funds to support infrastructure programs, further escalating the pool of funds available for state infrastructure grants in FY 1995 and 1996, even though appropriations for new awards were diminishing by this time.

Table 5–1 in Chapter 5 summarizes the principal activities to which each state directed its expanded infrastructure grants. Most commonly, states allocated their Section 317 increases to expanded service delivery, outreach and education, and development of registries. More specifically, states used this funding to improve immunization rates by, for example, undertaking collaborative efforts with groups such as WIC and Head Start to serve underimmunized clients, setting up reminder-recall systems, expanding clinic hours and locations, implementing targeted immunization campaigns for children and adolescents in pockets of need, and supporting local outreach efforts (Freed et al., 1999).

The increased Section 317 funding was viewed as a tremendous opportunity for new state efforts, especially since the creation of VFC added new responsibilities for data collection from and immunization audits of private health care providers. Yet significant barriers impeded states from reaping the full benefit of these expanded awards (Freed et al., 1999):



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