states to continue to meet residual needs of vulnerable groups that do not have access to vaccines within private or public insurance plans. These children and adults will continue to fall through the cracks within the national immunization system unless funds are made available from programs such as Section 317 to give the states flexibility in meeting the vaccination needs of populations that cannot afford insurance, but do not qualify for federal assistance. Therefore, CDC and state health officials need to work closely and expeditiously with HCFA, state Medicaid directors, and state SCHIP program officers, as well as professional associations of health care providers, to address three objectives:
To ensure that the states have a pool of Section 317 funds that is sufficient to meet routine vaccine needs, as well as unexpected outbreaks.
To be certain that disparities do not emerge in public and private health plans in access to recommended vaccines.
To develop guidelines and performance measures that will encourage providers to draw on new health finance systems (e.g., VFC and SCHIP) for vaccine coverage so that Section 317 vaccines can be reserved for residual needs.
Federal agencies (particularly CDC) also require additional resources so they can provide national and international leadership; assist in the coordination of programs among states as well as other nations; and create opportunities for the exchange of technical assistance, expertise, and experience in undertaking appropriate and adequate infrastructure efforts at the state and local levels.
Infrastructure Support. Section 317 infrastructure awards currently reflect historical patterns of expenditure and are allocated largely in response to statements of need prepared by state health agencies. Recognizing that the states spent more than 90 percent of the infrastructure grant awards distributed in 1998 and 1999, the committee believes that the demands on the states exceed their current capacity, and that their ability to respond to changes in such areas as the science of vaccines and information technology could become severely compromised. In addition, managed care contracting for Medicaid has eroded the public health infrastructure and funding base in many states so that in some areas, there is no longer a sustainable volume of personal health care demand to support the provision of public health services such as immunization. As state funds with-draw into private-sector contracts, county and local health departments have fewer resources to spend on public health services. The national immunization system is weakening, and we should not have to wait for