Question 4: How should federal grant funds be distributed among the states? (Supported by Findings 4–2 and 4–14 in Chapter 4 and Findings 5–12 and 5–16 in Chapter 5.)

Each state deserves some level of federal assistance, but some states require more help than others because of the characteristics of their populations. In addition, states that have more resources because of their tax base should be expected to bear a larger burden of the costs of immunization infrastructure. Finally, states that demonstrate success in increasing their immunization coverage levels should be rewarded when such increases reflect real improvements in the status of their most vulnerable populations. Since allocation by need and by achievement may run counter to each other, specific criteria will need to be developed to balance multiple goals.

For these reasons, the committee believes federal funds should be allocated to the states on a formula basis, with a state match requirement that reflects each state’s capacity to bear part of the burden of infrastructure costs. A small proportion (perhaps 5 to 10 percent) of the total federal grant awards for infrastructure should also be set aside so that CDC will have discretionary funds available to respond to unexpected outbreaks, gaps in immunization coverage, or other exceptional circumstances within the states.

Four Basic Principles for a Federal Grant Formula

Allocating federal immunization grants to the states requires consideration of several factors: need, capacity, performance, and the determination of a base-level grant award. The committee offers four basic principles to illustrate the nature of each of these factors and the types of measures that should be considered in estimating their value within the proposed formula.

Principle 1: Each state requires a base grant award, regardless of population size, level of need, or match contribution. There is a strong federal interest in ensuring a stable immunization infrastructure within each state so that vaccine coverage levels can be sustained among vulnerable groups, and appropriate sentinels will be available to detect emerging trends or problems having national significance. The size of the base award should be sufficient to allow each state to perform the six roles of the immunization system discussed in this report. CDC may want to consider cost-indexing these awards, possibly through multiyear grants, to adjust for salary increases and variations in salary structures for public health employees in different regions of the United States.

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