providers in the state’s Medicaid, SCHIP, and VFC programs. If the plan participants have access to adequate immunization services from their health care providers, and there are fewer administrative barriers that restrict the plan providers from offering services to vulnerable clients, the state has a stronger primary care capacity and less need for federal safety net programs to supplement its health care system.

These two measures—per capita wealth and state health care capacity—merit explicit consideration in the allocation of federal funds, including Section 317 grants. High marks for either indicator suggest that the state has the revenue to support the cost of vaccine purchase or is already investing substantially in immunization services for disadvantaged populations, reducing the demands on the public immunization infrastructure.

Principle 4: States that achieve higher levels of performance in immunization should be rewarded for those outcomes. The increasing use of performance measures in public health programs places greater importance on the selection of appropriate indicators and measures. CDC has recognized the importance of immunization performance over the past decade (with congressional guidance) by allocating a portion of the Section 317 grant awards to incentive awards based on improvements in immunization rates.

While important, statewide immunization rates can be deceiving because they often do not reveal small areas of concentrated need within the state (see Table 1–5 in Chapter 1). The size of within-state disparities is a second important measure of performance that can demonstrate how well or how poorly the state health system is doing in providing access to immunization services among hard-to-reach populations.

A third relevant performance measure is the level of immunization coverage within Medicaid and SCHIP populations. Baseline measures are especially important in determining the extent to which health finance programs can influence access to vaccines and the size of the safety net population within each state. In addition, the size of the denominator involves careful judgments about which clients should be included in performance assessment measures: all enrolled clients, all clients who make routine visits to the provider, or clients who have visited only once?

Finally, performance measures should encompass the efficiency with which the states administer federal funds. The committee did not identify any such measures in the state survey conducted for this study. Prototype research may be necessary to design and test appropriate efficiency measures for the public health environment. Relevant studies may be available in other fields (such as education) that offer insights and experience



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