their investments (in direct and indirect efforts) and the outcomes achieved by using different strategies to address common goals. Interagency collaboration at both the state and federal levels may be required to support public health efforts in the field of immunization. For example, guidelines at the national level could encourage Medicaid agencies to bear the costs of administrative services (including immunization audits of provider records and registry development) as part of case management expenditures. Whatever the source, states need to be able to predict the size of their immunization budgets on a multiyear basis, rely on steady sources of income to support both vaccine purchase and infrastructure efforts, and assess the performance of those efforts according to a consistent set of measures.

A set of proxy measures focused on need, capacity, and performance should be developed that can be monitored over time. These measures can be used to guide federal grant allocation decisions and the determination of state contribution levels, as well as programmatic and reporting requirements. A small set of comparable measures will allow federal and state agencies to monitor state need, capacity, and performance without imposing unnecessary effort on the states that restricts their ability to respond to local circumstances.

The committee believes the assignment of weights to the factors of need, capacity, and performance requires careful calculations that lie beyond the scope of this report. These calculations should be informed by a democratic process that takes individual state needs into account. The calculations required include the appropriate size of the federal base grant; appropriate “hold harmless” conditions; the nature of adequate state-level contributions; an appropriate set of proxy measures that reflect need, capacity, and performance in the field of immunization; and the appropriate multiyear finance mechanism for allocating federal funds. The calculation process requires an extensive dialogue with federal and state health agencies, state legislatures, state governors, and the U.S. Congress. The committee recommends that CDC initiate this dialogue immediately so that legislative reforms can be proposed by 2002, when Section 317 is scheduled for reauthorization.

Several different types of formula factors would alter the distribution of state grant awards relative to current allocation patterns. The factors considered in making other state health grant awards are the size of the population and federal poverty level measures, which can be set at different thresholds. The inclusion of any one formula factor would cause major shifts in the current distribution of federal funds. A small number of states (commonly states with large numbers of at-risk children, such as California, Texas, New York, and Pennsylvania) frequently rank much higher in formula distributions than smaller or more rural states. It is



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