important, therefore, to maintain stability by ensuring a base level of federal funds within each state while responding to specific state needs.

This need for stability in the national immunization system under-scores the importance of increasing the size of the pool of federal funds for state infrastructure awards, as discussed under Question 3 above. CDC has estimated that the use of certain formula factors in redistributing federal awards within an annual budget of $140 or $160 million for infrastructure grants would reduce the current size of a significant number of state awards, further burdening state efforts. A annual pool of $195 million, however, would minimize the need to reduce current state awards in order to increase federal assistance to states with larger poor populations (information provided by CDC).

Question 5: How should funds be targeted within states to reach high-risk populations without diminishing levels of coverage among the overall population? (Supported by Finding 3–6 in Chapter 3; Finding 4–11 in Chapter 4; and Findings 5–1 through 5–9, 5–12, 5–16, 5–18, and 5–19 in Chapter 5.)

The federal government’s role in supporting immunization activities within each state should strike a balance between helping the states achieve important national objectives and sustaining incentives for states to use their own funds to meet the needs of their residents. Given the primacy of the role of the states in public health, the federal government’s role might reasonably be restricted to certain key areas that require specific technical expertise, national data collection and analysis, and the development of benchmarks and indicators that benefit the nation as a whole. In states that do not have a sufficient revenue base to support adequate public health investments, however, the federal government has an important role to play in supplementing state funds to ensure that an adequate program is in place that can achieve national health objectives. Special considerations might include the examples that follow.

First is the size and location of the disadvantaged population within each state. Poverty remains a daunting obstacle to efforts to improve immunization coverage within any specific population. The size of a state’s population that resides in poverty and the extent to which this population is distributed or clustered within the state are important factors to consider in evaluating the size of the public health infrastructure and immunization program needed within the state.

As discussed in the response to Question 4, federal immunization investments should provide greater resources for those states that have larger pockets of need. At the same time, care needs to be taken so that federal funds are not used to support basic health services that are right-



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