fully the obligation of the state. Formula factors that might be built into the allocation of Section 317 grants might include, for example, the distribution of the state’s population above and below the federal poverty level, the percentage of uninsured families, the size of the child and adolescent Medicaid populations, and the size of the high-risk adult population within the state. The application of such factors would generate new winners and losers in the distribution of federal funds, possibly creating unfair discrepancies (e.g., fewer than 10 states receiving more than 90 percent of available funds). Balance needs to be achieved in leveling the playing field among the states and ensuring that each state receives a minimal grant award that is sufficient to maintain an effective partnership with the federal government.

A second special consideration might be the marginal costs of improving immunization coverage within highly disadvantaged groups. As discussed in Chapter 4, the cost of improving coverage within the final 10 percent of a total population in any given area is thought to be significantly higher than the cost of acquiring coverage for the majority of the community. However, the scale of this difference remains uncertain. Assigning costs requires consideration of such components as outreach, case management, record maintenance, disease exposure, frequency of contacts with primary care providers, and health beliefs and knowledge that influence efforts to obtain immunization.

What is known for certain is that highly disadvantaged populations seek services more frequently from multiple providers in multiple health care settings. Such populations frequently cycle among different health plans, including public and private health care finance arrangements, and are often uninsured for lengthy periods. Their case management and record maintenance costs are greater than comparable costs for individuals who remain with the same health care provider or the same practice over a period of years, especially those who remain within one health plan during the important immunization period of the early childhood years.

Despite these barriers, research has demonstrated that certain types of programs can improve immunization coverage within highly disadvantaged groups if focused on populations that have the most to gain from those programs (see Chapter 4). It is wasteful, for example, to distribute information packages and brochures about the importance of immunization within a community where parents may be illiterate or can read only in non-English languages. Similarly, it is wasteful to improve outreach and parental education programs in communities where most parents already believe in the importance of vaccines, but mistakenly believe that their children are already up to date in their immunization status.

CDC frequently relies on technical assistance to help states direct



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