The multiple public programs and agencies involved with vaccine purchase and administration reflect the dispersion of responsibilities within the national immunization system. This situation raises important questions about the respective leadership roles of federal and state agencies, as well as the appropriate distribution of effort between the private and public health care sectors. For example:
ACIP recommends vaccines for the U.S. population. ACIP’s pediatric recommendations are binding for VFC, Medicaid, and SCHIP. Most commonly, it is only after ACIP has recommended a new vaccine that CDC begins to negotiate a federal contract under which VFC and Section 317 can purchase the vaccine. Even before such contracts are in effect, however, Medicaid programs are required to reimburse providers for the newly recommended vaccine as a shared federal-state cost.
One strategy states have adopted to encourage private provider participation in VFC and Medicaid has been to increase Medicaid vaccine administration fees after VFC has made vaccines available to private providers at no cost. However, the impact of this strategy has been diminished by the growth of Medicaid managed care plan enrollments because these plans generally do not pay providers separately for vaccine administration.
Immunization records are maintained by multiple private and public parties. No single record-keeping system exists that can track clients across health care settings. For clients who use multiple providers, records are scattered, making monitoring of coverage levels as well as individual documentation difficult.
The array of public and private agencies involved with immunization in some manner is extensive. The public organizations include state and local public health agencies, insurance regulators, school systems, ACIP, state Medicaid agencies, HCFA (which administers Medicaid and Medicare), CDC, and Women, Infants, and Children (WIC) programs. Private agencies include individual providers, managed care organizations, health plans, and insurers. Each of these organizations has some responsibility for the immunization process, but no single entity has a universal role that allows it to establish data standards, criteria for record keeping, or performance guidelines, or to make cost allocation decisions. The result is a multifaceted enterprise that encourages diverse arrangements; tolerates discrepancies in policies and practices; and frustrates the analysis of trends and patterns, especially for vulnerable populations that depend on both public and private settings.