Despite these national consensus recommendations, however, substantial variations in coverage and payment policies among public and private insurers remain, a consequence of the nation’s multipayer approach to health care.
When there were few recommended vaccines, immunizations were financed as a public health service and were typically delivered by public health agency personnel. Most Americans over the age of 40, for example, can probably recall receiving polio vaccine from a public health nurse, typically at school. As the number and cost of immunizations increased, and as insurance expanded to cover primary and preventive services as well as traditional insurable events, the very concept of immunizations also evolved. Immunizations became less of a public health intervention and became increasingly integrated into comprehensive primary health care.
The sheer magnitude of the modern immunization effort has implications for both health care cost and quality, as well as the protection of the public’s health. Vaccine purchase and service delivery are essential features of the national immunization enterprise, and immunizations are optimally provided within the context of an ongoing primary care relationship. General health care financing provided through employment-based and other private insurance, Medicaid, the State Children’s Health Insurance Program (SCHIP), and Medicare aids in integrating immunizations into routine health care. Yet while these private and public health insurance programs account for the majority of immunizations provided nationally, they do not offer the U.S. population seamless and universal coverage. The federal Section 317 categorical grant program and state vaccine purchase and delivery programs address residual needs created by gaps and uncertainties in these health financing plans (see Box 3–1).
Over the past 50 years, public and private insurance initiatives at both the federal and state levels have expanded insurance coverage for immunizations among both publicly and privately insured children. In 15 states, pediatric immunization coverage has been achieved through the establishment of universal, public vaccine purchase programs that distribute vaccines directly to pediatric health care providers. The Vaccines for Children (VFC) program, enacted by Congress in 1993, created a similar direct purchase and delivery system for certain children on a nationwide basis.
Despite the fact that vaccine-preventable diseases can be spread by and affect individuals of all ages, finance policy with regard to adult immunization is significantly more limited and uneven. Both public and private insurers are less likely to cover recommended immunizations for adults, and adults are not included in universal state vaccine purchase and distribution systems.