As with many aspects of American health care financing, it is virtually impossible to determine with any precision the extent to which insured persons are covered for immunizations. The nation’s multipayer insurance system lacks any single cross-payer database that would provide information on the extent of coverage for particular items or services. Although several national probability studies are designed to measure insurance coverage and utilization of health services, none contains sufficiently detailed information to determine immunization coverage by type of insurance.2 Even within classes of public and private insurance (e.g., Medicaid, SCHIP, employer-sponsored plans), insurance coverage levels cannot be documented with accuracy, since plan sponsors (individual state Medicaid agencies or sponsoring employers) typically have significant discretion in formulating coverage and payment policies. Despite the limitations of available data, however, certain trends and patterns of coverage can be identified. The first three sections of this chapter examine immunization coverage and payment policies under private health insurance; Medicaid, SCHIP, and VFC; and Medicare. The fourth section reviews vaccine purchase grants under Section 317, while the fifth examines state vaccine purchase policies. The final section addresses current issues in vaccine purchase policy.
In 1998, 227 million Americans had some form of public or private health insurance. Yet more than 44 million people, one-fourth of them children, were uninsured (see Table 3–1). As Table 3–1 shows, about three-fourths of those with private health insurance obtain that insurance through employer-sponsored health plans.
By 1999, 28 states had enacted laws requiring insurers to cover childhood immunization services to at least some degree (Freed et al., 1999). As with any type of state insurance regulation, coverage standards vary considerably from state to state. For example, a state law might:
Regulate the scope of coverage, requiring that insurers cover immunizations in accordance with ACIP standards or refer to the standards endorsed by a professional society, such as the American Academy of Pediatrics.
Prohibit deductibles or coinsurance, resulting in what is called “first-dollar” coverage for immunizations.
Fashion less specific standards, simply requiring that insurers cover “appropriate” pediatric vaccines, with decisions regarding which vaccines to include or the nature of any cost sharing left to the discretion of the insurer.