qualified their distribution of free vaccines by placing greater emphasis on eligibility criteria. States that have tightened their screening and referral procedures have encountered some resistance from local health departments.

The intent of VFC was to eliminate a two-tiered system of care, in which poor children were precluded by cost from receiving immunizations in their medical homes. Yet a growing rift between VCF-eligible and -ineligible children has developed in many states. Recent additions to the primary immunization schedule—varicella, hepatitis A, the now rescinded rotavirus, and the new pneumococcal conjugate vaccine for infants—are relatively expensive vaccines. The recommended switch from OPV to inactivated polio vaccine also carries increased costs. Many states have faced difficult decisions regarding vaccine purchase for non-VFC children:

Issuance of new or expanded ACIP recommendations is one of our biggest problems. Every time a vaccine is added as an entitlement on VFC, we have to make sure that we don’t end up with different classes of children with different levels of protection; that means trying to come up with funding for that new vaccine for non-VFC children. The new recommendation doesn’t necessarily come along with extra 317 funds, and it doesn’t come with infrastructure funds that are needed to deliver the new vaccine and keep the records. It’s a constant juggling act to fund vaccines (Freed et al., 1999).

The problem is most pronounced for universal purchase states:

When the ACIP makes a recommendation for a new vaccine and they include it in the VFC program, then they are in effect pushing and controlling state budgets for universal purchase states. They do not take into consideration some very specific situations that exist for states. If our state was to lose universal status, it would have a very negative impact. We don’t have a lot of managed care, and most fee-for-service insurance does not cover immunizations. In many ways, we’re stuck between a rock and a hard place: even though universal status is costing more, it would be a real detriment to lose it.…

We have local health departments that are reluctant to provide the vaccine to VFC kids if they can’t do it for everybody. Our philosophy has been to push for the VFC kids to get vaccinated, because very often they are at higher risk for disease complications. We tell local health departments that they are able to vaccinate half the kids and they should do it. That doesn’t necessarily translate into universal acceptance of this policy at the local level (Freed et al., 1999).

The significant cost of immunizations may create point-of-service barriers to immunizations among both uninsured and underinsured children

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