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Preface
The U.S. immunization system is a national treasure that is too often taken for granted. Through an intricate maze of public- and private- sector activity, vaccines are delivered to thousands of children, adolescents, and adults each day. The process by which each of us achieves up-to-date immunization status for ourselves and our children differs in large part by the circumstances of birth. Geographic and economic differences in these circumstances can contribute to disparities in access to vaccines and lead to reduced levels of immunization coverage within a general population. Such disparities are not as important, for the purpose of immunization coverage, if they occur within populations that largely achieve complete immunization status. If such disparities are concentrated with certain groups, however, outbreaks of infectious disease that have tragic consequences can occur. Today we are involved in a national experiment with health care reform. The delivery of immunizations for disadvantaged populations, which once occurred primarily through public health clinics, has shifted in large part to the private sector. This shift has occurred swiftly and unevenly over the past decade, stimulated by changes in Medicaid policies and practices, the creation of new governmental programs such as Vaccines for Children (VFC), and the adoption of a new federal–state partnership known as the State Children's Health Insurance Program (SCHIP). These changes have occurred against a backdrop of traditional public health practices that served disadvantaged families for many decades in each state. The privatization of primary health care services for the nation's disadvantaged children has caused many individuals to question the scope and scale of federal assistance for state immunization programs. Childhood immunization coverage levels are currently high, and outbreaks of vaccine-preventable infectious disease are low. Adult immunization coverage rates are low, and programs designed to improve coverage levels are rare at the federal or state level. Given these conditions, is the federal government spending too much or too little to support immunization programs within each state? What role should state governments play in this area? And how important are the data collection, assessment, and outreach efforts of public health agencies if most immunization services are being delivered in the private sector? In this context, the U.S. Senate Appropriations Committee and the Centers for Disease Control and Prevention (CDC) asked the Institute of Medicine to examine the roles and responsibilities of the state and federal governments in supporting immunization programs and services. The Committee on Immunization Finance Policies and Practices was formed to conduct this study. The committee was asked to give attention to a specific program administered by CDC, known as Section 317, that makes annual awards to the states to help them purchase vaccines and support infrastructure efforts. The committee was asked to consider the history of this program, as well as its relationship to newer federal health initiatives such as VFC and SCHIP. In conducting this study, the 15-member committee met five times during the period February 1999 through January 2000. We commissioned a state survey and eight case studies to inform our deliberations, and we hosted a workshop on issues related to pockets of need, held in September 1999 in Washington, D.C.* Several committee members, consultants, and staff participated in site visits conducted during the period September 1999 through January 2000 in four areas: Detroit, Michigan; Houston, Texas; Newark, New Jersey; and Los Angeles and San Diego, California. We received testimony from a distinguished group of federal, state, and local health officials; representatives of state organizations; congressional staff; and researchers engaged in studies of the national immunization system. The committee benefited from a series of reports and briefings provided by the staff of the National Immunization Program within CDC, which is responsible for administering the Section 317 grants and the VFC program. CDC staff attended many of the committee meetings and participated in the September workshop. We are grateful to each of these officials for their thoughtful contributions and expertise over the course of the study: Angie Bauer, Kristin Brusuelas, Jose Cordero, Russell Havlak, Glen Koops, Joel Kuritsky, Martin Landry, Edward Maes, Dean Mason, James Mize, William Nichols, Dennis O'Mara, Walter A. Orenstein, Lance Rodewald, Jeanne M. Santoli, Abigail Shefer, Allyson Shoe, and Nicole Smith. State health officials also contributed perspectives and information in meetings and conversations with committee members, staff, and consultants. We are especially grateful to the immunization project directors, program managers, and other health officials in each of the states who made themselves available for lengthy phone interviews as part of the project's state survey and case studies. We would particularly like to thank the following individuals for their efforts: Christine Grant, New Jersey Department of Health and Human Services; David Johnson, Michigan Department of Community Health; Brad Prescott, Texas Department of Health; Natalie Smith, Immunization Branch, California Department of Health; and Donald Williamson, Alabama Department of Public Health. Several federal officials assisted in arranging meetings with key agency personnel who provided background information relevant to the study, and we are grateful for their assistance: Patricia MacTaggart, Health Care Financing Administration; Doris Barnette and Rita Goodman, Health Resources and Services Administration; and Barbara Hallman, U.S. Department of Agriculture. Data collection and analysis and the development of the final study report required an extensive staff effort. Study Director Rosemary Chalk organized our discussions and prepared several drafts of the study report to guide our analysis and recommendations. Senior Program Officer Wilhelmine Miller was responsible for overseeing the development of the case studies and preparation of the site visit reports and provided much of the analysis for Chapter 3 of this report. Two senior program assistants provided valuable assistance over the course of the study. Suzanne Miller prepared materials for Chapter 2, coauthored two papers on adult immunization and the role of immunization registries, and contributed to the production of the numerous charts and figures in this report. Heather Schofield ably administered the myriad activities associated with each meeting, briefing book, workshop, and site visit, and also prepared our public access files over the course of the study. Other staff made important contributions during the initial or final stages of data collection: Division Director Janet Corrigan prepared the initial project proposal, Senior Program Officer Jane Durch prepared descriptive materials and an analysis of the carryover problem in the Section 317 grant awards, Research Assistant Stacey Patmore conducted initial bibliographic searches on behalf of the committee, and Senior Program Assistant Tracy McKay completed final edits of the report and assisted with bringing the manuscript into production. We also thank our editors Rona Briere, Kristin Motley, and Mike Edington; Sally Stanfield and Estelle Miller from the National Academy Press; and Stayce Bush from the reprographics unit, whose efforts all made significant contributions to the organization and presentation of the committee's views. The committee was extremely fortunate in obtaining the services of a talented and dedicated group of consultants who prepared background papers and case studies to guide and inform the committee's deliberations: Gerry Fairbrother, Amy Fine, Robin Flint, Roy Hogan, Kay Johnson, Hanns Kuttner, Eamon Magee, Heather McPhillips, Victor Miller, Greg Poland, Barbara Richards, and Kathy Stroup. Gary Freed, Sarah Clark, and Anne Cowan in the Division of General Pediatrics, University of Michigan, prepared the state survey that provided much of the data supporting our analysis of state immunization policies and practices. Other individuals, including Harris Berman from Tufts Health Plan; Steven Boedigheimer from the Delaware Health and Social Services; Victoria Freeman from the University of North Carolina at Chapel Hill; Alan Hinman from the Task Force for Child Survival and Development; Vince Hutchins from the National Center for Education in Maternal and Child Health; Kala Ladenheim of the National Conference of State Legislatures; Donald Mattison from the March of Dimes; and William Roper from the University of North Carolina offered useful suggestions and perspectives at critical times in the development of the report. We also benefited from the expertise of staff from professional organizations that are concerned with immunization and the vitality of the nation's public health system. These include Karen Hendricks, American Academy of Pediatrics; Craig Carlson, American Association of Health Plans; Catherine Hess, Association of Maternal and Child Health Programs; Claire Hannan, Association of State and Territorial Health Officers; Tom Musco, Health Insurance Association of America; Cynthia Phillips, National Association of City and County Health Officers; and Doug Greenaway, National Association of Women, Infants, and Children (WIC) Directors. Additional materials regarding state roles in public health were provided by Joan Henneberry of the National Governors' Association and Mary Smith from the National Conference of State Legislatures. We thank each of these individuals and organizations for their assistance and advice over the course of this study.
*Selected materials from the case studies, state survey, and background papers commissioned by the committee will appear in a special supplemental issue of the American Journal of Preventive Medicine, Vol. 19, No. 3S, in October 2000.
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