PEDIATRICS Vol. 120 No. 5 November 2007, pp. e1148-e1156 (doi:10.1542/peds.2006-3654)
ARTICLE |
Out-of-Pocket Costs of Childhood Immunizations: A Comparison by Type of Insurance Plan
Immunization Service Division, National Center for Immunization and Respiratory Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia
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ABSTRACT |
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BACKGROUND. The "Guide to Community Preventive Services" strongly recommends reducing out-of-pocket costs to increase vaccination rates among children. Nevertheless, out-of-pocket expenses are still incurred during the receipt of childhood vaccines, vaccine administration, and associated well-child visits.
OBJECTIVE. Our goal was to estimate total and out-of-pocket costs of childhood immunization.
METHODS. We used the 2003 benefit-plan data for all 1217 private and public health plans registered in Georgia and the 2003 Advisory Committee on Immunization Practices recommended vaccine schedule to calculate costs to vaccinate children aged 0 to 5 years in 2003 dollars. By applying published estimates of health insurance enrollment of Georgia children, we calculated the total and out-of-pocket costs per child according to insurance status and race/ethnicity. Immunization coverage according to payer type was based on National Immunization Survey data.
RESULTS. Out-of-pocket costs ranged between $0 (Medicaid/Peachcare) and $652 (uninsured/Medicare). Most out-of-pocket costs were incurred during the first year of life. Up-to-date immunization status ranged from 63.7% for uninsured persons to 83.2% for privately insured persons. Up-to-date status was negatively correlated with out-of-pocket costs and the proportion of the population below 250% of the federal poverty level.
CONCLUSIONS. For most Georgia families, out-of-pocket expenses for childhood immunizations were low, favoring compliance with the recommended immunization schedule. However, families least able to afford the expense faced disproportionately high out-of-pocket costs. Out-of-pocket costs were inversely correlated with immunization coverage levels. Uninsured children whose families lived below 250% of the federal poverty level experienced the lowest immunization coverage levels. Immunization coverage through the Vaccines for Children Program and Medicaid/State Children's Health Insurance Programs should be promoted to minimize or eliminate out-of-pocket costs related to childhood immunizations, especially among children of low-income families.
Key Words: immunization • out-of-pocket costs • insurance
Abbreviations: OOP—out-of-pocket • CI—confidence interval • VFC—Vaccines for Children • UTD—up-to-date • CPS—Current Population Survey • SCHIP—State Children's Health Insurance Program • CDC—Centers for Disease Control and Prevention • FPL—federal poverty level • 4:3:1:3:3—
4 doses of diphtheria, tetanus, and acellular pertussis vaccines, 3 doses of poliovirus vaccine, 1 dose of measles, mumps, and rubella vaccine, 3 doses of Haemophilus influenzae type b vaccine, and 3 doses of hepatitis B vaccine
Reducing out-of-pocket (OOP) costs is 1 evidence-based strategy that is strongly recommended by the "Guide to Community Preventive Services" to increase vaccination rates among children.1–3 In 2003, the Advisory Committee on Immunization Practices recommended 23 immunizations for children before their fifth birthday, to be administered over 7 visits.4 Routine surveillance of 19- to 35-month-old children in the general US population in 2003 indicated that vaccination coverage for the 4:3:1:3:3 immunization series (4 doses of diphtheria, tetanus, and acellular pertussis vaccines, 3 doses of poliovirus vaccine, 1 dose of measles, mumps, and rubella vaccine, 3 doses of Haemophilus influenzae type b vaccine, and 3 doses of hepatitis B vaccine) was 79.4% (95% confidence interval [CI]: 78.5–80.3), with state means ranging between 67.5% and 94.0%.5
The total cost of each vaccine has 3 separate additive components: the cost of the vaccine itself, the cost of its administration by a health care provider, and the cost of a concomitant well-child examination. The US Vaccines for Children (VFC) program provides the vaccine free of charge to qualified children but does not cover the cost of vaccine administration or well-child examination.6 The latter 2 represent OOP expenses typically paid by the parent at the point of service. Although Medicaid-insured children face little or no OOP expense, privately insured children also incur OOP expenses in the form of copayments for 1 or more components.
The Task Force on Community Preventive Services first published its recommendation to reduce OOP costs for childhood immunizations in 1999.7 However, neither the studies systematically reviewed by the task force nor those published since then provide an estimate of OOP costs of the childhood vaccination schedule, for a general population or by payer type.8,9 Accordingly, our purpose was to (1) estimate OOP costs of childhood vaccination for children aged 0 to 5 years for a defined general population, Georgia's 2003 birth cohort, stratified by type of insurance coverage and race/ethnicity and (2) determine the extent of any association between OOP and up-to-date (UTD) rates, controlling for race/ethnicity and poverty level. By detailing OOP costs for each payer type and quantifying the degree to which a reduction in OOP costs will increase immunization coverage for a defined general population, this study advances the topical literature.
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METHODS |
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TOPABSTRACTMETHODSRESULTSDISCUSSIONCONCLUSIONSREFERENCES |
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Insurance Status of Georgia's 2003 Birth Cohort
The Current Population Survey Annual Social and Economic Supplement (CPS) 2004 data provides information on insurance status by age, race/ethnicity, income, and location. We used the CPS to calculate the number of children in Georgia's 2003 birth cohort in each race and ethnicity group according to each payer category.9 Because the 2004 CPS reported insurance status for children younger than 5 years, we assumed that (1) the entire birth cohort survived to 5 years of age and (2) insurance distribution did not vary by age.
Calculation of Costs by Plan Type
This study incorporated data from multiple sources in an aggregate analysis that describes insurance and immunization coverage in Georgia (see Table 1 for details). We obtained benefit-plan data for 1217 health insurance plans registered in Georgia in 2003. These plans represented all potential payers in Georgia: (1) private insurers (employer-sponsored large-group plans, individually purchased and employer-sponsored small-group plans, and the military [Tricare]); (2) the uninsured; and (3) public payers (Medicare, Peachcare [Georgia's State Children's Health Insurance Program [SCHIP], and Medicaid). Table 2 describes the distribution of plans and the percentage of the 2003 Georgia birth cohort insured by each plan.9
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For purposes of cost calculations, we assumed that the costs of services were fairly represented by the rate at which those services were reimbursed rather than some proportion of provider charges. We further assumed that (1) each child received all appropriate vaccines at the earliest eligible date according to the 2003 recommended immunization schedule,10 (2) each visit after the birth visit included a well-child examination, all age-appropriate vaccines*, and a vaccine-administration fee for each injection, (3) all vaccines other than diphtheria, tetanus, and acellular pertussis and measles, mumps, and rubella were single-antigen vaccines, (4) no covered charges were disallowed by the insurer, (5) no vaccine shortages occurred, and (6) prices remained constant relative to each other during the study period. These assumptions reflect what parents could have reasonably expected when they anticipated the cost to vaccinate their child.
For each visit, the total cost per visit was calculated as the sum of the well-child examination fee, the vaccine antigen fee(s), and the vaccine-administration fee(s):
 | (1) |
Reimbursement rates, copayments, and coinsurance rates for vaccines, vaccine-administration fees, and well-child examinations were obtained from separate sources, which depended on the type of insurer. For large-group, employer-sponsored private insurance plans, we obtained average reimbursement rates, copayments, and coinsurance rates for vaccine antigens, vaccine-administration fees, and well-child fees from Medstat's Marketscan 2003 insurance claims database according to plan type in Georgia.11 For individual and small-group private insurance plans, we obtained average reimbursement rates according to plan type in Georgia for vaccine-administration fees and well-child fees from Medstat's Marketscan 2003 insurance claims database. Private-market wholesale vaccine prices were obtained from the Centers for Disease Control and Prevention (CDC) vaccine price list for 2003 and were increased by 25% to adjust for retail pricing.12,13 Using benefit-plan data filed with Georgia's Department of Insurance in 2003, we obtained copayments and coinsurance rates for individual and small-group private insurance plans. We calculated average OOP and total costs per visit for each plan type, and results were weighted to reflect plan type distribution by using data from the CDC's Health Insurance Plan Enrollment Survey (Tricare South, unpublished data, 2005).
For children served by military health insurance (Tricare), the average total cost per visit was calculated by using military reimbursement rules on allowable reimbursements for vaccine antigens, vaccine administration, and well-child examinations in Atlanta and the rest of Georgia. Average OOP costs per visit were based on Tricare Extra copayments and coinsurance rates (Georgia Department of Community Health, unpublished data, 2004). Results were weighted by using the proportion of Georgia medical treatment facilities located in the Atlanta area versus the rest of Georgia to reflect military enrollments in the state.
In Georgia, children who are covered by Medicaid, Peachcare, and Medicare and those who are uninsured qualify for free vaccines through the VFC program.14 For children who are covered by Medicaid and Peachcare, Georgia Medicaid regulations governed reimbursement rates, vaccine-administration fees, and well-child visit rates for both Medicaid and Peachcare providers. Medicaid charged no monthly premium. Infants from households with incomes up to 200% of the federal poverty level (FPL) and children aged 1 to 5 years from households up to 133% of the FPL were eligible for Medicaid. The Peachcare monthly premium was graduated on the basis of the ability to pay and did not exceed $20 for 2 children in the same household in 2003. Children from households up to 235% of the FPL were eligible for the program.14 We used data on Medicaid-allowable charges and VFC vaccine prices to calculate the total costs per visit for Medicaid- and Peachcare-covered children.12,14 Medicare did not cover well-child examinations or childhood vaccines in 2003.15 Therefore, Medicare-covered children were eligible for free vaccines through the VFC but had no insurance coverage for vaccine-administration fees and well-child visits. As a result, Medicare-covered children faced the same OOP costs for immunizations as did children with no health insurance coverage. Although the VFC does not cover vaccine-administration charges, the maximum vaccine-administration fee that VFC providers are allowed to charge is set by the Centers for Medicare and Medicaid Services. We used VFC vaccine prices, Georgia VFC-allowed vaccine-administration charges, and Medicaid-allowable charges for well-child examinations to calculate cost per visit for Medicare-covered and uninsured children.12,14
To calculate the cost in 2003 dollars of a child's vaccinations and associated well-child visits, we summed the cost of the 7 visits and then discounted on a monthly basis by using a 3% annual discount rate:
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We multiplied the total and OOP costs per child in each payer category by the number of children in each payer category. Our results represent the population-weighted total and OOP costs to immunize Georgia's 2003 birth cohort.
Relationship Between OOP Costs and Immunization Coverage
To assess possible associations between costs and UTD coverage, we calculated the correlation between (1) 4:3:1:3:3 UTD immunization coverage and the OOP costs for the 4:3:1:3:3 series and (2) 4:3:1:3:3 UTD immunization coverage and the proportion of population below 250% of the FPL by using the National Immunization Survey 2003 data.
for Georgia.17 Statistical analysis was conducted by using Pearson correlation coefficients and simulation by using a weighted generalized linear model with log link, which was weighted for the proportion of population in each insurance category and given race/ethnicity in that insurance category. Keeping in mind that the 7 payer types represented the state of Georgia, we bootstrapped our results by (1) randomly sampling 1000 times from the data with replacement, assuming a log-normal distribution and (2) generating data from a fitted distribution for simulation.
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RESULTS |
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TOPABSTRACTMETHODSRESULTSDISCUSSIONCONCLUSIONSREFERENCES |
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In the Georgia 2003 birth cohort, most children (66%) were covered by private insurance (57% large-group insurance, 7% small-group/individual insurance, and 2% military). Almost 14% were not covered by any type of insurance. The remaining 20% of children were publicly insured (
1% Medicare, 8% Peachcare, and 12% Medicaid). Among privately insured children, 
61% were white, 34% nonwhite, and the remaining 5% Hispanic. Nonwhite children were primarily black but also included children of American Indian, Alaskan Native, Native Hawaiian, Pacific Islander, Asian, and mixed-race descent. Uninsured children were 34% white, 45% nonwhite, and 21% Hispanic. Children covered by public insurance were 51% white, 40% nonwhite, and 8% Hispanic. Table 2 shows the Georgia 2003 birth cohort according to insurance plan type and race/ethnicity. During the first year of life, the typical immunization visit, which occurs after the birth visit, cost an average of $264 (range: $192–$347). OOP costs averaged $59 per visit (range: $0–$122). When considering all immunization visits of children through 4 years of age, after the birth visit, the average visit cost was $228 (range: $166–$297), and OOP costs averaged $53 per visit (range: $0–$111). Children covered by Medicaid/Peachcare had the lowest average cost per immunization visit and lowest average OOP cost. Children covered by individual/small-group insurance had the highest average cost per visit. Uninsured children and those covered by Medicare had the highest average OOP cost per visit. Table 3 presents total and OOP costs for each immunization visit according to insurance status and type and total costs to vaccinate a child.
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In general, vaccines accounted for the largest portion of total cost, followed by well-child visits and administration fees (Fig 1). In contrast, vaccines represented the smallest component of OOP costs, followed by administration fees and well-child visits. Total costs were highest for the large-group privately insured and declined toward public insurance. OOP costs were lowest for Medicaid/Peachcare, which was followed by the large-group privately insured. OOP costs were highest among the uninsured and children covered under Medicare.
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Total costs were highest for non-Hispanic white children and lowest for nonwhite Hispanic children. OOP costs were highest for white Hispanic children and lowest for nonwhite Hispanic children (Fig 2).
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The total cost to immunize Georgia's 2003 birth cohort from 0 to 4 years of age was $190.9 million (CI: $158.6 to $237.9). Approximately $22.6 million (95% CI: $20.2 to $25.1) was paid OOP at the point of service. Although 57% of Georgia's children were covered by large-group employer-sponsored insurance, they accounted for 67% of total costs and 37% of OOP costs. Small-group–and individually insured children comprised 7% of the cohort and faced 8% of total costs and 7% of OOP costs. Military-insured children comprised just over 2% of the cohort and faced 2% of total costs and nearly 4% of OOP costs. The uninsured, which comprised
14% of the cohort, faced 10% of total costs and 50% of OOP costs. Less than 1% (0.4%) of the children were covered by Medicare; they faced 0.3% of total costs and >1% of OOP costs. The remaining 20% of children were covered by Medicaid or Peachcare. Approximately 13% of total costs and 0% of OOP costs were attributed to this group.
More than 55% of Georgia's 2003 birth cohort was white; 57% of total costs and 48% of OOP costs were attributed to them. Nearly 37% of the cohort was nonwhite; almost 36% of total costs and 39% of OOP costs were attributed to them. Although just over 7% of the birth cohort was white Hispanic, <7% of total costs and 13% of OOP costs were attributed to these children. The remaining 0.6% of the cohort was nonwhite Hispanic; they paid 0.5% of total costs and 0.4% of OOP costs.
By using simple 1-way correlation, immunization coverage was negatively correlated with OOP costs to bring children UTD for 4:3:1:3:3 (
= –0.71) and negatively correlated with the proportion of enrollees below 250% of the FPL ( = –0.49) (Tables 4 and 5). When controlling for race/ethnicity and the proportion of the cohort in each insurance category, 1% increase in OOP cost of the 4:3:1:3:3 series was associated with a 0.07% (95% CI: –0.090 to –0.056; P < .01) reduction in 4:3:1:3:3 UTD coverage. Similarly, a 1% increase in the proportion of enrollees below 250% of the FPL was associated with a 0.09% (95% CI: –0.105 to –0.071; P < .05) reduction in 4:3:1:3:3 UTD coverage.
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DISCUSSION |
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TOPABSTRACTMETHODSRESULTSDISCUSSIONCONCLUSIONSREFERENCES |
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This study, an aggregate analysis that incorporated data from multiple sources that describe insurance and immunization coverage in Georgia, indicated that
12% of all vaccination costs were paid OOP. The burden of these OOP costs fell disproportionately on the uninsured; although the uninsured comprised 14% of the population, they paid >50% of all OOP costs. These children also experienced the lowest UTD immunization rates of children in our sample (63.7%). Note that 70% of Georgia's uninsured children lived in households with an income below 250% of the FPL; at least 1 adult was employed in 78% of the uninsured households.9 In contrast to the uninsured, children covered by Medicaid and Peachcare experienced the lowest OOP costs, and immunization coverage among this group was 79.1%, which was nearly equivalent to coverage among children who were privately insured. This finding, that low OOP costs are associated with increased coverage, indicates the value of decreasing OOP costs for low-income families in promoting immunization coverage. A number of studies have suggested that decreasing OOP costs will increase immunization coverage.18–23 The Task Force on Community Preventive Services noted in their "Guide to Community Preventive Services" that strong evidence indicates the effectiveness of increasing UTD coverage by reducing OOP costs.24 In their review, a 15% median increase in vaccination coverage was achieved by a reduction in OOP expenses, by providing free vaccines, reducing administrative costs, providing insurance when it was lacking, reducing copayments at the point of service. Our study quantified the degree to which a reduction in OOP cost could be effective, and we found that a 1% decrease in OOP cost would result in a 0.07% increase in UTD coverage. Assuming constant elasticity, the elimination of all OOP expenses in Georgia (ie, a reduction of the mean OOP costs of $175 per person to $0) would result in a 7% UTD increase in immunization coverage for the 4:3:1:3:3 series, which would bring coverage to 85.4% statewide at a cost of $19.1 million.
One strategy to decrease OOP expenses for childhood immunizations is to increase enrollments in Medicaid/SCHIP of the uninsured and underinsured who are already eligible and/or to relax eligibility requirements. However, increased enrollment would have budget implications beyond immunization-related costs and the funding of both Medicaid and SCHIP have not kept pace with enrollment expansion.25–30 In fact, in 2005, 20 states tightened Medicaid/SCHIP eligibility criteria, which made enrollment in the programs more difficult, and 21 states reduced program benefits and/or increased cost sharing.28 These measures may contribute to reduced immunization coverage among who are those not eligible for enrollment. A sustained, comprehensive, state-based approach to these regulations is needed to reverse this trend.
In our study, the majority of OOP immunization costs were incurred during the first year of life, when parents often experience a reduced income that is related to time off work for the mother and additional expenses for the new child. Parents who anticipate preventive care consider OOP vaccination costs against expenses for other necessities. Annually, the average family of 4 spends $2581 for health care and $7472 for food.31 During the first year of a child's life, average OOP vaccination costs are $242. Although these OOP vaccination costs may not seem steep by comparison, for the uninsured, average OOP vaccination costs during the first year are $652. These OOP costs may compete unsuccessfully with other monthly necessities, especially because, in 2003, 11% of families in Georgia lived below the FPL ($18400 annually for a family of 4).31
Although children covered by Medicare represented only a very small proportion of children in Georgia (0.4%), OOP costs experienced among these children on an individual level were equivalent to those incurred by uninsured children. Children covered by Medicare are dependents of Medicare beneficiaries, such as children in the care of grandparents, who may experience unique difficulty in covering immunization-related costs because of their fixed income and their own increasing age-related personal medical costs. These children should be considered to be at risk for underimmunization. Medicare coverage of well-child visits and administrative fees associated with dependent minor children's immunization visits would help ensure that such children receive recommended immunizations. To help ensure that such children receive recommended immunizations, the well-child visit and administrative fees associated with dependent minor children's immunization visits should be covered by Medicare.
OOP costs per child did not differ significantly according to racial/ethnic group when controlling for payer category and poverty, except for white Hispanic children. White Hispanic children, who make up 21% of the Georgia's uninsured children but represent only 14% of the total population, incurred the highest OOP costs.
This study has several limitations. The analysis was conducted at the aggregated insurance-plan type level and may, therefore, be subject to ecologic fallacy. However, the negative association between OOP price and demand for a product has been well documented at the individual and aggregate levels, which suggests that ecologic fallacy is unlikely. The analysis was limited to Georgia, which is not representative of the United States. Georgia, however, does include a demographically diverse population, and Peachcare, Georgia's SCHIP, is separate from Medicaid, as is the case in 18 other states. The Health Insurance Plan Enrollment Survey (CDC institutional review board protocol 4205), which provided plan enrollments used to weight private insurance, had a 61% response rate. With the exception of large-group insurance, copayments were based on benefit-plan descriptions. Weights for military insurance were based on the locations of medical treatment facilities rather than the locations of military personnel in Georgia. Although we do not believe these limitations greatly impacted our results, the degree of sensitivity of the results to these assumptions is reflected in the CIs surrounding our estimates.
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CONCLUSIONS |
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TOPABSTRACTMETHODSRESULTSDISCUSSIONCONCLUSIONSREFERENCES |
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For most Georgia families, OOP expenses for childhood immunizations were fairly low, which favored compliance with the recommended immunization schedule. However, families who were less able to afford the expense, the uninsured, faced disproportionately high OOP costs. OOP costs were significantly inversely correlated with immunization coverage levels so that uninsured children whose families lived below 250% of the FPL experienced the lowest immunization coverage levels. Enrollment in and immunization insurance coverage through the VFC program and Medicaid/SCHIP should be promoted to minimize or eliminate OOP costs related to childhood immunizations, especially among children of low-income families.
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ACKNOWLEDGMENTS |
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We thank Dr Philip J. Smith, who provided Georgia's immunization coverage rates, and Edith Gary and Heather Purk for research assistance.
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FOOTNOTES |
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Accepted Apr 12, 2007.
Address correspondence to Noëlle-Angélique M. Molinari, PhD, Immunization Service Division, National Center for Immunization and Respiratory Diseases, Centers for Disease Control and Prevention, 1600 Clifton Rd, MS E-52, Atlanta, GA 30333. E-mail: nmolinari{at}cdc.gov
The authors have indicated they have no financial relationships relevant to this article to disclose.
* We concluded that well-child visits with each immunization after birth because this represents the gold standard of care. Although uninsured children can receive immunizations at a federally qualified health center or rural health center without the concurretn well-child visit, this represents a suboptimal outcome. Furthermore, pediatricians do not routinely provide immunizations without the concurrent well-child visit. 
We used 4:3:1:3:3 UTD, which indicates the proportion of 19- to 35-month-olds who are UTD for recommended vaccinations and received the 4:3:1:3:3 series.
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PEDIATRICS (ISSN 1098-4275). ©2007 by the American Academy of Pediatrics
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