The US system for immunizing children involves a complex mixture of private- and public-sector roles and responsibilities. By most measures, the immunization program has been successful, having introduced a number of new vaccines and expanded the use of existing vaccines during this decade, so that the current immunization schedule protects infants, children, and adolescents from 16 infectious diseases.
A universal recommendation establishes a medical standard that should be available to all children. However, emerging evidence indicates that substantial numbers of children do not receive new vaccines or the receipt of vaccines is delayed because of increased costs. Mechanisms in the public and private sectors to finance vaccines have become strained to the point that ad hoc prioritization of vaccine implementation is occurring throughout the United States, particularly for those with private insurance.1 This has led some to advocate for explicit prioritization of vaccines on the basis of the type of health insurance the child has.2 However, vaccine prioritization segregates children on the basis of insurance status and other issues unrelated to individual and public health. The American Academy of Pediatrics and many others think that this situation is unacceptable.3
In the United States, health insurance coverage remains optional and underinsurance allows for a structural gap in the immunization system. In contrast, in the United Kingdom and various other developed countries, the immunization program is part of an integrated system of public health and clinical care funded at the national level. The UK government purchases all vaccines recommended by its advisory committee, which allows new vaccines to be introduced to the targeted populations in a much more seamless manner in the United Kingdom than in the United States. The social equality created by the UK system offers an important advantage over the US system.
In the United States, the infrastructures supporting the private and public sectors are closely intertwined. Private-sector physicians immunize 84% of all children, and the private sector finances ∼50% of the public health effort to immunize all children. Federal and state governments currently do not have regulations, infrastructure, and financial resources in place to immunize all US children if private-sector support of the immunization program weakens. Private-sector physicians are immunizing most Vaccines for Children-eligible children but too often cannot cover their practice costs because state Medicaid and the State Children's Health Insurance Program do not cover the true costs of vaccine administration. If this continues, then Vaccines for Children-eligible children will increasingly need to receive vaccines in health departments or other public entities, rather than their medical home.
The goal of the National Vaccine Advisory Committee (NVAC) is that every child and adolescent would receive all vaccines recommended by the Advisory Committee on Immunization Practices without financial barriers. I think this can best be accomplished by developing a national vaccine program that does not depend on the current incremental approach, which would occur even if all of the 2008 NVAC recommendations were adopted. Many of these recommendations have been made by previous NVAC and Institute of Medicine committees but have not been implemented or have not eliminated existing financial barriers. Even with these new recommendations, the vaccine program would continue to be implemented on a state-by-state basis, and advocacy for program improvements would need to continue in each state. Although these efforts might increase the number of children receiving all Advisory Committee on Immunization Practices–recommended vaccines in some states, it is likely that little progress would occur in others.
A nationally financed immunization program is needed to ensure that all children receive all of their vaccines. This immunization program could be part of a comprehensive, national, health care program for all children. If such a program does not become reality, then a national immunization program funded through a partnership between the federal and private sectors should be developed. The states might still be responsible for administering the program, but monies to pay for vaccine purchases and administration would not depend on annual appropriations in 50 states.
Funding the program at the national level would help to eliminate pricing differences that occur when private-sector providers purchase vaccines and to reduce the wide variability in the payments for administering vaccines to children. Currently, Medicaid reimbursement for administering a vaccine to a child varies according to state, with a range of $2 to $18. The amount paid for vaccine administration stands in contrast to the situation for adults, in which Medicare pays at least $18 in all states.
At the time NVAC passed its new recommendations, the idea of a national immunization program was thought not to be achievable by some members of the working group. However, NVAC voted on those recommendations before the recent national elections. Given the new composition of the executive and legislative branches, the possibility of a nationally financed immunization program should be pursued. The public health benefits of ensuring that every child has access to all recommended vaccines go well beyond state borders and cannot be achieved if individual insurance companies and states continue policies that result in vaccine prioritization.
- Accepted August 25, 2009.
- Address correspondence to Jon S. Abramson, MD, Wake Forest University School of Medicine, Department of Pediatrics, Medical Center Boulevard, Winston-Salem, NC 27157. E-mail:
Financial Disclosure: The author has indicated he has no financial relationships relevant to this article to disclose.
- Copyright © 2009 by the American Academy of Pediatrics