Vaccines are one of the most cost-effective, successful interventions in the history of public health. In the United States, they are financed through an intricate patchwork of public and private funding mechanisms and programs. An important component of vaccine financing is the “safety net” that provides vaccines for individuals who fall through the cracks of the system. State public health agencies rely on this safety net to ensure that children and adults are vaccinated and communities are protected against infectious diseases. However, safety nets need constant maintenance. Small rips or tears weaken the net and, if left untended, can grow into gaping holes. The vaccine safety net has been weakened by neglect and needs repair.
Public funding has not kept pace with the cost of vaccinations, causing the safety net to fray. The National Vaccine Advisory Committee (NVAC) appropriately sounds a warning in its report, Assuring Vaccination of Children and Adolescents Without Financial Barriers.1 The NVAC recommendations to strengthen and to fund fully the existing vaccine safety net programs should be adopted immediately, before we experience serious disease outbreaks.
For the majority of children in the United States, cost is not a barrier for vaccinations. Most health insurance plans cover the costs of vaccinations. For children without insurance, the federal government provides free vaccines through the Vaccines for Children (VFC) program. However, ∼11% of young children and 21% of adolescents fall outside the care of private insurance and government programs, because they are not covered by health insurance and are not eligible for free VFC vaccines.2 These are the children of working families with health insurance that does not cover immunization, children traditionally covered by vaccines purchased through a federal grant program known as Section 317. These underinsured children are most in need of the safety net offered by state and local public health departments. Many public health officials are concerned that, with worsening economic conditions, the number of children who depend on this safety net for their vaccines will increase beyond the ability to support the demand.
Historically, state and local public health departments, through a combination of state and Section 317 federal grant funds, have been able to provide vaccines for underinsured children and adults. This safety net of coverage has kept overall immunization coverage rates high and ensured widespread community protection against outbreaks of vaccine-preventable diseases. New, more-expensive vaccines have taxed the system, however, and challenging economic times have forced many states to cut back on vaccine purchases because of lack of state or federal funding. Twenty-four states are unable to provide vaccines for underinsured children in the private sector.3 At least 13 states have changed their policies regarding provision of publicly purchased vaccines since 2004 and now restrict access to selected vaccines.4 The cost to vaccinate a child fully has increased 653% over the past 8 years, although federal funding for vaccine purchases through the Section 317 program has remained essentially the same.5 There are at least 10 different variations of state vaccine supply policies and even more differing policies for specific vaccines and care settings. (G.L. Freed, MD, MPH, verbal, personal communication, 2008).
Although national immunization coverage rates are still high, this patchwork of vaccine-financing structures shows our increasing vulnerability. The risks associated with neglect to our public health immunization system are high and have been demonstrated. In the late 1980s, economic pressures led to decreased immunization infrastructure funding, and national surveys tracking immunization coverage rates were suspended. The result was the worst measles outbreak in >1 decade. In 1989–1991, there were 55622 cases and 123 deaths.6 Without a strong, consistent, public safety net across all states, isolated cases of imported diseases can turn quickly into costly, tragic outbreaks. It is time to heed the warning signs and to strengthen our vaccine safety net.
The NVAC is to be commended for its work in convening stakeholders to identify vaccine financing challenges and to develop recommendations to address them. Two recommendations are of primary importance in repairing the vaccine safety net. (1) Additional funding must be provided immediately to the Section 317 immunization program (NVAC recommendation 14). This program provides funding for public vaccine purchases and strategies to improve access and to ensure high coverage rates for adults and children. (2) Immediate action must be taken to enable underinsured children to access vaccines through the VFC program in all public health settings, including public health clinics as well as federally qualified health centers and rural health clinics (NVAC recommendation 1). This should ensure that the safety net is maintained for children who are not covered adequately by insurance.
The remaining NVAC recommendations should be the subject of consideration as lawmakers move forward with overall health care and insurance improvements. Prevention is a hallmark of true health care reform, and prevention of disease through preservation of our vaccine safety net must be a top priority.
- Accepted August 25, 2009.
- Address correspondence to Claire Hannan, MPH, Association of Immunization Managers, 620 Hungerford Dr, Suite 29, Rockville, MD 20850. E-mail:
Financial Disclosure: The authors have indicated they have no financial relationships relevant to this article to disclose.
- ↵Lindley C, Orenstein WA, Shen A, Rodewald L, Birkhead GS. Assuring Vaccination of Children and Adolescents Without Financial Barriers: Recommendations From the National Vaccine Advisory Committee (NVAC), U.S. Department of Health and Human Services. Washington, DC: National Vaccine Advisory Committee Vaccine Financing Working Group; 2009
- ↵Centers for Disease Control and Prevention. Report to Congress on Section 317 immunization program, February 2009. Available at: www.317coalition.org/legislativeupdate/senate317reportfinal.pdf. Accessed April 21, 2009
- ↵Association of Immunization Managers; University of Michigan Child Health Evaluation and Research Unit. Private provider vaccine supply policy. Available at: www.immunizationmanagers.org/about/state_programs.phtml. Accessed January 8, 2009
- ↵Centers for Disease Control and Prevention. CDC vaccine price list. Available at: www.cdc.gov/vaccines/programs/vfc/cdc-vac-price-list.htm. Accessed January 8, 2009
- ↵Atkinson W, Hamborsky J, McIntyre L, Wolfe S, eds. Epidemiology and Prevention of Vaccine-Preventable Diseases. 10th ed. Washington, DC: Public Health Foundation; 2008
- Copyright © 2009 by the American Academy of Pediatrics