Study reveals gaps in vaccine financing for underinsured children

A national survey of state immunization program managers reveals gaps in coverage for the current vaccine financing system, suggesting that many underinsured children may not receive recommended vaccinations, such as for pneumonia and meningitis, according to a report in the August 8 issue of JAMA.

“The number and cost of new vaccines routinely recommended for children and adolescents has increased considerably since 2003. New or expanded recommendations for meningococcal conjugate, tetanus-diphtheria-acellular pertussis (Tdap), hepatitis A, influenza, rotavirus, and human papillomavirus vaccines have led to a 7.5-fold increase in the cost to fully vaccinate a child in the public sector (from $155 in 1995 to $1,170 in 2007),” the authors write.

Childhood vaccines in the U.S. are financed by a patchwork of public and private sources. Anecdotal reports from state policy makers and clinicians suggest that new gaps have arisen in financial coverage of vaccines for children who are underinsured (i.e., have private insurance that does not cover all recommended vaccines). In 2000, approximately 14 percent of children were underinsured for vaccines in the United States, requiring families to either pay out-of-pocket for the cost of vaccines not covered or forego receiving vaccines, according to background information in the article.

Grace M. Lee, M.D., M.P.H., of Harvard Medical School, Children’s Hospital Boston and Harvard Pilgrim Health Care, Boston, and colleagues examined the status of financing and distribution of new pediatric vaccines at the state level. For the 2-phase study, the researchers interviewed nine state immunization program managers and subsequently interviewed and surveyed 48 state immunization program managers from January to June 2006.

The researchers found that many states were not able to provide state-purchased vaccines for underinsured children in the private sector, public sector, or both. For example, for vaccines given in the private sector, 46 percent of states did not provide publicly purchased varicella (chickenpox) vaccine to underinsured children and 70 percent of states did not provide publicly purchased meningococcal conjugate vaccine to the underinsured. For vaccines given in the public sector, 17 percent of states were unable to provide publicly purchased pneumococcal conjugate vaccine to underinsured children and 40 percent were unable to provide publicly purchased meningococcal conjugate vaccine. “This meant that underinsured children were not able to receive state-purchased vaccine in either the private or public sectors in these states. None of the vaccines we studied was covered for all underinsured children in the United States,” the authors write.

Due to limited financing for new vaccines, 10 states changed their policies for provision of publicly purchased vaccines between 2004 and early 2006 to restrict access to selected new vaccines for underinsured children. The most commonly cited barriers to implementation in underinsured children were lack of sufficient federal and state funding to purchase vaccines.

“Assuming 14 percent of children are underinsured in the United States, we estimate that 2.3 million children are unable to receive state-purchased meningococcal conjugate vaccine in the private sector, and 1.2 million children are unable to receive this vaccine even if they are referred to the public sector,” they write. “Current trends in health insurance products, including enrollment in high-deductible health plans that may or may not provide immunizations or other preventive benefits before a high deductible has been met, are likely to increase the magnitude of this gap and must be carefully monitored.”

(JAMA. 2007;298(6):638-643. Available pre-embargo to the media at www.jamamedia.org)

Editor’s Note: Please see the article for additional information, including other authors, author contributions and affiliations, financial disclosures, funding and support, etc.

In an accompanying editorial, Matthew M. Davis, M.D., M.A.P.P., of the University of Michigan, Ann Arbor, comments on the study by Lee and colleagues.

“Strong proponents of immunization will likely object to the concept of universally recommended vaccines ranked on their relative merits. Nonetheless, that position fails to acknowledge the implicit prioritization of recommended vaccines that is already occurring at the state level, as illustrated by the findings by Lee et al. Rather than continuing a program in which de facto prioritization creates inconsistencies across states that are difficult for the public to understand, the public health and medical communities may benefit from making prioritization of vaccines more explicit and consistent.”

“The process of explicit prioritization is challenging in the public sector, as witnessed in recent years during shortages of influenza vaccine. However, the lists of priority populations that emerged through evidence-based deliberations about the burden of influenza illness have improved the influenza immunization effort by clarifying steps to take in case of vaccine supply shortage. Explicit prioritization of financing for newly recommended vaccines, as a remedy for shortfalls in financing for underinsured children, cannot be far behind.”

(JAMA. 2007;298(6):680-682. Available pre-embargo to the media at www.jamamedia.org)

Editor’s Note: Please see the article for additional information, including other affiliations, financial disclosures, funding and support, etc.

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