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Health care reform bill targets improved access to immunizations
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Access to health care and the quality of health care are suboptimal for uninsured and underinsured children, a recent study showed.
In 2007, an estimated 11 million children were without health insurance for at least part of the year, and 4.1 million children (22.7%) with continuous insurance coverage were underinsured, said a special article by Kogan and colleagues in a recent issue of The New England Journal of Medicine.
The latest findings support a 2003 Institute of Medicine report, which estimated that 11 million children and 59 million adults have private insurance that does not fully cover immunizations. This inadequacy of health insurance often equates to children missing well visits and the recommended age-appropriate vaccines generally given during those office visits.
An AAP policy statement from 2009 cited inflated cost-sharing requirements, benefit limitations and inadequate coverage of services as the major reasons for not receiving preventive care.
Solution on the horizon?
According to Alexandra Stewart, JD, the Patient Protection and Affordable Care Act and the Health Care and Education Reconciliation Act of 2010 are designed to address the issue of children with insufficient insurance and will reduce barriers to immunization.
Stewart, director of the Epidemiology of U.S. Immunization Law Project at George Washington University’s Department of Health Policy, told the National Vaccine Advisory Committee recently that qualified private health plans are now required to cover, without cost-sharing, all immunizations recommended by the Advisory Committee on Immunization Practices. All preventive care services recommended by the Health Resources and Services Administration for infants, children and adolescents are also covered by qualified plans, effective Sept. 23. There are some exceptions for grandfathered plans, Stewart told Infectious Diseases in Children.
Under the new Medicaid plan, more adults and children will have insurance coverage, including those with family incomes less than 133% of the federal poverty level. States will receive increased federal medical assistance percentages if they cover, without cost-sharing, adult immunizations recommended by the ACIP. Under private health plans, coverage for dependents is now extended to age 26.
Nearly all states currently provide Medicaid and/or Children’s Health Insurance Program (CHIP) coverage to children up to 200% of the federal poverty level, with 25 states covering children at or more than 250% of the federal poverty level. Families without health coverage who are ineligible for public programs will have the option to buy affordable insurance through state-based exchanges, according to the authors of a health care reform summary published by the Center for Children and Families at Georgetown University.
On the state level, as part of the reauthorization of the Immunization Grant Program (Section 317), states can now purchase adult vaccine from manufacturers at the price negotiated by the
Department of Health and Human Services. Previously, states could only purchase childhood vaccines on federal contracts. Further clarification on this matter is expected from HHS later this year.
Also under Section 317, a demonstration program will be created and run by the CDC to award states grants for the improvement of immunization programs for children, adolescents and adults by using evidence-based, population-based interventions for high-risk populations.
State immunization managers are concerned about Section 317 funding because those resources are needed for program activities such as patient education, vaccine tracking and monitoring, said Claire Hannan, MPH, executive director of the Association of Immunization Managers.
“Like many people in the health care field, the managers are having a difficult time understanding the bill and its impact,” Hannan said. “They are very worried about Section 317 funding.”
Walter Orenstein, MD, deputy director for vaccine-preventable diseases at the Bill & Melinda Gates Foundation and former director of the CDC’s National Immunization Program, said the continuation of Section 317 funds is necessary for a successful immunization program.
“If there is adequate coverage for vaccines and their administration, that’s one part of an immunization program, but it is not sufficient,” Orenstein said in an interview with Infectious Diseases in Children. “Financial barriers are necessary to be overcome, but that’s not enough to get children vaccinated. That’s where Section 317 funding becomes important.”
Insurance coverage
Under the new law, nearly everyone is expected to secure coverage for themselves and their families through an employer, a public program or insurance plans offered in the new state-based exchanges. Health insurance exchanges are marketplaces designed to provide uninsured, and in some cases underinsured, individuals and small-business owners with the ability to purchase affordable health insurance coverage for themselves and their employees. States that establish and operate exchanges must abide by federal guidelines but will also have the flexibility to make distinctive choices.
The options for insurance coverage include the following:
- A government-sponsored health plan, such as Medicare, Medicaid, CHIP, Veterans Administration or TRICARE.
- An individual or family plan through an employer, including through an exchange.
- A plan purchased in the individual insurance market, including through an exchange.
As of 2014, all new individual and small group plans (inside or outside an exchange) will have to provide an essential health benefits package, meet cost-sharing standards and provide either a bronze, silver, gold or platinum level of coverage. Large group plans and grandfathered health plans are exempted, according to a report from the Georgetown University Center for Children and Families and the Community Catalyst.
Reimbursement
The Congressional Budget Office estimated that the federal government will finance approximately 96% of the increase in Medicaid coverage attributable to the health reform legislation during the next 10 years. All states will receive large increases in federal financing, but the actual share of coverage financed by the federal government for any given state will vary based on factors such as the state’s Medicaid matching rate, coverage decisions before enactment of reform and the rate at which eligible people participate in its Medicaid program, according to the Henry J. Kaiser Family Foundation.
According to a recent commentary published in Pediatrics, the law improves access to pediatric services for low-income families, with an $8.3 billion investment of federal funds to make Medicaid and Medicare payments the same for primary care physicians. The increase applies to payments for evaluation and management codes recognized by Medicare starting in 2013 and running through 2014.
“Inadequate payment through Medicaid has been a critical barrier to care for vulnerable children across the United States. On average, Medicaid has paid pediatricians approximately 66% of what Medicare would pay internists for primary care services,” the authors wrote in their commentary.
Payment rates to PCPs who provide primary care services will be at least 100% of Medicare payment rates in 2013 and 2014. These include services related to immunization administration for vaccines. States will receive 100% federal funding for the additional costs of meeting this requirement, Stewart said.
Quality assurance
To ensure that these programs are operating effectively, four separate population health and prevention initiatives have been established. First, the National Prevention, Health Promotion and Public Health Council will be a federal interagency council to promote healthy policies. This group will also establish a national prevention and health promotion strategy and will report annually to Congress on health promotion activities and progress toward meeting goals of the national strategy, Stewart said during her NVAC presentation.
Second, the Prevention and Public Health Fund will be established to invest in prevention, wellness and public health programs, and activities authorized by the Public Health Service Act. This will be a mandatory appropriation of $15 billion over 10 years ($2 billion a year beginning in fiscal year 2015), ending with $500 million in fiscal year 10 and $750 million in fiscal year 11.
Third, clinical and community preventive services will expand the efforts and improve the coordination between the U.S. Preventive Services Task Force and the Task Force on Community Preventive Services.
Finally, there is an education and outreach campaign regarding preventive benefits. The secretary of HHS will convene a public/private partnership to conduct a national prevention and health promotion outreach and education campaign to promote health and prevent disease, according to Stewart.
Also, under the population health and prevention program, the secretaries of HHS and the CDC may award grants to states to improve the provision of recommended immunizations for children, adolescents and adults through the use of evidence-based and population-based interventions.
Biggest challenges to success
According to Stewart, one aspect of providing vaccines to children is left unanswered by the health care reform law.
“Neither preventive services nor immunizations are specifically included in the definition of comprehensive primary health services to be offered by school-based health centers,” she said. “However, funding for these centers may create opportunities for qualified providers to administer vaccines to children and adolescents during school hours.”
One of the biggest challenges to the success of these new policies will be competing initiatives surrounding prevention (ie, obesity, tobacco).
“It will be important to ensure that immunizations are a priority,” Stewart said.
Richard Lander, MD, a pediatrician in private practice and member of the Infectious Diseases in Children Editorial Board, said pediatricians also have a challenge ahead.
“The biggest challenge will be for those pediatricians who will see an influx of patients because they will be accepting the new insurance plans. This new health care plan will be good for patients, but we don’t know yet if this plan will be good for pediatricians,” Lander said. “From a vaccine standpoint, it will depend on where we get our vaccines. There are already a few states, like Massachusetts, where the vaccines are provided by the state to all the pediatricians. It takes a lot of the hassle out of ordering and paying for the vaccines. On the other hand, you also lose the ability to make money on the products purchased.” – by Cassandra A. Richards
For more information:
- AAP Committee on Adolescence, Committee on Child Health Financing. Pediatrics. 2009;123:191-196.
- Center for Children and Families and Community Catalyst. The New Responsibility to Secure Coverage. Available at: ccf.georgetown.edu/index/cms-filesystem-action?file=ccf%20publications/health%20reform/coverage%20requirement%20faq.pdf. Accessed Sept. 17, 2010.
- Congressional Budget Office. Cost Estimate of H.R. 4872, Reconciliation Act of 2010. Available at: www.cbo.gov/doc.cfm?index=11379. Accessed Sept. 17, 2010.
- Georgetown University Health Policy Institute Center for Children and Families. Summary of Medicaid, CHIP, and Low-Income Provisions in Health Care Reform. Available at: ccf.georgetown.edu/index/cms-filesystem-action?file=ccf%20publications/health%20reform/health%20reform%20summary.pdf. Accessed Sept. 17, 2010.
- Institute of Medicine. Financing Vaccines in the 21st Century: Assuring Access and Availability. Washington, D.C.: National Academies Press; 2003.
- Fielding JE. JAMA. 1994;271:525-530.
- Kogan MD. N Engl J Med. 2010;363:841-851.
- McGlynn EA. N Engl J Med. 2003;348:2635-2645.
- Palfrey JS. Pediatrics. 2010;126;374-375.
- Perrin JM. N Engl J Med. 2010;363:881-883.
- Physicians for a National Health Program. What is an accountable care organization? Available at: pnhp.org/blog/2010/07/09/what-is-an-accountable-care-organization/. Accessed Sept. 17, 2010.
Will health care reform provide physicians with adequate remuneration for vaccine administration?