Many underinsured children not eligible for newer vaccines

Some states are expanding the designation of FQHCs and RHCs to provide vaccines to underinsured children.

Issue: August 2007

ATLANTA — A growing number of underinsured children are not receiving vaccinations due to the current vaccine financing system, according to Grace Lee, MD, MPH.

The cost to fully vaccinate a child increased from $45 in 1985 to $1,200 to vaccinate a girl and $900 to vaccinate a boy in 2006, according to Lee, of the Center for Child Health Care Studies, Department of Ambulatory Care and Prevention, Harvard Pilgrim Health Care and Harvard Medical School.

“We found that the current vaccine financing system is resulting in a growing gap for underinsured children in the United States,” Lee said at the Meeting of the Advisory Committee on Immunization Practices, held here.

Lee and colleagues examined variations in vaccine implementation programs and barriers to implementation among cities and states.

Who is eligible for government funding?

Many children (46%) are enrolled in a private insurance plan and considered fully insured, which includes most of the cost of the ACIP–recommended childhood vaccinations. However, some children are privately insured but considered underinsured because their insurance does not cover all or any of the childhood vaccines, according to Lee. These children will have to pay out-of-pocket or obtain referrals to the public health sector.

“However, it is really dependent on whether a state has adequate Section 317 or state funding available in that situation,” Lee said.

The Vaccines for Children Fund is federal and associated with ACIP recommendations, so as the number of recommended childhood vaccines increases, VFC funding increases. Funding for Section 317 has remained level, though, according to Lee. VFC and Section 317 funding account for 49% of vaccine funding, and state funding accounts for about 5%.

The children eligible for VFC–funded vaccines include uninsured children, children insured through Medicaid, and American Indian or Alaska native children. Underinsured children are eligible for VFC vaccines only if they are served at a federally qualified health center (FQHC) or rural health clinic (RHC), according to Lee. The number of these centers is limited throughout the country, however.

“Historically, vaccinating underinsured children was not a problem because many vaccines were quite inexpensive, and Section 317 funding was available. Now we can see this gap that’s widening,” Lee said.

When the ACIP recommended pneumococcal conjugate vaccine (PCV7, Prevnar; Wyeth) in 2000, the cost of immunization doubled, according to Lee. Although the VFC program covered the vaccine for VFC-eligible children, many states could not afford to cover PCV7 for other children, which resulted in two new vaccine finance policies in addition to the universal, VFC-enhanced and VFC-only policies: the universal select and the VFC enhanced select.

Lee and colleagues conducted a two-phase study of state and city immunization managers from across the United States to assess the differences among states regarding underinsured children’s access to vaccines.

Limitations of financing

During the first phase of the study, which occurred from November 2005 to December 2005, the researchers conducted telephone interviews with nine state immunization program managers from states that had varying vaccine financing policies, according to Lee.

In the second phase, the researchers sent surveys to program managers throughout the United States and conducted telephone interviews with program managers that were not included in the first phase of the study. The program managers answered questions about the status of implementation of newly recommended vaccines and barriers they encountered in implementing vaccine finance policies.

Forty-eight state program managers and two of the six city program managers replied to the surveys and interviews, according to Lee. Fourteen percent of the states had universal VFC coverage, 12% had universal select, 20% had VFC-enhanced, 16% had VFC-enhanced select, and 38% had VFC-only. Ten states restricted their vaccine financing policies because of the number of vaccines approved during the last two years, according to Lee.

From 2004 to 2006, two states had to change from universal to universal select, five states changed from VFC-enhanced to VFC-enhanced-select, and three states changed from VFC-enhanced-select to VFC-only. However, one state temporarily secured additional funding to cover PCV7 vaccination for the underinsured. The state expected to return to VFC-enhanced select when the other new vaccines, including the meningococcal conjugate vaccine (MCV4, Menactra; Sanofi Pasteur), were implemented, according to Lee.

The researchers asked the states and cities whether they were able to provide vaccines for underinsured children in the private sector. Lee and her colleagues found that 45% of underinsured children could not receive varicella vaccine in the private sector, 50% could not receive PCV7, 70% could not receive MCV4, 50% could not receive tetanus-diphtheria-pertussis (Tdap) vaccine and 56% could not receive hepatitis A vaccine.

She and her colleagues found that 45% of underinsured children could not receive varicella vaccine in the public sector, 15% could not receive PCV7, 40% could not receive MCV4, 45% could not receive Tdap vaccine and 15% could not receive hepatitis A vaccine.

“Underinsured children are unable to receive publicly purchased vaccines from either the private sector or public sector unless they can pay out-of-pocket,” Lee said. “This is a big concern because, typically, the public sector has been seen as the safety net for many of these children.”

The immunization program managers also had to address barriers to implementation among the underinsured children. Program managers said that Section 317 funding limitations and insufficient state funding were significant barriers. These were significant issues for 75% to 100% of the finance programs, depending on vaccine, according to Lee.

State strategies to vaccinate

The researchers asked the program managers to discuss strategies they used to address limitations in vaccine financing. To purchase the least expensive vaccines and be able to buy more vaccines for the population, 27 states limited provider vaccine choice. Twenty-five states received additional state appropriations to purchase new vaccines, and nine of the 32 states that had an adult vaccination program in addition to the childhood program decreased the number of vaccines for adults purchased so there was enough funding for the childhood vaccines.

In addition, 13 states expanded the designation of FQHCs and RHCs or increased the number of sites where VFC vaccines were available so that more underinsured children could receive vaccine. Three states designated all public VFC providers as FQHCs or RHCs so that underinsured children could receive vaccine anywhere in the public sector, according to Lee. One state designated all public and private providers as FQHCs or RHCs.

With the growing gaps in vaccine financing that underinsured children face, Lee said that expanding access through funding and legislation is needed to protect these children. – by Lauren Riley

For more information:

Lee G. Emerging gaps in vaccine financing for underinsured children in the U.S. Presented at: the Meeting of the Advisory Committee on Immunization Practices; June 27-28, 2007; Atlanta.