State Vaccine Policies: Current Status and Challenges Sarah J. Clark, MPH Anne E. Cowan, MPH Gary L. Freed, MD, MPH Child Health Evaluation and Research (CHEAR) Unit University of Michigan

Background Institute of Medicine reports described state policies related to immunization financing and delivery –Calling the Shots (1999) –Financing Vaccines in the 21st Century: Assuring Access and Availability (2002)

Background Key IOM recommendations –317 funding increases for new vaccines –317 and state funding increases for adult immunization –Expansion of insurance mandates

Purpose To document immunizations policies among CDC immunization grantees To describe current challenges to immunization programs

Methods Semi-structured interviews with immunization program managers and/or designated staff for 57 grantees –50 states, 6 cities, and 1 territory Interview transcripts reviewed to document policies, identify common challenges

Program Characteristics (Data reported for 50 states and DC)

Vaccine Supply Policies For Private Providers

VFCVFC + Underinsured “Select” VFC + UnderinsuredUniversal Purchase “Select” Universal Purchase Alabama Arkansas California Colorado Delaware District of Columbia Florida Iowa Louisiana Mississippi Missouri Montana Nebraska New Jersey North Dakota Ohio Oklahoma Oregon Pennsylvania Tennessee Virginia West Virginia Wisconsin Illinois Indiana South Carolina Arizona Georgia Kansas Kentucky Maryland Michigan Minnesota New York Texas Utah Connecticut Hawaii Idaho Maine Massachusetts Nevada North Carolina South Dakota Vermont Alaska New Hampshire New Mexico Rhode Island Washington Wyoming

Factors Affecting Vaccine Supply Policies Cost, pace of new vaccine recommendations 317 funding levels State funding, tradition, commitment Trends in underinsured FQHC availability and delegation of authority

Non-Federal Funding for Childhood Vaccine Purchase

Definitions of Non-Federal Funding Categories Significant: State allocates or facilitates funds for substantial target population(s); expected to be ongoing. Actual amount varies widely across states. Includes taxes on payers, MCH block grants, and funds from other state agencies. Does not include SCHIP. Limited: State allocates small amount of funds for outbreaks or limited-use situations. Includes periodic availability of funds due to surplus (not planned or budgeted). Less than $100,000 per year. None/minimal: No allocated or planned funding for childhood vaccines. Small amounts may be purchased at local level.

Non-Federal Funding for Childhood Vaccine Purchase

Factors Affecting Non-Federal Funding for Childhood Vaccine Purchase Political climate / “champion” for immunization State economy Pressure/assistance from vaccine manufacturers

Non-Federal Funding for Adult Vaccine Purchase

Factors Affecting Non-Federal Funding for Adult Vaccine Purchase Mission of immunization program Traditional adult programs, target groups Extent of unmet needs for childhood immunizations

State Mandates for Insurance to Cover Childhood Immunizations

Factors Affecting State Mandates for Insurance Coverage Variable targets (e.g., limited age range or number of vaccines) Concern about “opening up” immunization policy ERISA plans exempt Other mechanisms for insurer contributions to vaccine financing

Overview of Findings Some program improvements since 2000 –Improved adequacy of VFC funds to cover VFC-eligible children –Overall stability in the VFC provider population

Overview of Findings Common challenges/concerns include: –Increased program requirements and program complexity: priorities and adequacy of funding –Transition to VMBIP: maintaining positive relationship with providers, having sufficient data to manage program –VOFA/spend plans: review process

Moving Forward Federal leadership needed to: –Advocate for increased 317 funding –Improve allocation and award processes for 317 operations funding

Moving Forward Federal leadership needed for: –Expand vaccine financing options for underinsured –Address ERISA exemption from coverage mandates and payer-based vaccine purchase

Moving Forward Federal leadership also may be helpful to: –Promote mechanisms to minimize barriers to vaccine purchase with non-federal funds –Promote strategies to address barriers to immunization program understaffing –Assist grantees in predicting funding needs for expected new vaccine recommendations

Moving Forward Grantees seek a genuine partnership with CDC –To articulate objectives that foster efficiency and focus on highest priorities –To identify and solve problems, with opportunities to field test and re-work new initiatives and tools –To recognize areas where uniformity is essential and those where flexibility is preferable –To support testing of new ideas and dissemination of successful strategies

Acknowledgments Immunization program managers / staff Sabin Institute