The public-private dynamics of national immunization policy.

One of the conclusions reached by the Committee on Immunization Finance Policies and Practices was that all public and private health plans that provide primary care coverage should cover immunization services up to the standard of care. The Committee agreed on this principle early in its deliberations, with remarkable speed and consensus. Regardless of their individual backgrounds or areas of expertise, Committee members quickly concluded that if the nation’s immunization system is to work properly and efficiently, then all third-party payers, both public and private, must participate in the advancement of that system. Translated into insurance policy, this means coverage by all payers up to the standard of care (i.e., both routine and “catch-up” or “as needed” immunizations). Among all forms of health insurance, none requires immunization coverage of all enrollees, regardless of age, up to the recognized standard of practice (i.e., the standard set by the Advisory Committee on Immunization Practices [ACIP]). Medicaid and the State Children’s Health Insurance Program (SCHIP) require pediatric coverage up to the ACIP standard, but Medicaid contains no mandatory policies with respect to adults. As the Institute of Medicine (IOM) report1 points out, only a small number of states currently require insurance issuers to cover immunizations, and these requirements appear to be limited to pediatric patients only. Moreover, even where they exist, state immunization laws do not apply to self-insured employee health benefit plans, which cover an estimated 50 million workers and their family members and which are exempt from state insurance regulation under the Employee Retirement Income Security Act (ERISA). Government employee health benefit plans (which fall outside the scope of ERISA) also may fail to provide immunization coverage up to the standard of care for all members. Although the Medicare program does cover certain antigens, its coverage standards are by no means complete. As the IOM report makes abundantly clear, the nation’s immunization policy is intertwined with the public’s health. As a result, insurance policy in the area of immunization becomes a matter of national public health, and policymakers cannot afford to allow insurers—as the major source of personal health financing—simply to elect to either minimize their involvement or to avoid it altogether. Government could, of course, choose to establish a universal and direct entitlement in all residents to complete immunization coverage, financed through various revenue sources and structured to extend coverage independently and outside of the insurance system. Indeed, in 1993 President Clinton offered this type of universal direct financing approach in the case of children. (No similar proposal ever has been made for adults.) Congress rejected this proposal in favor of the Vaccines for Children (VFC) Program and, later, SCHIP, both of which limit their scope to children in low-income families. In doing so, many members of Congress indicated their preference for continued reliance on insurance whenever available. Once direct and mandatory financing is rejected, the practical alternatives become insurance reform, reliance on individual out-of-pocket payments, or use of the annual discretionary appropriations process through expansion of existing programs. (One could perhaps imagine individual tax credits to help underwrite the cost of immunization; but the paperwork alone to support such a system would be overwhelming given the relatively small cost per antigen and the high frequency of the service, at least in the case of children.) The option for out-of-pocket payment overlooks the fact that those persons who are most at risk for underimmunization may be those who are least likely to be able to afford its cost. In addition, as the IOM report underscores, the discretionary appropriations strategy is a risky one for any essential public health benefit, in light of the fact that appropriators tend to respond not to evidence of public health needs but to the peculiarities of the federal budget process and various political imperatives that wax and wane. From The George Washington University Medical Center, School of Public Health and Health Services, Washington, DC Professor Rosenbaum is a member of the Institute of Medicine Committee on Immunization Finance Policies and Practices. Address correspondence and reprint requests to: Sara Rosenbaum, JD, Director, Center for Health Services Research and Policy, School of Public Health and Health Services, The George Washington University Medical Center, 2021 K Street, NW, Suite 800, Washington, DC 20006. E-mail: ihosxr@mail.gwumc.edu.