Improve Texas Immunization System for Children

Texas should improve its immunization system for children and should target areas for special projects where immunization rates are lowest.


Background
Children typically receive immunizations five times during their first 18 months of life, once when they are four or five years of age and once again between ages 11 and 15.

Texas ranks last among states in its percentage of children who have been fully immunized against disease. In 1990, the share of two-year-olds with full immunization ranged from 84 percent in Vermont to 30 percent in Texas. 1

Measles cases and deaths have risen sharply, both nationally and in Texas. During 1989, more than 18,000 cases and 41 deaths were reported across the U.S.; 3,313 of these cases were in Texas. Outbreaks among preschool children dominated the total, with thr ee inner-city epidemics in Chicago, Houston and Los Angeles accounting for one-third of all cases. In 1990, the epidemic intensified with more than 27,672 measles cases and more than 60 deaths reported nationally. Texas had 4,409 of the 1990 cases, about 16 percent of the total.

Nearly half of all measles cases occur among children less than five years old. Minority children are disproportionately affected, with Hispanic and Black preschool children facing seven to nine times higher risks of measles than Anglo children. 2 In 1990, 104 Texas counties reported measles. Three counties accounted for about 57 percent of measles cases Dallas County, with 1,896 reported cases; Travis County, with 326; and El Paso County; with 295.

The United States current childhood immunization system is a patchwork of private physicians and local, state and federal governments. Half of all vaccines are administered by private doctors and half by the public sector.

The federal government provides grants to states and some large county and city hea lth departments to purchase vaccines through the Vaccine-Immunization Program established by the 1962 Vaccine Act. The grants are discretionary; the amounts distributed are based primarily on a state s population. The Center for Disease Control (CDC) administers the program at the federal level while the Texas Department of Health (TDH) administers it at the state level.

TDH is requesting $40.9 million in general revenue to supplement the $12.4 million in total federal funds it expects to receive in fiscal 1994 for immunization-related programs.

The combination of federal and state funds is used to purchase vaccines at the CDC contract rate, which is a wholesale rate. Vaccines are then distributed to county health clinics and Medicaid physicians.

The vaccines are free to the public, but clinics and physicians may bill up to $10 for administering them. The Early Periodic Screening, Diagnosis and Treatment (EPSDT) program which includes immunizations in its screening process covers the cost of admini strat ion, but regular Medicaid does not. The state offers EPSDT coverage to all Medicaid-eligible children under the age of 21; however, they do not have to accept it. Texas uses its state funding of the Vaccine-Immunization Program as state match for vaccines under the EPSDT Medicaid program.

Four barriers prevent successful immunization for all children missed opportunities for administering vaccines, barriers within the system for the delivery of immunizations, poor access to health care and inadequate publi c awareness. Studies of unvaccinated measles patients in some epidemics have shown that about one-third of these children had one or more contacts with health care providers during which an opportunity for vaccination was missed. 3

Failures to vaccinate in emergency rooms and acute-care clinics is particularly troubling because they are the primary sources of care for many inner-city children. In addition, many poor preschool children are in regular contact with public assistance pro grams such as Aid to Families with Dependent Children (AFDC) and Women, Infants and Children (WIC). Opportunities exist through these programs to screen for immunization and vaccinate children on-site.


Recommendations
A. The Legislature should mandate that insurance companies and HMOs (health maintenance organizations) regulated by the state cover routine childhood immunization as part of their basic benefits package.

This recommendation would increase immunization coverage for some children but would not be a requirement for self-insured companies exempted from state regulations by federal law. Self-insured companies are usually larger companies that can afford the costs of self-insuring.

B. The Legislature should require hospitals to provide a printed flyer to new parents explaining the recommended immunization schedule and where immunizations may be obtained at little or no cost in the community. It also should require hospitals to send r eminder postcards to parents when children are due for immunization.

C. The Legislature should mandate that the Texas Department of Health (TDH) seek discretionary funding from the U.S. Department of Health and Human Services (HHS) or from foundations for an Emergency Immunization Demonstration Program that would target five counties in Texa s with the lowest immunizations rates and create model programs for those counties.

D. The Legislature should direct TDH to seek discretionary funding from HHS or from foundations to develop models for building public awareness concerning the importance of preschool immunization among high-risk populations.


Implications
These recommendations would improve immunization rates among all Texas children. They would also target the areas of Texas with the worst immunization rates and develop effective ways to reach more children in these areas.

The recommendations also would require hospitals and insurance companies to take more responsibility for ensuring that children are immunized. This action would reduce costs to insurance companies, hospitals and other health care providers for treating children who become ill from diseases that could have been prevented with immunization.


Fiscal Impact
Although these recommendations would provide some long-term savings through avoided health care costs in the future, insufficient data exist to determine estimated savings from these recommendations. The fliers and postcards would cause some minor administ rative costs for local hospitals; developing grant proposals on public awareness and the Emergency Immunization program would entail minor administrative costs to TDH. Insufficient data exist to determine these administrative costs.



Endnotes
1 Children s Defense Fund, The State of America s Children 1992 (Washington, D.C., 1992).
2 National Vaccine Advisory Committee, The Measles Epidemic: The Problems, Barriers, and Recommendations (Washington, D.C.: January 8, 1991), p. 6.
3 Ibid., p. 2.