Barriers to Immunization

February 14, 1993|By BERNARD GUYER

The good news about the Clinton administration's plan to make free immunizations available to all children is that our nation is paying attention to children and making up for the neglect of more than a decade. By focusing on appropriately immunizing our children and creating a more equitable delivery of health care, children and families benefit. The administration's recognition that children's health is a barometer of our health system is a welcome development.

Concern about childhood immunization levels is not new. A decade ago, during the Carter administration, a national initiative raised immunization levels above 80 percent. Childhood immunization levels declined during the 1980s in part because our fragmented system of health care failed to keep track of the TTC health status of the population -- or what the New York Times has called "the Reagan administration's callous inattention to the health of poor children."

The bad news is that getting children immunized just isn't as simple as the new plan suggests.

Nearly all children in this country begin their series of "baby shots" on time during the second month of life, even in the inner cities, where populations are at the highest risk for failing to receive routine preventive health care. Many children, though, appear to get out of sync for their immunizations over the course of the first year of life. They fall behind.

National data indicate that by 24 months of age 50 to 60 percent of inner city children are up to date for all their immunizations. The rest catch up when they enter school because complete immunization is a requirement for school entry in all states.

The risk lies in the interim, when those children who miss their scheduled shots become vulnerable to vaccine-preventable diseases. The measles epidemics of 1989 and 1990 occurred primarily among these preschool-age children who had been delayed in receiving their shots.

Three factors account for the failure to get these young children immunized on time. The first relates to parental behavior. The importance of this single factor has probably been overestimated in the past. Parental belief about the susceptibility of their children to diseases and about the effectiveness of vaccines hardly differs between the families whose children are immunized and those who are not.

The second factor is related to access to health care. Ironically, the poorest children in inner cities, those receiving Medicaid, are least likely to be fully immunized, despite the fact that Medicaid pays for vaccine and well-child visits. This is partially explained in a report by the Children's Defense Fund which pointed out that Medicaid reimbursement policies inadequately compensate providers for these services -- and this becomes a barrier. Other problems, such as transportation to the doctor's office or child care for the children at home, are also barriers to children getting their shots.

Middle-class children covered by private insurance are at risk because insurance may or may not cover immunization. Free universal vaccine would, in effect, subsidize insurance companies that currently cover vaccinations.

The final factor is related to provider practices. An entire new body of research over the last few years has demonstrated that poor record-keeping systems, misinterpretation of indications about when vaccine should not be given, concern about medical liability and other factors have resulted in missed opportunities for immunization. In particular, providers fail to immunize children against measles during the early part of the second year of life.

The new plan to undertake universal purchase of vaccine by the government is intended to make immunization more accessible. By reducing the price of vaccine and increasing Medicaid reimbursements to cover the costs of administration, some of the access barriers will be reduced.

Unfortunately, the evidence does not support a simple relationship between vaccine purchase and success in immunizing children. The states that currently provide free vaccine do not have immunization coverage levels that are substantially different from states that do not do so. The provider practices that result in missed opportunities are found just as frequently in publicly-funded clinics, where the price of vaccine is not a factor, as they are in the private sector, where vaccine prices might be expected to influence practices.

While the Clinton administration's plan is hailed as victory for our youngest and most vulnerable citizens, several important policy questions arise. For example, should we provide free vaccine to families who can afford to pay? As a matter of "values," the nation must provide universal access to health care for children, as it has already done through Medicare for those over age 65. At the same time, we must be realistic about which strategies will improve children's health status.

Bernard Guyer chairs the department of maternal and child health at the Johns Hopkins School of Hygiene and Public Health. He was director of family health services in Massachusetts from 1978 to 1986.

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