While much of the attention of the public health community has been focused on expansions of public health insurance to low income women and children, there are other public health measures aimed at improving utilization of care which have had a significant impact. One of the most notable of these was the national effort to increase childhood immunization rates during the 1990s.
Immunizations are one of the few health care services to have been unambiguously shown to be cost effective. Some estimates suggest that a dollar spent immunizing a child can save up to $14.00 in future costs. Yet, a measles epidemic among preschoolers in the early 1990s highlighted the fact that immunization rates for preschoolers in the U.S. remained disturbingly low as of 1991 and 1992. Initial inquiries into the question suggested that one possible suspect should be ruled out. It is sometimes argued that relative to European countries, for example, the U.S. faces special public health problems because of a relatively large minority population. However, immunization rates were low even if one focused only on white children. For instance among three year old white children only 69 percent were up-to-date on Diptheria, Polio and Tetanus immunizations (Harvey, 1990).
Financial barriers seemed a more likely suspect, especially given the evidence that many American children were uninsured. The hypothesis that poverty might play a role prompted the federal government to develop the Vaccine for Children program in 1993. This program provides free vaccines to all children 18 and younger who are eligible for Medicaid, uninsured, under-insured (i.e. their private insurance coverage does not cover vaccines), or Native American. The aim of the program is to provide states with vaccines for free distribution to eligible children. However, four studies conducted by the Centers for Disease Control and Prevention concluded that vaccine costs had not been a major barrier to immunizations in the past because most children already had access to free vaccines through Medicaid or public health clinics.
The CDC concluded instead that many children were not immunized because their doctors failed to vaccinate them! "Missed opportunities" to vaccinate occur when a child who is eligible for a vaccination sees a provider and is not vaccinated, even though there are no valid contraindications. Researchers found that a high fraction of under-immunized children had in fact seen a provider recently (U.S. GAO, 1995a). For example, data from the 1988 National Maternal and Infant Health Survey suggested that 60 percent of inadequately immunized children in this national survey were reported to have received three well child visits by eight months of age (Mustin, Holt, and Connell, 1994).
The last few years have seen dramatic declines in the incidence of vaccine preventable diseases. In contrast to the thousands of cases of vaccine-preventable disease that occurred annually in the early 1990s, there were no cases of tetanus among children in 1996, or of polio, and only 4 cases of diptheria (U.S. DHHS, 1997). Moreover, indigenous transmission of measles has been interrupted, meaning that all new cases are brought in from outside the country (Orenstein, 2000). This tremendous improvement has been attributed to the Childhood Immunization Initiative (CII) launched by the federal government in 1993.
This initiative had many different components. First, new federal resources were given to state and local agencies to enable them to develop computerized tracking systems. Second, a national outreach program aimed at both parents and providers was launched. For example, providers can obtain a kit from CDC called "Make Every Visit Count" that enables them to assess their immunization practices. Third, the Centers for Disease Control undertook to develop a National Immunization Survey of preschool children which would allow them to identify problem areas. Fourth, efforts were made to coordinate the activities of federal agencies that provide vaccines or have access to high-risk populations of children (such as the Special Supplemental Feeding Program for Women Infants and Children (WIC), which serves approximately 44 percent of the U.S. birth cohort) so that it would be possible to keep better track of immunizations. Finally, funding was set aside for research into improved vaccines (such as new combination vaccines) which would make it easier to comply with immunization schedules. The initiative also included the federal Vaccine for Children Program discussed above, as well as funds to hire personnel and extend immunization clinic hours (U.S. Centers for Disease Control 1994, 1997).
This example suggests that even in the case of an intervention that is known to be cost effective, and is widely accepted as being beneficial by parents, it takes a concerted and multi-pronged effort to make sure that the intervention is delivered to everyone who needs it. The elimination of financial barriers was not sufficient to get every child immunized. It was also necessary to undertake outreach to both providers and parents, and to track children in order to insure that they were getting the needed immunizations.