Underinsurance for child & adolescent vaccines: The reasons and remedies

ANN ARBOR, MI – When it comes to coverage for recommended child and adolescent vaccinations, privately insured children are surprisingly often at a greater disadvantage than those children who are publicly insured or even uninsured.

In an editorial appearing in the Aug. 8 issue of the Journal of the American Medical Association (JAMA), University of Michigan C.S. Mott Children’s Hospital pediatrician Matthew M. Davis, M.D., M.A.P.P., explains the reasons why many privately insured children are not covered for recommended vaccines. He also offers remedies to increase child and adolescent vaccinations by making national vaccine priorities explicit and consistent across the country.

“With a growing number of recommended vaccines that are progressively more expensive, some private health plans are electing not to cover certain vaccines, even though those vaccines are recommended by the Centers for Disease Control and Prevention, the American Academy of Pediatrics, and the American Academy of Family Physicians. That leaves some privately insured children underinsured for vaccines,” says Davis, an associate professor of pediatrics and internal medicine in the Child Health Evaluation and Research (CHEAR) Unit in U-M C.S. Mott Children’s Hospital’s Division of General Pediatrics.

Davis’ editorial accompanies a study in this issue of JAMA conducted by researchers at Harvard University and the CDC. The study found that states’ varying approaches to vaccine financing, as well as inconsistencies in the vaccines that are covered, are preventing some underinsured children, including those with private health insurance, from getting recommended vaccines.

Today through the federal Vaccines for Children program, children who are underinsured, Medicaid-eligible, or of American Indian/Alaska Native origin are covered for all recommended vaccinations. The program provides consistent coverage across the country, and ensures recommended vaccines are available to children who are typically most vulnerable.

Privately insured children and adolescents, on the other hand, are generally expected to have coverage for ACIP-recommended vaccines. Yet inconsistencies in private health insurance coverage have left many of these children underinsured for vaccines. In fact, in 2000 an estimated 15 percent of children were underinsured for vaccines.

Several states try to accommodate these gaps in vaccine coverage through federal or state funding. But like many private health insurance companies, coverage varies, leading to a patchwork of state-to-state and vaccine-to-vaccine coverage, which can be very confusing for parents and physicians alike.

“Ironically, this is a situation where privately insured kids may be worse off than publicly insured or even uninsured kids,” says Davis, associate professor of public policy at the Gerald R. Ford School of Public Policy.

In his editorial, Davis discusses two possible remedies to the problem of underinsurance for child and adolescent vaccines. The first is to increase government funding to pay for all recommended vaccines for U.S. children, or to mandate that private health insurance plans pay for the vaccines. But given the current state of the economy, it may be difficult to move forward with such a plan, says Davis.

Instead, Davis recommends creating a system to prioritize vaccines in a consistent manner across the country. This plan would establish “tiers” of recommended vaccines, similar to tiers of medications that are used today in most prescription drug plans.

The most preferred tier vaccines would be purchased for all children through an expanded Vaccines for Children program, eliminating the problem of underinsurance for the highest priority vaccines. Less preferred vaccines would still be purchased for the most vulnerable children eligible for the current Vaccines for Children program. Health plans would then have the option to decide which lower tier vaccines are worthy of coverage, says Davis.

“Making national vaccine priorities consistent across the country could address underinsurance for vaccines judged to be the most valuable,” he notes. “Such a plan might parallel recent efforts at the national level to prioritize the flu vaccine for the high-risk groups at greatest risk for influenza, during recent years with flu vaccine supply shortages. Setting the highest priority groups was difficult but ultimately extremely helpful for physicians, public health officials and the public – because the priorities were explicit and out in the open.”

While creating vaccine tiers could prove challenging, Davis expects the results could be very helpful for patients, physicians and the community.

“Sometimes we forget that child and adolescent vaccines are some of the most effective tools we have to safeguard the health of the United States population. Not only do vaccines protect kids, but we know that recently recommended vaccines against chicken pox and meningitis protect adults too. With that in mind, we have to find a way to make vaccines available for the greater benefit of our communities,” says Davis.

Reference: JAMA, Aug. 82007, Vol. 298, No. 6.

Written by Krista Hopson