For childhood and adolescent vaccination, having private insurance may be worse than having no insurance at all, according to reports in the August 8, 2007, issue of the Journal of the American Medical Association.

As many as 14 percent to 20 percent of children in the United States are “underinsured,” meaning they have private insurance that covers some, but not all, of the vaccines recommended for children by the Advisory Committee on Immunization Practices (ACIP). And at a time of rising vaccine costs and state and local budget constraints, the children and their parents may find it hard or impossible to get public help to make up the shortfalls, especially for newly recommended vaccines.

The situation is ironic, researchers say, because children who have no insurance at all or who have public insurance such as Medicaid can receive their vaccines free of charge, at any site, under a federal entitlement, the Vaccines for Children Program.

To start with, researchers point out that the number of new vaccines recommended for children and adolescents has nearly doubled during the past five years, and the cost of fully vaccinating a child has increased dramatically in the past decade. “New or expanded recommendations for meningococcal conjugate, tetanus-diphtheria-acellular pertussis (Tdap), hepatitis A, influenza, rotavirus, and human papillomavirus vaccines have led to a 7.5-fold increase from $155 in 1995 to $1170 in 2007.”

In interviews with immunization program managers from 48 states, researchers found that underinsured children were ineligible for publicly purchased vaccines such as meningococcal or pneumococcal conjugates in most states, and 10 states had changed their policies for providing selected new vaccines between 2004 and 2006, to restrict access by underinsured children. “The most commonly cited barriers to implementation in underinsured children were lack of sufficient federal and state funding to purchase vaccines.”

Contrasting that with the Vaccines for Children Program, the researchers pointed out that funding in that program is available for all recommended vaccines for eligible children, including the uninsured and children on Medicaid.

And it’s also true, they said, that there are some limited and hard-to-access options for underinsured children in the Vaccines for Children Program. The Vaccines for Children law says underinsured children can receive vaccines at federally qualified health centers or rural clinics, but such clinics do not exist in every community because of requirements that the clinics must be located in medically underserved geographic areas. More typically, the researchers report, funding for underinsured children who seek vaccines in public health clinics has been provided by other federal sources, such as section 317 discretionary grants of the Public Health Service law.

Immunization program managers interviewed for the study described growing discomfort about their inability to give state-purchased vaccines to underinsured children “Being forced to turn away underinsured children or asking families to pay out-of-pocket for expensive vaccines is creating significant ethical dilemmas, particularly for public health practitioners whose role is to serve vulnerable populations.”

A research report, “Gaps in Vaccine Financing for Underinsured Children in the United States,” and an editorial, “Reasons and Remedies for Underinsurance for Child and Adolescent Vaccines,” appear in the August 8, 2007, issue of the Journal of the American Medical Association.