Infant and Child Immunization: Consequences of Federal Legislation 2017

Editorial

It is difficult to predict the final federal health care legislation at this time; however, it may have life and death ramifications as well as public health consequences. Medicaid is now the largest source of health care insurance in the United States, covering 34 million children and 40% of the 4 million live births in the US each year. These programs comprise about 20% of the $545 billion spent for Medicaid in 2015 [1]. The Children’s Health Insurance Program (CHIP) covers an additional 9 million near-poor and middle-income children at a cost of almost $15 billion. Together with Medicaid, these two programs cover nearly one-third of all US children.

Thirty-one states have opted into the Medicaid expansion set up by the Affordable Care Act (ACA) also known as “Obama care”. This legislation expanded the ability for more children and others to qualify for coverage. Among other provisions, this groundbreaking legislation mandated coverage by commercial health insurance companies for essential health benefits including preventive care (such as immunizations) and for pre-existing medical conditions [2]. The ACA currently mandates “first dollar” coverage for ACIP recommended immunizations as well as the attendant physician visits, without any co-pays or other expenses for the patient or their family. The unfortunate Republican efforts to “repeal and replace” the ACA would terminate many of the most important provisions including Medicaid expansion and would cap federal contributions to states for all Medicaid programs. These and other callous efforts would lead to a 25% reduction in federal Medicaid spending and up to 22 million individuals loosing their health insurance coverage!

The currently proposed federal budget would cut the CDC by about 17% or $1.3 billion. The CDC is the main organization responsible for delivering vaccines, alerting us about outbreaks of contagious vaccine preventable diseases such as influenza, pertussis, measles, and mumps and helping to control these outbreaks. One of these programs which pays for vaccines, the Section 317 funds would be cut by as much as $600 million. Another important program, the Vaccines for Children Program (VFC) may suffer a familiar fate.

A recent study suggests that even a 5% reduction in vaccine coverage in children could result in a 300% increase in a vaccine preventable disease such as measles and millions of dollars in increased public health costs [3]. This penny unwise, pound stupid policy of cutting funding for disease prevention has repeatedly proven that prevention of infectious diseases saves ten times money which then must be devoted to direct and indirect medical costs. This of course neglects the even more important tragedy of individuals and their families suffering the experience of illness and even death.

Lack of funding for immunization programs is not limited to children. Appropriate maternal immunization can prevent infantile disease and death from vaccine preventable infectious diseases such as measles, pertussis, hepatitis, and influenza. The maintenance of herd immunity can prevent outbreaks of infectious diseases to individuals of all ages, who are immune compromised or who were too young or otherwise ineligible for immunization.

Another, more subtle, consequence of dramatic cuts in programs funding access to health care, such as Medicaid, CHIP and programs funding vaccine purchase and delivery, such as the VFC and Section 317 programs, is lack of full access to continuity of care. Physicians need to be paid for their services to stay in practice. Likewise since vaccines have become more and more expensive and since the numbers of doses of old and new vaccines for each child have increased, reimbursement for this expense must be available. Lack thereof may result it the child’s trusted primary care pediatrician not being able to continue to care for this patient. Alternatively, lack of financial coverage for vaccines may require the pediatrician to refer the infant to other sources of immunization such as resource stretched public health clinics. This too will interfere with the child’s medical home and continuity of care. Clearly, trusted pediatricians and their staff can be very effective in reassuring a nervous patient or parent regarding the safety, effectiveness, and advisability of recommended immunizations [4].

An additional more indirect but significant problem in terms of optimal immunization practices is the phenomena of vaccine hesitancy and even vaccine refusal. Continuity of care provided in a well functioning medical home optimized the potential for the pediatrician to convince their patients and their parents that the proposed immunizations are safe, effective and indicated. Antivaccine forces use the Internet and other forms of communication to influence their vulnerable audience to believe and act on misrepresentations, delusions, and outright lies while ignoring solid science which endorses proven and appropriate immunization recommendations. These misrepresentations and lies inform conspiracy theories which have in part, recently resulted in measles and pertussis outbreaks [5].

The need for our Congressional leaders, members of the Senate and House of Representatives, and indeed for all Americans to carefully consider legislation effecting the complex and consequential place in the US economy and the lives and health of everyone in our country is great. Yes, our current health care system is far from perfect but legislation and the federal budget should promote constructive changes that will not hurt our most vulnerable population, infants and children, but every one of us.

References

1. Sommers BD and Grabowski DC. What is Medicaid? More than Meets the Eye. JAMA. 2017.
2. Frenkel LD. The Real Issues in Health Care Funding and Delivery. Bulletin-AAP Section on Senior Members. 2017; 26: 10-11.
3. Lo NC, Hotez PJ. Public Health and Economic Consequences of Vaccine Hesitancy for Measles in the United States. JAMA Pediatrics. 2017.
4. Maron DF. Improved Vaccination Rates Would Fall Victim to Senate Health Cuts. Scientific American. 2017.
5. Watson J. Conspiracy Nation: How the Growing Trend of Unfounded Beliefs Hurts patients. Medscape Infectious Diseases. 2017.