1. Insurance Coverage of Vaccines Matthew M. Davis, MD, MAPP Assistant Professor Pediatrics and Communicable Diseases, Internal Medicine, and Public Policy; Child Health Evaluation and Research (CHEAR) Unit, University of Michigan Divisions of General Pediatrics and General Internal Medicine, & Gerald R. Ford School of Public Policy, University of Michigan

2. Challenges for Insurance Coverage of Vaccines Scope –Who and how many children are potentially affected? Why insurance coverage ≠ vaccine coverage –Public programs –Private insurance plans Opportunities to address the challenges –What more do we need to know?

3. When Insurance and Vaccines Weren’t Linked … Polio vaccination drive in a school gym, Kansas, 1950s (courtesy of Bentley Historical Library)

4. When Insurance and Vaccines Weren’t Linked … Polio vaccination drive in a school gym, Kansas, 1950s (courtesy of Bentley Historical Library) Single vaccine efforts Infancy of private health insurance plans Little or no public insurance coverage

5. … To Linking Insurance and Vaccine Receipt

6. Multiple vaccines Employer-sponsored plans as dominant source of health insurance for children National public insurance programs for children (Medicaid and SCHIP)

7. What insurance coverage do children have? Kaiser Family Foundation, 2004 # children (millions) % with private insurance % with public insurance % uninsured Overall77.6612712 Age <1 yr 1-5 yrs 6-18 yrs 3.5 20.3 53.8 52 58 63 36 32 25 12 10 12

8. Public-Sector Vaccine Financing Federal funds –Vaccines for Children Program Covers vaccine purchase for: –Uninsured –Medicaid –Native American / Alaska Native –Underinsured, in federally qualified or rural health centers –Section 317 Vaccine purchase and system infrastructure State funds Vaccine purchase and system infrastructure

9. Challenges to Public Insurance and Vaccines Patient access to Medicaid/VFC providers –Worse with states’ frozen and/or decreasing reimbursement to providers Funding for public-sector vaccine purchase in face of rising vaccine costs –Increasing numbers of vaccines –Comparatively higher costs of newer vaccines –Timing of new recommendations vis-à-vis government budget cycles

10. Underinsurance in Private Health Plans Definition: Child has insurance coverage, but benefits do not include coverage for all recommended vaccines Estimated to affect >10% of child enrollees in private plans (Institute of Medicine, 2004) –Approximately 5 million children Known to promote fragmentation of care (Davis et al, Pediatrics 2003)

11. Etiologies of Underinsurance in Private Plans Trends in benefits and plan design Regulatory factors Employers’ benefit decision-making –Role of employees (proxies for children)

12. Trends in Therapeutic versus Preventive Benefits Traditional emphasis on coverage of therapeutic benefits Role of managed care –Initially higher likelihood of coverage for preventive services –With managed care backlash  return to plans with fewer restrictions and more emphasis on catastrophic coverage Failure to control rises in health care costs –Implementation of preventive care caps that limit coverage for vaccines

13. New Trend: “Consumer-Driven” Health Plans High-deductible (≥$1000) health plans –“Give people the chance to say ‘no’ to themselves” Health savings accounts (HSAs) Increasing enrollment –Unclear implications for vaccinations

14. Regulatory Factors Legislative mandates for children’s vaccines VFC provision for underinsured children

15. Limits of State Vaccine Coverage Mandates “Self-insured” health plans –Employer (typically >500 employees) bears financial risk –>50% of US employees enrolled in such plans Number of children enrolled not known –Catastrophic > preventive coverage Employee Retirement Income Security Act (ERISA, 1974) –Federal statute –Self-insured plans exempt from state insurance mandates

16. Provisions for the Underinsured under VFC VFC –Must receive vaccines at rural or federally qualified health centers –Fragmentation of care –Challenging to verify underinsurance State-specific extensions of VFC –Depend on private provider participation –Challenging to verify underinsurance Employer awareness of VFC provisions –Employers not encouraged to cover more recent vaccines if employees don’t complain about fragmented care

17. Benefit Decisions of Self-Insuring Employers Inadequate information about short-term return on investment for newly recommended vaccines –Costs more evident than benefits New vaccine recommendations contrast with other benefit considerations that are more expensive –Vaccines may be crowded off employers’ agenda Essential to benefits design: employees’ preferences –What are employees’ demands about children’s vaccines?

18. Addressing Challenges: Insurance and Vaccines Parents’ demand for childhood vaccine coverage Employers’ “buy-in” for newly recommended vaccines Effects of current trends in health plan benefit design

19. Parents’ Demand for Childhood Vaccines “Carrots” –Information campaigns about the benefits of new vaccines, targeting parents Will parents communicate demands for broader coverage in private plans to employers and insurers? If coverage not available, will parents seek public-sector vaccines or pay out-of-pocket? “Sticks” –Daycare and school entry requirements Could requirements be implemented more broadly and more rapidly after new recommendations? Potentially hindered by vaccine shortages

20. Employers’ “Buy-in” for Childhood Vaccines Acknowledge and target employers’ economic interests –What are empiric data about productivity and absenteeism related to childhood vaccine coverage? –What are employers’ incentives to design benefit plans that prioritize prevention for children? Communicate with employers as a unique and influential constituency –Distinct from parents and providers –Influenced by consultants –Can the case be made for the importance and urgency of coverage for newly recommended vaccines?

21. Effects of Current Health Plan Design Trends Consumer-directed health plans –What are immunization rates for children enrolled in high- deductible health plans? –Do parents with high-deductible plans seek public-sector vaccines rather than pay out of pocket, or forgo newer vaccines altogether? –What are opportunities to encourage preventive care utilization in high-deductible plans? Preventive care caps –Within a family, whose preventive care gets priority – the parent who needs a mammogram or the adolescent who is eligible for newly recommended vaccines (meningococcal conjugate, Tdap, HPV)?

22. Conclusions Insurance coverage likely an influential factor in undervaccination for US children –Uninsured and publicly insured – limited access to care and to VFC providers in context of constrained public funds –Privately underinsured – benefit coverage not in step with latest recommendations Opportunities to address underinsurance –Parents – employees –Employers’ decision-making –Effects of plan benefits and payment designs

24. Employees’ Preferences for Vaccine Coverage National sample of adults (potential employees) Offered hypothetical scenario of plans that differed only in vaccine coverage –$3 more per month to assure coverage of any newly recommended vaccine(s) in the next year Davis and Fant, 2005

25. Employees’ Preferences for Vaccine Coverage National sample of adults (potential employees) Offered hypothetical scenario of plans that differed only in vaccine coverage –$3 more per month to assure coverage of any newly recommended vaccine(s) in the next year 79% of parents with children in household said they were willing to bear higher premiums to assure coverage of new vaccines Davis and Fant, 2005

26. Employees’ Preferences for Vaccine Coverage National sample of adults (potential employees) Offered hypothetical scenario of plans that differed only in vaccine coverage –$3 more per month to assure coverage of any newly recommended vaccine(s) in the next year 79% of parents with children in household said they were willing to bear higher premiums to assure coverage of new vaccines –Are such plans feasible? –Will employees indicate they want coverage like this? Davis and Fant, 2005