A shot in the dark: Vaccine funding cuts a gamble for good health

by Kim Krisberg

It's too early to tell just how many families Elizabeth Frerking and her colleagues at the Saline County Health Department in Marshall, Mo., will have to turn away, but it's likely to be too many. As of Oct. 1 and due to cuts in federal immunization funding, Frerking can only administer vaccines to children with no insurance at all or those with Medicaid coverage. However, it wasn't always like that.

"Previously, any family could come here and get immunizations -- we didn't turn anybody away," Frerking, the department's vaccine coordinator, told me. "Now, we get to be the ones who break the news to people and that's pretty awful. But so far, everybody has been really understanding about it."

After working so hard to make immunizations a priority, it was a shock when funds were cut as drastically as they were, said Frerking, who reported that Missouri's 317 program funding was cut by about $1 million in 2010 and by about $982,000 in 2011. The Centers for Disease Control and Prevention's Section 317 program, which derives its name from section 317 of the Public Health Service Act, provides discretionary federal grants to all states to provide vaccines to underinsured children who are not eligible for the federally funded Vaccines for Children program. 317 dollars are also used to support adolescent and adult immunization efforts as well as to strengthen immunization infrastructure and capacity.

Back in Marshall, Frerking said she hopes that those she can no longer serve will seek out immunizations from private providers, but she worries that struggling families may try to forgo vaccines for financial reasons.

"It's very frustrating," she said. "But it's definitely a sign of the times."

Indeed it is. As state and federal decision-makers slash away in an attempt to balance their budgets, vaccines are getting little special treatment. Here are just a few unfortunate examples: Alaska recently eliminated all funds for adult immunizations; North Carolina completely eliminated its universal childhood vaccine program; California cut $18 million from its vaccine program; and in Indiana, county health departments can no longer provide low-cost vaccines to people with insurance.

At the federal level, 2011 funds for the 317 program were technically level with 2010; however, the program received an extra funding boost via the Prevention and Public Health Fund, which is a part of the Affordable Care Act. So far, the federal funding levels have not buffered states against reductions in their 317 grants and federal dollars aren't able to fill in for state budget cuts. The cuts have many public health advocates baffled, as vaccines are among the most cost-effective ways to prevent disease. According to the 317 Coalition, for every $1 spent on vaccines, $16.50 is saved in medical and other indirect costs.

"It's a complete injustice that people who are working hard and don't have enough insurance are getting turned away," said Amy Pisano, executive director of the vaccine advocacy group Every Child By Two. "If our last possible venue of health departments aren't there to cover those families, we're really looking at possible outbreaks in the future."

Not only do vaccine funding cuts create openings for disease comebacks, they can also affect a health department's ability to conduct outreach and education -- efforts that Pisano says are sorely needed to counteract misinformation about vaccine safety. Paul Etkind, director of infectious diseases at the National Association of County and City Health Officials (NACCHO), told me that local health departments are facing a triple whammy: cuts in federal and state funds as well as critical staff losses. According to a recent NACCHO survey, about 19 percent of the nationwide local health department workforce has been eliminated since 2008. That loss of "institutional memory and the oral history of how these things are done is huge," Etkind said.

Etkind pointed to the "tremendous burst of creativity" that happened during the H1N1 flu outbreak as an example of the kind of immunization success that health departments have garnered with the right amount of resources. Bolstered with public health preparedness dollars, health departments were able to reach into communities like never before, holding flu vaccine clinics in nontraditional settings and reaping the payoff of years of planning and relationship building. Today, Etkind said, local health departments report having to cut back on flu vaccine clinics and outreach. For example, due to state budget cuts, county health departments in Oklahoma can no longer offer free flu shots to all residents. Luckily, Etkind noted, this season's flu strain hasn't been particularly virulent.

"Local health departments are being forced to limit their accessibility and that's damaging," he told me. "We're not saving any money with these cuts. The bill for illness is always much greater than the bill for prevention."

Will health reform help?

Under the Affordable Care Act, insurers participating in state health insurance exchanges will be required to cover recommended vaccines and state Medicaid programs have new incentives to cover vaccines. But can they cover cuts in state and local vaccine services? Like many aspects of the landmark health reform law, it's hard to know, said Alexandra Stewart, assistant professor in the Department of Health Policy at George Washington University's School of Public Health and Health Services.

"It's a wonderful step forward, but it's hard to know how things will shake out," Stewart said. "If states continue to cut (vaccine) services before the health reform provisions can be implemented, there will definitely be a gap...and that is a gamble."

Stewart noted that while states are having to make some "incredibly tough" decisions, they are also "stretching and turning every way they can." For example, in Alaska, the state's Medicaid program now covers adult immunizations -- not a benefit it had offered previously. The change could help offset the elimination of state funds for adult immunizations, but there will be a residual population with no coverage at all, Stewart said.

"Once (disease) get into a community, it's very hard to eradicate," she told me. "We've got to maintain our rates of immunization, regardless of a person's immigration or insurance status."

In the United States, the threat of vaccine-preventable disease may be low, but it's definitely not gone. Just look toward California, where last year a severe outbreak of pertussis, commonly known a whooping cough, resulted in more than 9,000 cases and 10 infant deaths. That's the worst pertussis outbreak in more than 60 years. In the same year as the outbreak, California legislators cut $18 million in state immunization funds. According to Catherine Flores Martin, director of the California Immunization Coalition, $3.5 million of the cut was in funds that go to community health centers -- that means that such centers have lost the ability to offer walk-in immunization clinics and to conduct outreach to some of the state's most vulnerable families.

"We have to be vigilant (against vaccine-preventable diseases) and this is impacting our ability to contain diseases when they occur," Martin said. "We intend to be back at the legislature and make sure they understand that this is not an optional activity -- it needs to happen and we need to make sure it's funded adequately."

Debra Rosen said she was "shocked" at the funding cut, especially since it happened around the same time as California's pertussis outbreak.

Rosen directs public health programs, chronic disease and health education at the Northeast Valley Health Corporation, a federally qualified community health center serving residents in northern Los Angeles County. Before the funding cuts, Rosen said the center was able to offer free vaccines to children at express immunization clinics at five different sites. Of the 8,000 people served a year during the express clinics, about half were community members and half were regular patients of the center. Now, due to the state funding cut, the center is only able to offer immunizations to its patients. Rosen said she's been busy applying for grant money so the center can reinstate its successful vaccination program, but she suspects the funding cuts will contribute to lowered immunization rates.

"If we don't continue immunizations, these diseases will come back," Rosen told me. "They'll cause disability, death and it'll cost the country a lot of money."

Kim Krisberg is a freelance health reporter living in Austin, Texas, and has been writing about public health for almost a decade. While her education is in journalism, her heart is in public health.