Faced with persistent disparities in vaccination rates among children and pregnant women, a five-state community of practice, coordinated by the National Academy for State Health Policy (NASHP), AcademyHealth and Immunize Colorado, formed interdisciplinary, cross-agency teams to address access and other challenges to reduce immunization gaps among low-income pregnant women and children. Their approaches and lessons learned can help states address current immunization disparities and be used when a COVID-19 vaccine is available.
Vaccines are a powerful and cost-effective tool to prevent diseases and save lives. According to research estimates, of 4.3 million infants born in 2009 in the United States, vaccines will prevent 40,000 deaths and 20 million illnesses over their lifetimes. Vaccinating children is also cost effective, saving $10.20 for every $1 invested in immunizations. In recognition of these benefits, states continue working to improve immunization rates and use multiple levers, including Medicaid programs, to promote full immunization coverage.
While the Vaccine for Children and Medicaid programs have reduced racial and ethnic disparities for women and children, disparities persist, especially in adult populations. According to a Centers for Disease Control and Prevention (CDC) report published in the Morbidity and Mortality Weekly Report, pregnant women enrolled in Medicaid are less likely to be vaccinated for the flu and diphtheria and pertussis (Tdap) compared to those with private insurance. Common barriers to reaching full immunization coverage include:
- Access challenges, including geographic barriers and disparities in health insurance coverage;
- Data challenges, including policy, legal, and technical limitations to integrating data between immunization information systems (IIS) and Medicaid information systems (MMIS); and
- Policy challenges, including vaccine opt-out policies and optional participation in IIS.
To address these challenges and reduce immunization gaps among low-income pregnant women and children, NASHP, AcademyHealth, and Immunize Colorado coordinated efforts through a three-year CDC cooperative agreement to support states in implementing improvement strategies and policies. The project team convened a community of practice comprised of staff from Medicaid agencies, immunization programs, and IIS, in Colorado, Hawaii, Kentucky, Montana, and New Mexico. These interdisciplinary cross-agency teams worked together towards a shared public health goal of increasing immunization rates. A steering committee of state Medicaid and public health leaders, immunization-focused national organizations, and subject matter experts also provided expertise and guided efforts.
NASHP, AcademyHealth, and Immunize Colorado provided technical assistance in several key areas, including resources around IIS funding and sustainability, cross-agency collaboration, data infrastructure including IIS onboarding support, and provider and community outreach. Over the course of the project, the five states made improvements in those areas of work and developed fact sheets highlighting their successes. For example:
- Hawaii and New Mexico strengthened their IIS infrastructure by applying for and receiving a 90 percent match rate through federal Health Information Technology (HITECH) administrative funding.
- Kentucky and Montana onboarded new providers (e.g., pharmacists and non-pediatric immunizing health care practices) to their IIS to encourage vaccination of children and pregnant women.
- Colorado, Hawaii, Kentucky, and New Mexico improved data-sharing and data analysis capabilities, creating documented memorandum of understanding (MOUs), data dashboards, and data matching between IIS and Medicaid data systems.
- Two states enacted legislation to increase access to vaccinations: Hawaii required students entering seventh grade to receive the human papillomavirus (HPV), TDap and meningococcal vaccines (which affect more than 13,000 children per year), and Montana lowered the minimum age for which pharmacists may vaccinate children.
- States also added immunization measures to state Medicaid value-based programs to capture and reward quality improvement.
|Changes in State Medicaid and Children’s Health Insurance Program Measures and Incentives for Childhood and Adolescent Immunizations|
|State||2015 Measures and Incentives for Immunizations||2020 Measures and Incentives for Immunizations||Change?|
|Colorado||Managed Care Organization Performance Improvement Project (MCO PIP)||MCO tracking measure
MCO performance measure
|Hawaii||Medicaid performance measure||Medicaid performance measure|
|Kentucky||MCO-required Healthcare Effectiveness Data and Information Set (HEDIS) reporting measure||MCO-required HEDIS reporting measure|
|Montana||N/A||Patient-centered medical home (PCMH) measure
Medicaid performance measure
|New Mexico||MCO PIP||MCO tracking measure
MCO performance measure
Data from NASHP’s State Strategies to Promote Children’s Preventive Services. Chart updated March 2020.
States worked towards their project goals of improving immunization rates for pregnant women and children by creating and strengthening partnerships between Medicaid and public health agencies. Stronger Medicaid and public health partnerships enable states to identify disparities and target additional outreach and interventions.
These state partnerships and system improvements ensure a foundation for future immunization efforts. States will be able to use this strong foundation for more efficient vaccine distribution, data tracking and reporting, communication, and provider outreach and engagement, and, these frameworks will be critical in a future dissemination of a COVID-19 vaccine.
As these states continue to implement their immunization strategies and navigate this new health landscape with the added challenge of COVID-19, NASHP, Academy Health, and Immunize Colorado will engage additional states in efforts to improve immunization systems through cross-agency collaboration, using the lessons from these five states to address disparities in immunization rates among children and pregnant women.