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Health Law's Aim:
Multiple Vaccines For More People

Dec 06, 2010

It's flu season: Time to get your flu shot.

For many adults and their doctors, if they discuss immunizations at all, the conversation ends there. It shouldn't. There are several vaccines that adults need, depending on their age and risk factors, to protect against serious diseases, including shingles, pneumonia, hepatitis and cervical cancer. 

New data from the Centers for Disease Control and Prevention show that while rates of adult immunization have inched up in recent years, they are still far below what they should be.

Only a third of all people over the age of 18 got a flu shot last year, for example, despite the CDC's recommendation that everyone over 6 months of age receive it. Immunization levels were even lower for many other vaccines. All adults who are age 60 or over should get the shingles vaccine, but just 10 percent of that group had received it, according to the CDC. Likewise, only 17 percent of women between 19 and 26 had gotten even one of the three doses of the human papillomavirus vaccine, which protects against cervical cancer.

With its emphasis on prevention, the health-care overhaul law aims to improve vaccination rates by expanding coverage requirements. "It's a total game-changer in terms of adult coverage of immunizations," says Sara Rosenbaum, chair of the department of health policy at George Washington University's School of Public Health and Health Services. The new law, however, leaves some gaping holes, experts caution.

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The United States already does a pretty good job immunizing kids. Vaccination rates are often in the 90 percent range, thanks to the federally funded Vaccines for Children program and other initiatives that provide subsidized immunizations to kids until their 19th birthday.

But then things change. "The moment we cross the threshold of the 19th birthday, when according to the CDC a child becomes an adult, the system is uncoordinated, meager and, it turns out, quite unsatisfactory," says William Schaffner, president of the National Foundation for Infectious Diseases (NFID) and chairman of the department of preventive medicine at Vanderbilt University Medical School.

Private insurers cover adult vaccines to varying degrees, often with hefty co-payments. Immunization coverage isn't required under the traditional Medicaid insurance program for low-income people, leaving decisions up to the states. Medicare, meanwhile, covers vaccines, but getting access to them through physicians can be tough and may be pricey as well, as seniors and disabled people have discovered.

DichterWhen Joan Dichter developed an excruciating pain in her left leg a few years ago, at first she thought it was nerve pain from sciatica. The pain was so bad that Dichter, then 64 and a special education teacher in New York, couldn't lie still in bed at night. Weeks passed, and then she developed the skin rash that's typically associated with shingles, a painful infection that occurs when the virus that lurks in the body after a case of chickenpox becomes reactivated, often decades later. Her doctor finally diagnosed Dichter's condition and within a few days of taking antiviral medication she began to feel better.

Had Dichter known about a shingles vaccine that might have saved her from those painful weeks, she would have gotten it in a heartbeat, she says. But her doctor never mentioned it. "Once you're 50, they always discuss tests: Have this test, have that test," she says. "But there's no emphasis at all on vaccines."

A pair of surveys by the NFID found that only 37 percent of patients said their doctors bring up the subject of vaccines with them, though 87 percent of physicians said they always did so.

The new health law makes it clear that adult immunizations are a priority. Starting this fall, new health plans are required to cover, without cost sharing, all vaccines recommended by the Advisory Committee on Immunization Practices. (The committee is a group of 15 experts that evaluates vaccines and makes recommendations for their use.)

The law also expands Medicaid eligibility to cover adults with incomes up to 133 percent of the federal poverty level ($14,404 in 2010). Immunizations for this group will be covered as an "essential health benefit," says Rosenbaum. But in a twist, the law doesn't require immunization coverage for people already enrolled in Medicaid. "So the poorest people may not have full coverage," she says.

Although Medicare beneficiaries will receive certain preventive services for free starting in 2011, vaccines aren't among them.

Making it even more challenging to raise immunization rates, most vaccines fall under Part D, the prescription drug portion of the Medicare program. That means they're not necessarily available at doctors' offices. As a result, some Medicare beneficiaries have to "brown bag" the vaccine, says Ilene Stein, policy counsel for the Medicare Rights Center, an advocacy group: They get a prescription from their doctor, go to a pharmacy, pick up the vaccine and carry it back to their doctor's office so he can administer it. The CDC and professional medical groups strongly discourage this practice because many vaccines are supposed to be kept refrigerated or, in some cases, frozen.

The health law directed the comptroller general to study barriers to Medicare beneficiaries' access to recommended vaccines. That study is due no later than June 1, 2011.

As for Dichter, her doctor referred her to an infectious-disease specialist who gave her the shingles vaccine, which can prevent recurrences of the disease. Because her private health plan didn't cover it, she paid more than $200 to get it.

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