Financial barriers to vaccinating adults include challenges facing both patients and practitioners, particularly in Medicaid programs across the nation. The Patient Protection and Affordable Care Act (ACA) extended health insurance coverage to millions of individuals through an expansion of Medicaid, attempting to shore up gaps in the health care delivery system, particularly for adults. The law also mandated coverage of 10 essential health benefits, largely preventive services, including vaccinations, at no cost to the consumer.1 Although the federal government establishes certain parameters for all states to follow, each state administers its Medicaid programs differently, resulting in variations in Medicaid coverage across the country. States establish their own policies on coverage benefits, cost sharing to patients, and payment rates to practitioners and dictate where vaccinations can be given. Because Medicaid programs in each state differ, it is challenging to identify gaps in the health care delivery system and barriers that adult patients and their practitioners face in obtaining access to services. Determining coverage benefits for enrollees and payment levels to practitioners by insurance plan type—more so for managed care than fee-for-service plans—is difficult to accomplish, given the complex nature of benefit and payment arrangements in capitated plans.
Through a patchwork of public (Medicaid and Medicare) and private mechanisms, most adults in the US have insurance coverage for vaccines and vaccination services. Still, coverage gaps exist in traditional Medicaid because the ACA only unified vaccination benefits in Medicaid expansion plans for newly eligible beneficiaries and for those enrolled in private insurance plans (with some minor exceptions such as grandfathered plans).1 Moreover, mandates for vaccination coverage, at no cost to the consumer, did not extend to traditional Medicaid recipients, and ACA provisions did not apply to the Medicare program that covers all vaccines recommended by the Advisory Committee on Immunization Practices, albeit some with cost-sharing for some vaccines.
The study by Granade et al2 on the state of Medicaid coverage for adult vaccines and vaccination practices provides a much-needed and timely update to previous work by Stewart et al.3,4 Granade and colleagues2 provide a comprehensive and consolidated view of adult vaccination policies and practices across state Medicaid programs, the safety net mechanism that serves the most clinically vulnerable individuals in communities. Medicaid enrollees have higher health risks, greater health care needs, and disproportionately lower utilization of preventive services. This study2 shows that state programs provide some level of coverage for adult immunizations; however, only 43% cover all 13 Advisory Committee on Immunization Practices–recommended adult vaccines. Variability across programs and the incomplete vaccination benefits that are offered are likely to continue to contribute to fewer Medicaid beneficiaries receiving recommended vaccinations.
Medicaid acts as a high-risk pool, providing coverage for many uninsured individuals who are excluded from the private, largely employer-based markets because of low income, poor health status, or disability. Although every state Medicaid program is evolving to facilitate access to care for enrollees, gaps in access are an ongoing challenge. Granade and colleagues2 found that only 12 expansion states chose to leverage the 1% increase in the Federal Medical Assistance Percentage offered by Section 4106 of the ACA. This provision of the ACA was designed to incentivize state programs to cover and limit cost-sharing not only for vaccines for adults and their administration but also for US Preventive Service Task Force Grade A and B services and comprehensive tobacco cessation services for pregnant women. Without complete benefit coverage for all Advisory Committee on Immunization Practices–recommended vaccines, Medicaid enrollees will most likely face financial barriers to receiving all adult vaccinations, because Medicaid is their primary source of funding for health-related services.
The incidence of vaccine-preventable diseases in the Medicaid adult population can be sizable, with higher incidence proportions for certain diseases (eg, pneumococcal disease, meningococcal disease, hepatitis A, and hepatitis B).5 Moreover, this population includes many individuals with complex and costly needs for care. Decreasing financial barriers to vaccination could be central in reducing vaccine-preventable disease burden and the associated mortality and morbidity, as well as costs to the health care system and productivity costs to society, for this population.
Barriers to adult vaccination also include financial barriers to practitioners. Historically, Medicaid practitioner payment levels have been much lower than Medicare or private sector levels, which factors into the ability for practitioners to cover the costs of vaccination. Practitioner concerns about low payment for vaccines and vaccination services may culminate in a tipping point, one at which practitioners may decide not to stock and carry vaccines. Low payment levels contribute to an even greater challenge of incentivizing new practitioners to begin vaccinating. Granade et al2 highlight this persistent problem of low payments and the implication that this barrier limits access to vaccinations as practitioners have little incentive to vaccinate, beyond a fundamental commitment to serve America’s poorest citizens. A recent study by Yarnoff et al6 documents, in a handful of adult health care practices, that vaccinating adults can be profitable, driven primarily by the payer mix among Medicare and private payers, with Medicaid being the lowest payer. Without the higher payment levels from private insurance and Medicare, physician practices would lose money providing vaccination services. The updated payment levels for vaccine and vaccination services provided in the study by Granade et al2 remind us of the wide variability in payment across payer types, with some states paying $5.00 or even less for vaccine administration (the range of median prices was $9.81-$13.98 per dose) compared with $25.86, the national average Part B payment for vaccine administration in 2018 and 2019.7
Vaccines are unique, not only in the benefits they provide to individuals and communities, but unlike other drug products where patients are given a prescription to be filled at the pharmacy, vaccines are purchased up front at an opportunity-carrying cost to the health care practice to be reimbursed by payers at some point after the vaccination event. Financing adult vaccines and vaccination services is a well-established challenge. State purchasing of vaccines can help but often does not, given limitations in state funding.8 Because physician practice trends show a shift from solo and small practices to integrated delivery networks or health systems, these systems can often ease the up-front purchase and carrying costs of vaccines for practitioners who work in these health systems. Regardless of practitioner setting, low payment across the Medicaid program overall beyond adult immunization undercuts physicians’ ability to meet their practice expenses.
Practitioners committed to caring for Medicaid recipients are most likely seeking to focus on what is best for their patients, while keeping their practices financially solvent. Among the things that are best for patients are evidence-based health screenings and preventive interventions that serve patients in the long run by keeping individuals and communities healthy. Payment challenges hinder the ability of the patchwork system of practitioners, who care for adults, to optimize the full potential of vaccines. The study by Granade et al2 highlights the weaknesses of the fragmented health care delivery system, specifically regarding adult immunization policies. Although complete insurance benefit coverage and higher physician payment do not guarantee higher coverage rates for vaccination, a close look at how to fill program gaps is needed to close the equity gaps in our current fragmented system as the nation works toward a more complete picture of universal health coverage.
Published: April 27, 2020. doi:10.1001/jamanetworkopen.2020.3887
Open Access: This is an open access article distributed under the terms of the CC-BY License. © 2020 Shen AK et al. JAMA Network Open.
Corresponding Author: Angela K. Shen, ScD, MPH, Immunization Action Coalition, 2550 University Ave W, Ste 415, St. Paul, MN 55114 (firstname.lastname@example.org).
Conflict of Interest Disclosures: Dr Shen is a public health consultant to public and private sectors. No other disclosures were reported.
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Shen AK, Orenstein W. Continued Challenges With Medicaid Coverage of Adult Vaccines and Vaccination Services. JAMA Netw Open. 2020;3(4):e203887. doi:10.1001/jamanetworkopen.2020.3887
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