Make it simple; make it free. That's a neat formula for an effective childhood immunization program -- one of the most basic parts of any adequate public health system.
But if it can't be both, many health officials think the more important priority is to make it simple. This week the Clinton administration acknowledged that it can't easily get both simple and free into the same childhood immunization package any time soon.
The administration agreed to scale back its plan to have the government buy up all childhood vaccines and provide them free regardless of ability to pay. Instead of spending $1.1 billion each year, the compromise plan would cost only about $300 million yearly, to cover vaccines for children who are on Medicaid or who are uninsured.
But that won't be a major setback if the administration can keep its focus on simplifying the immunization delivery system. Even though cost is often bandied about as a major barrier to full vaccinations, a closer look suggests that plenty of other obstacles complicate the picture.
Convenience is one. When parents have to take time off work to take their children for immunizations -- then encounter long waits and crowded and understaffed public health clinics -- preventive health care may understandably take a back seat to keeping a job. The Maryland General Assembly took one small step toward helping alleviate this problem when it passed legislation this year allowing parents to authorize other responsible adults to take their children for vaccinations.
The bigger need, of course, is for improvements to public health clinics. That would include more money to pay for more staff members, longer hours and other changes that will make vaccinations more accessible, but there is also a need for education and outreach programs. When parents know the importance of protecting their children against diseases that were once common, but are now eminently preventable, they are more likely to make sure their children get their vaccinations.
Even so, as many public health experts point out, the problem isn't necessarily "those dumb parents." It's also a system radically askew.
T. Berry Brazelton, the well-known pediatrician, notes that a good health care system would take advantage of immunizations as a chance to do take a wider view of preventive care. Instead of just poking children and sending them on, a good health care system would use the opportunity to do the kind of early intervention that is essential to helping children thrive. This would be especially true for children at risk of running into problems later on.
Rather than waiting until children and families are in trouble, why not use immunization as an outreach program? Give them a shot, but also say "What a gorgeous baby." Mention some parenting tips or answer some questions.
"Give 'em something special and they'll come," Dr. Brazelton says. This approach, he insists, depends not so much on spending more valuable time on each child and parent, but rather on cultivating a different kind of attitude -- an attitude that says, "this is important."
As things stand now, immunizing children isn't considered important -- at least that's the message sent by the health care system and the insurance companies that see no need to reimburse parents for "well-baby care."
Among children under 6, U.S. immunization rates hover between 40 percent and 60 percent. (School-aged children are required by law to be vaccinated.) In many inner-city areas, immunization rates drop as low as 10 percent.
Cost is an important issue, but it's not as clear-cut as some people contend. The poorest Americans have access to free vaccines, and in 11 states all children can be immunized at no cost. But while those states have somewhat better immunization rates, they don't approach the rates prevalent in virtually every other country in the Western hemisphere. (The United States ranks with Bolivia and Haiti as the only countries in the Western hemisphere that fail to immunize at least 80 percent of pre-school children.)
Figures from the Centers for Disease Control show that, between 1982 and 1991, the cost of immunizing a child through a private physician rose from $23.29 to $196.43. In the public sector, the increase rose from $6.69 in 1982 to $90.55 in 1991. However, during that period, two new vaccines have been added to the regimen, in addition to an extra dose of another vaccine.
Liability costs have also increased, and excise taxes levied by the federal government to provide compensation for children damaged by vaccines have added to the cost.
Yes, it would be ideal to make immunizations both simple and free. It's acceptable to compromise on making them free -- but not on finding ways to make them simple.
Sara Engram is editorial-page director for The Evening Sun.