Childhood vaccinations in the U.S. were steady for the decade before the pandemic, but have shown a decline for the past couple of years. We sat down with Dr. Pam Shaw, a professor of pediatrics at the University of Kansas Medical Center, who explained some of the reasons for that decline. She also discussed other disruptions to vaccinations and some of the challenges to getting children vaccinated, particularly those who were uninsured. Also on the show is Shannon Kolman, who follows vaccine policy for NCSL. She notes the large number of vaccine related bills introduced in the past couple of years, and explains how legislatures have tried to make it easier for children to get vaccinated.
Childhood vaccinations in the U.S. were steady for the decade before the pandemic, but have shown a decline for the past couple of years. We sat down with Dr. Pam Shaw, a professor of pediatrics at the University of Kansas Medical Center, who explained some of the reasons for that decline. She also discussed other disruptions to vaccinations and some of the challenges to getting children vaccinated, particularly those who were uninsured.
Also on the show is Shannon Kolman, who follows vaccine policy for NCSL. She notes the large number of vaccine related bills introduced in the past couple of years, and explains how legislatures have tried to make it easier for children to get vaccinated.
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Ed: Hello and welcome to “Our American States,” a podcast from the National Conference of State Legislatures. This podcast is all about legislatures, the people in them, the policies, process, and politics that shape them. I’m your host, Ed Smith.
PS: If you are uninsured and/or you are underinsured, its difficult for you to access vaccination. It can be very expensive.
Ed: That was Dr. Pam Shaw, a professor of pediatrics at the University of Kansas Medical Center and an associate dean for Medical Education. She is one of my guests on the podcast to discuss the status of childhood vaccinations coming out of the COVID-19 pandemic. Childhood vaccinations in the U.S. were steady for the decade before the pandemic but have shown a decline for the past couple of years. Dr. Shaw explains some of the reasons for that decline. She also discussed other disruptions to vaccinations and some of the challenges to getting children vaccinated particularly those who are uninsured.
My second guest is Shannon Kolman, who follows vaccine policy for NCSL. She notes the large number of vaccine-related bills introduced in the past couple of years and explains how legislatures have tried to make it easier for children to get vaccinated.
Here is our discussion starting with Dr. Shaw.
Dr. Shaw thanks for coming on the podcast.
PS: Thank you for inviting me.
Ed: We want to talk about childhood vaccines today. And as I understand it, in the decade prior to the COVID-19 pandemic, childhood immunizations were pretty steady. But since the pandemic, the national kindergarten vaccination rate for state-required vaccines has declined about 1% a year or 2% total through the end of 2022 school year. What kind of effect does this trend have on children and on states?
PS: The biggest concern we have regarding a decrease in vaccinations is the possibility of some of the childhood diseases that we’ve seen in the past coming back and infecting children. We have to reach a certain level of immunity in the population in order to prevent that. And as we see childhood immunizations drop, the concern increases that we may see more preventable immunization related diseases.
Ed: So, let me ask you just a little bit more about that because we know that legislators are very concerned about costs and whether that’s in terms of lost productivity or what have you, but what kind of costs are associated with lower vaccination? Certainly, the cost of children’s health, but what other costs should people think about?
PS: There are other costs, and we shouldn’t forget about that. Not only are there costs associated with the children getting sick like hospitalizations and loss productivity from the parents who have to lose work during that period of time. But here are societal costs as well. If you look at the statistics, there is about $2.2 trillion in total societal costs if you look at what the vaccination program has prevented so far. So, when you think about the opposite of that, we could get somewhere up to $1 to $2 trillion societal costs if we continue to decrease the rate of immunization.
Ed: I guess that we are returning to normal after the pandemic, we are largely with in person learning and other activities. But pandemic related disruptions continue to affect the vaccination coverages as I understand it. And why is that? What are some of those disruptions and barriers to children getting vaccinated?
PS: That’s a great question and there is a multitude of things that happened during the pandemic. The first being there was an interruption in pediatric preventative care. Many offices closed down and were not immunizing regularly children. Our public health departments were inundated with fighting the COVID-19 pandemic and so normally they provide immunizations as well. So again, there was another drop in immunizations due to that. We also think that there are some housekeeping things that happened like recordkeeping at the schools didn’t occur in a regular fashion. And then we also know that some schools were more lenient with kids not perhaps completing their immunization requirements before they entered school just to get them back into school post pandemic. There is not only the loss of opportunity, but also we may have missed some recordkeeping and some kids have missed immunizations because of that.
Ed: Let me ask you about the issue of exemption and we know in some states, people can get an exemption from their children being vaccinated. I guess it is true in every state. You can do that for medical reasons and in some states for religious or philosophical reasons. I think we’ve also new stories over the last couple of years about people very vocally objecting to the COVID vaccine. And I wonder if school vaccination exemption rates for required school vaccinations changed during this period or affected childhood immunization rates in other ways.
PS: Luckily the immunization rate has or the exemption rate, pardon me, has stayed about 2.6% nationally. So, we haven’t seen an increase in exemption rates. We have seen both nationally in many states the move towards allowing more exemptions and in state legislatures. And that’s concerning because again when you have increased exemption rates, you run the risk of increasing the susceptibility of children to those preventable diseases. So, we do know that medical exemptions are present in every state. And they are there for a reason for children who can’t medically get the vaccination. But the other types of exemptions have proven to be slippery slopes if you will. It provides the opportunity for those preventable diseases to make a comeback such as measles and even an episode of polio in New York. That happened with someone who was unvaccinated. Most of the outbreaks of disease are in unvaccinated individuals which makes sense. And we really want to prevent these diseases. That’s the cornerstone of pediatrics is prevention. And so the best way to do that is to vaccinate.
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Ed: I’m old enough that when I was growing up, there were people with polio, and I don’t think a lot of younger people even young parents really have any idea what a devastating situation that can be. So, as I understand it, nationally the latest two dose MMR, measles, mumps and rubella vaccination was 93.5% in the 21/22 year. It seems high. But as you just noted, there’s been recent outbreaks of measles in several cities in the U.S. and how common are these and what are the consequences for the rest of us?
PS: We do see an increase in these types of outbreaks since the pandemic started honestly. In fact, if you translate the number 93.5% which is high. That still leaves about 250,000 children vulnerable to the disease if they are not immunized which is also a significant number. So, the idea that 93.5% is good is true. But to get the immunity we need; we need a slightly higher level especially with things like measles which can have breakthrough infections. Things that we do remember measles, mumps and rubella and polio happening in populations that I was associated with as well. But measles can cause a lot of severe infection especially in children. So, it can cause encephalitis. It can cause pneumonia. And those numbers are not without consequences for both the parents and the children who are infected. It also has consequences for schools. For churches. For all the places where children go because the vulnerable which includes older individuals as well as children can get infected by these diseases as well.
Ed: Let me ask you a little bit about some disparity in terms of who gets vaccinated. The latest national immunization survey 9-in-10 babies in young children in the U.S. received their recommended vaccinations. In the percentage of uninsured children not vaccinated by their second birthday which was a surprise to me was 8 times that of privately insured children. That’s concerning certainly and I what are some of the reasons for this? Why do these disparities exist and what should policymakers know so if they want to address this?
PS: One is access honestly because if you are uninsured and/or you are underinsured, it’s difficult for you to access vaccination. It can be very expensive. The other part of that access question and I live in a largely rural state is where are the providers who are giving this vaccine. And one of the programs that has been very successful is the Vaccine for Children’s Program and it exists in every state. And this provides vaccines for children who are not insured or for children who are in the Medicaid or CHIP program. And because it is very successful, it has prevented a lot of disease. The problem is not every provider is a VFC provider and that includes places like pharmacies which have been places for children to go get vaccines. But pharmacies are not VFC providers. So, they can’t provide the access that many of these underserved children need in those available places. So, we have some work to do for access. And we do know that insurance provides not only access to providers for well childcare, developmental screening and all the other things that we know children need to be ready and healthy for school, but also for the ability for their parents to take them to get the vaccines they need. So, insurance is a big issue so if you don’t have insurance, you don’t always have a way to get those vaccines. And even if there is a vaccine for children program in your state doesn’t mean you can access it depending on where you live.
Ed: Dr. Shaw, one issue I know has been a key concern of legislators is workforce overall. In fact, I’m doing a podcast in another couple of months about nursing shortages. Is this workforce problem affecting vaccinations and the ability to get people vaccinated particularly through public health?
PS: Yea that is a huge concern I think that we do need to highlight. We know that at least 300 people who were public health directors across the country have either resigned or retired since the pandemic began. And because of that, the public health departments may not be able to provide vaccinations in the way that they did before including helping with the VFC program. So we really need to make sure that our public health departments are not only staffed, but are staffed with people who are knowledgeable about vaccinations and prevention of disease.
Ed: The public health emergency will end May 11 and how is the end of the emergency going to affect rates of childhood vaccination? Do you have any sense of that?
PS: Our biggest concern right now during the unwinding period where the pandemic health emergency is winding down is that it will increase the rate of uninsured children. The statistics or the prediction is that even up to 6 million children may lose coverage when this happens. And a lot of it even up to 4 million of these children is basically because of paperwork. Either the parents have not turned in their paperwork or the paperwork has been sent to the wrong address or they are no longer accessible by all the ways that the states are looking at. So, we have tried to help in each state our state chapters are working with as many of the practices they can to provide this information to the families and children in their practices, so they do get their contact information updated. Because the idea of losing Medicaid, you may still be eligible for CHIP, or you may be eligible for something on the exchange. So it shouldn’t be a total disaster that has been predicted, but we are very concerned that with the loss of insurance that many of these children will end up in that underserved rate that we were talking about earlier and not be taken care of either in the pediatrician or the pediatric healthcare provider home.
Ed: I’m not sure how keenly aware everyone is about the upcoming cliff in Medicaid. I’m sure state legislators are at least aware of it. Maybe a little more detail would be helpful for them. Speaking of which as we get ready to wrap up, I wonder what else you would like to share with this audience which is largely legislators and legislative staff.
PS: I think it is important to remember that Medicaid and CHIP cover about 55% of children in our country. So, it is a very important lifeline for many of our children and families. It went up during the pandemic because obviously many parents lost jobs and were became income eligible. But the reality is many people depending on where they live and where they are are eligible for Medicaid and CHIP and may no longer be once the unwinding occurs. So it really is important that we think about the percentage of children that are covered and how vulnerable they will be without coverage once this occurs.
Ed: Well Dr. Shaw thank you so much for walking us through this. This has been a very enlightening conversation and I thank you. Take care.
PS: Thank you.
Ed: I’ll be right back after this short break with Shannon Kolman from NCSL.
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Ed: Shannon, welcome back to the podcast.
SC: Thank you for having me. I’m happy to be here.
Ed: Shannon, I’ve just been speaking with Dr. Pam Shaw who is a professor of pediatrics at the University of Kansas Medical Center. And we were discussing the drop-off in childhood vaccination rates during the pandemic and some of the reasons behind that. These vaccinations are a key public health concern. I wonder what sort of state legislative action has been around this issue.
SC: Yes, regarding the topic of vaccine legislations in general, there has been a very large amount of bills introduced by states over the last few years. For example, NCSL tracked about 800 vaccine related bills in 2021, just shy of 600 in 2022. And we’ve already seen more than 600 vaccine-related bills introduced so far in 2023.
Over half of all of those bills introduced regard prohibiting vaccine mandates mainly for the COVID-19 vaccines such as employer vaccine mandates. But also, some that prohibit COVID-19 vaccine requirements for businesses, schools or other settings.
The second most common category of vaccine related bills which makes up approximately 15 to 20% of all the vaccine bills introduced during the last few years are those related to providing authority for more professionals to administer vaccines such as pharmacists, pharmacy technicians, dentists, or even podiatrist or optometrist in a few instances. We also looked at the percentage of vaccine related bills that were enacted. And overall between 12 to 15% of all the vaccine related bills that were introduced in 2021 and 2022 were enacted.
Ed: Another issue that Dr. Shaw touched on talking about childhood vaccines is the difficulty in accessing vaccines for some children. And I wonder in that area are states taking any action there.
SC: Yes. There have been states that have taken action regarding access to childhood vaccines. There was a huge push during the pandemic to authorize more professionals to administer vaccines. The Federal Public Readiness and Emergency Preparedness Act or PREP Act authorize certain professionals including pharmacists to administer vaccines including the COVID-19 vaccines. The PREP Act is set to sunset in 2024 which could mean that in some states pharmacists will no longer have the ability to administer vaccines especially to children without legislation that provides such authority.
Many states have given pharmacists the authority to administer vaccines, but often that authority specifies only the influenza or COVID-19 vaccines for children. There are however some states that have authorized pharmacists to administer vaccines to children under certain circumstances such as with a prescription order. So, for example New York passed legislation that allows a physician or a certified nurse practitioner to order an influenza vaccine for pharmacists to administer to patients two years of age and older. On the other hand, Oklahoma enacted a bill that allows a pharmacist who has completed requisite coursework to administer vaccines approved by the FDA without a prescription or standing order. And in 2022, Arizona enacted legislation that allows a pharmacist to administer vaccines to those who are at least three years of age with a prescription order or a collaborative practice agreement. And that bill also provides for a process for a pharmacist who wishes to order or prescribe vaccines along with administering them to do so by meeting certain board rule requirements.
Ed: Well, it does get complicated doesn’t it in terms of how these things work out in different states. But of course, that is what we would expect for each state to take its own course. Are there other issues states are taking into account in terms of this access issue?
SC: Yes. Some state legislatures are looking at other issues around access to childhood vaccines such as well child visits with primary care providers and the Federal Vaccines for Children Program. So, for example, Maryland enacted legislation that allows a pharmacist to administer a vaccine to a child age three to 18 if the pharmacist has had specific training and when administering the vaccine informs the child’s parent or caregiver about the importance of well child visits with the primary care provider. That same Maryland bill also requires the health department in consultation with the State Board of Pharmacy to study whether the option to administer vaccines by pharmacists has lead to changes in well child visits with primary care providers as well as changes to community access to for vaccines.
And then Arkansas took a little different approach and passed legislation that allows a pharmacist to administer vaccines to those three years of age and older, but if the pharmacist is administering a vaccine other than influenza or Covid 19 to a child three to six years of age, the pharmacist must participate in the Federal Vaccines for Children Program. And also inform the parent or caregiver about the importance of well child visits.
So yes as Dr. Shaw pointed out, there are a lot of factors that legislatures are having to take into account when looking at the access to childhood vaccines.
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Ed: So, Shannon I think probably a lot of the folks in our audience know that the federal Pandemic Public Health Emergency is set to come to an end on May 11 and I think they also know that that’s probably going to have a tremendous effect on Medicaid roles. But it could also affect both access and affordability of vaccines for children as I understand. And I’m wondering how state legislatures are preparing for those changes that result from the end of the emergency when it comes to those immunizations.
SC: Yeah, in addition to the PREP Act sunsetting, there is another event associated with the end of the Pandemic Public Health Emergency that could be concerning for childhood immunizations. The continuous coverage requirement for Medicaid ended as of April 1, this month, and states will now have a year to start redetermining eligibility for all their Medicaid enrollees as well as eligibility for their children’s health insurance program or CHIP enrollees. And this redetermination process is a significant undertaking because there are almost 85 million people in the country now who are currently enrolled in Medicaid as well as approximately 4 million children who have healthcare coverage through CHIP. One challenge with the redetermination process is what some people call administrative churning which refers to the fact that some people may lose Medicaid or CHIP coverage not necessarily because they are no longer eligible, but because they have difficulty navigating the renewal process. Or because a state is unable to contact them because of a change in address or some other type of administrative hurdle.
There are a few states thought have introduced or enacted legislation recently to help prevent such administrative churning issues. For example, Utah enacted Senate Bill 217 just last month which creates alternative eligibility requirements for their CHIP benefits. So, this legislation allows the state to create new eligibility criteria to enroll children who are eligible under this new criteria for CHIP benefits which will then be paid out of a newly created fund. The new eligibility criteria removes the requirement that the child needs to be a citizen or legal resident of the US but allows them to enroll if they are a resident of Utah, have no other health insurance, are not eligible for Medicaid and have a household gross income at or below 200% of poverty. So basically, if the child is ineligible for Medicaid or the regular CHIP program, they may be eligible for CHIP benefits under this new criteria. Also, several states have pending bills such as Rhode Island which is considering a bill to cover children in rural in Rhode Island’s Medicaid program with continuous eligibility through age six. And this is similar to a demonstration initiative that was approved for the state of Oregon by the Centers for Medicare and Medicaid Services or CMS which will ensure that children in Oregon will have continuous Medicaid coverage until the age of 6. So those are just a few examples of how states are acting to ensure that children maintain healthcare coverage for care and immunizations.
Ed: Well Shannon thanks for running that down for us. I’m always amazed at the innovations that states think of. Thanks a lot for going through this with us. Take care.
SC: Thank you. My pleasure.
Ed: I’ve been talking with Dr. Pam Shaw, a professor of pediatrics at the University of Kansas Medical Center and Shannon Kolman of NCSL about the state of childhood vaccinations coming out of the COVID-19 pandemic. Thanks for listening.
You can check out all the podcasts from the National Conference of State Legislatures by searching for NCSL podcasts wherever you get your podcasts. Tim Storey, NCSL’s CEO, hosts “Legislatures: The Inside Storey” where he focuses on leadership and legislatures. The “Our American States” podcast dives into some of the most challenging public policy issues facing legislators. On “Across the Aisle” host Kelley Griffin tells stories of bipartisanship. Also check out our special series “Building Democracy” on the history of legislatures.
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