Letter to the United States Senate Finance Committee

IAC calls for a reduction of cost-sharing for all vaccines recommended for older Americans by ACIP and the consolidation of all such vaccines under Medicare Part B

May 22, 2009

To the United States Senate Finance Committee:

I am writing to comment on the Committee’s recent policy options paper entitled “Expanding Health Care Coverage: Proposals to Provide Affordable Coverage to All Americans.” As Executive Director of the Immunization Action Coalition, the leading national nonprofit immunization education organization, I am keenly aware of the extent to which federal policy affects immunization rates and practices, and offer the following observation on the vaccine policy implications of this report.

Among the Medicare-related topics within Section VI (Options to Improve Access to Preventive Services and Encourage Health[y] Lifestyles) is a policy option regarding incentives for older Americans to make use of preventive services and engage in healthy behaviors (page 44). The report’s synopsis of the current law on this topic notes that the Medicare Improvements for Patients and Providers Act of 2008 (MIPPA, P.L. 110-275) allows preventive services to be covered under Medicare if they are reasonably necessary, and appropriate for the individual, and rated “A” or “B” by the United States Preventive Services Task Force (USPSTF).

The report notes with approval that cost-sharing has been reduced or eliminated for influenza and pneumococcal vaccination of Medicare recipients. I urge that the Committee specifically include in this policy option the reduction or elimination of cost-sharing for all vaccines recommended for older Americans by the Advisory Committee on Immunization Practices (ACIP), to which the USPSTF has delegated its evaluative authority and the consolidation of all such vaccines under Medicare Part B.

Currently, influenza and pneumococcal vaccines for adults fall under Medicare Part B. Unfortunately, other important vaccines, including zoster vaccine and tetanus-diphtheria vaccine, which are also recommended for older adults, have recently been relegated to Part D. The zoster vaccine, which prevents shingles, is recommended for all persons 60 and older, but it is rarely used in spite of this broad recommendation. Shingles is often complicated by post-herpetic neuralgia, a painful and debilitating condition that can last months to years. Shingles can also involve the face and eye, leading to loss of vision. Shingles and its serious complications can be prevented by the use of zoster vaccine. Similarly, the tetanus-diphtheria vaccine is recommended by ACIP every ten years, yet most seniors are not receiving this vaccine on the recommended schedule.

Under Medicare Part B, patients have no difficulty obtaining recommended vaccinations, and it is a straightforward process for healthcare professionals to obtain reimbursement for vaccination services just as they do for any other covered service. In contrast, it can be a nightmare for patients to access vaccines under Medicare Part D, both because the uncertainty of reimbursement makes their providers reluctant to administer it and because of a number of factors that create uncertainty for the patient.

The difficulty for patients begins with the complexity of understanding their own Part D vaccine coverage. Patients are often uncertain about which vaccines are covered, to what extent they are covered, and whether they fall within the “doughnut hole.” Because there are hundreds of different Part D plans, few providers are able to offer help in interpreting plan language.

Moreover, because Part D is a prescription benefit, some patients must buy Part D-covered vaccines at pharmacies and then bring them back to their doctor’s offices to have them administered. CDC strongly discourages this practice because some vaccines require special handling. In particular, the zoster vaccine is subject to stringent temperature controls during transport.

The proposed policy’s potential to protect the health of older Americans can be significantly enhanced by revising this section of the report to make clear that zoster vaccine, tetanus-diphtheria vaccines, and any future ACIP-recommended vaccines for his age group should be fully covered under Medicare Part B, in the same manner as influenza and pneumococcal vaccines are currently covered, so that no patient has to go without ACIP-recommended vaccines. I hope the Committee will commit these adjustments to the final version of the report.


Deborah L. Wexler, MD

Deborah L. Wexler, MD
Executive Director

Julie Murphy
Direct of Development
(651) 647-9009

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