By Katie Kerwin McCrimmon

Deep into a whooping cough epidemic and a long struggle with poor immunization rates, Colorado can no longer tap a $4 million pot of federal money to give vaccines to needy children.

As of Jan. 1, the federal government barred local public health agencies from using so-called “317 funds” to give children vaccines if they have health insurance other than Medicaid. Parents are supposed to take these children to their primary care providers and have the doctors bill private insurance instead.

But many doctors are no longer stocking vaccines because it costs thousands of dollars to keep the vaccines on hand while providers wait months for reimbursement. The problem is most pronounced in rural areas where Colorado’s 54 local public health agencies are sometimes the only place to find immunizations.

“The funding was critical as we are the only provider of vaccines in our county,” said Vicky Kosch, a public health nurse who runs the immunization program in Kit Carson County on Colorado’s eastern plains.

Health experts and lawmakers now worry that hundreds of Colorado children will not get the vaccines they need because of  the new federal limits.

“So many of our Colorado families rely on their local public health agency to provide affordable vaccines because they are underinsured,” said Sen. Jeanne Nicholson, D- Black Hawk, a former public health nurse. “I am afraid some of our children won’t receive the vaccines they need because of this cut in federal funding.”

In Kit Carson County, Kosch is struggling to negotiate contracts with insurance companies that typically will not certify public health agencies as “preferred providers” because they don’t offer the full gamut of health services.

Her agency is also having to bill parents, set up payment plans and is hoping for either a federal waiver from the new rule or some emergency funds from the state. What she’s not willing to do is encourage parents to skip vaccines.

“We’re willing to work with families. The state needs to fill in with cash or the feds need to give a waiver to public health (agencies). We buy these vaccines as cheaply as we can,” Kosch said. “They’re essential to prevent diseases that have been obliterated and could come back in a heartbeat.”

The first round of immunizations for a 2-month-old costs $370 in Kit Carson County. Aside from a $10 administrative fee, the “317 fund” used to cover those costs for all children, regardless of their insurance status. Kosch now must ask for a $50 deposit from parents and is sending them home with claim forms so they can try to get reimbursement from their insurance companies.

She said her office has long prided itself on successfully reaching out to families and following up them to assure that babies and children are fully vaccinated. Altogether about 8,000 people live in the county, which is also home to ranches, and wheat and wind farms.  As a result of their outreach efforts, Kosch said her county historically has had relatively high immunization rates, unlike some metro-area counties where parents sometimes reject vaccines. The whooping cough or pertussis epidemic — which has so far sickened more than 1,500 people in Colorado and can be deadly to infants — has not been as severe in the area as it has been along the Front Range.

Each year, Kit Carson’s public health agency spends about $250,000 to keep vaccines in stock, Kosch said.

“We have two medical clinics, so we have adequate coverage of providers, but they can’t afford the cost of (keeping vaccines in stock).”

Since the local public health agency has always handled vaccinations in the county, the providers also don’t have adequate staff to track and report immunization records which providers must report to a state database.

“They would have to hire a full-time data person. Those costs would be crazy,” Kosch said.

Now the question is, without the federal funding, who will pay for vaccines: families, insurance companies, the state or the federal government?

Children who are uninsured, eligible for Medicaid or who are Native American can still receive vaccines through a separate $40 million pool of federal funds. Children who receive care at federally qualified health centers also can get immunizations.

But, the insured and underinsured children are the ones who will fall through the cracks.

Joni Reynolds, public health director for the Colorado Department of Public Health and Environment, is working with leaders of local public health agencies to come up with solutions. Their most promising efforts so far include arranging contracts with insurance companies. Yet, even if insurance companies want to “play ball” with the 54 local agencies, setting up contracts with each of them can be cumbersome and time-consuming.

Reynolds said that under the Affordable Care Act, private insurance companies must cover immunizations without charging co-pays unless people have old health plans that allowed charges to patients’ families for vaccines. Some states also require insurance companies to allow patients to get care at the public health agencies.

“We may need that here,” Reynolds said. “It may be one of the ways to address this issue.”

The trouble for some families is finding a doctor who has vaccines or connecting with that primary care provider in the first place.

“There are access issues,” said Reynolds. “Sometimes parents can’t get time off from work when their child’s primary care doctor is open. Or, if they’ve ever been in before and have an outstanding bill, they might be afraid to go back. Sometimes the Gestapo at the front desk won’t let them make an appointment .”

Reynolds said it’s difficult to see roadblocks to receiving vaccines for families who want them when the state has fought so hard to educate parents about vaccine safety.

“We’ve worked so hard to develop a system that ensures kids and parents alike have the information they need,” she said. “Any negative impacts on how the system is working are very concerning.”

She sees the brunt of the impacts in rural areas where health access is already a problem.

“There are lots of miles and long distances in these communities. The local public health agencies are the immunization experts in these areas. They’re the ones who know the immunization schedules and who have historically stocked the vaccines,” she said. “To tilt that…and give them less capacity is a big problem.”