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A summary of presentations from the weekly Summit partner webinars

July 10, 2025 – The latest Summit Summary

Ensuring Access to Preventive Services through Policy — Focus on Immunizations

Brenda Gleason, MA, MPH, gave an update about ensuring access to preventive services, with a focus on immunizations.

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Ensuring Access to Preventive Services through Policy — Focus on Immunization – Brenda Gleason, MA, MPH
HR1 is a major piece of legislation that will change the health insurance landscape in the United States, and most of the focus has been on Medicaid cuts (with cuts coming from work requirements and eligibility requirements accounting for about half of the roughly trillion dollars in cuts). There are potential changes at the state policy level that can be made to address these changes that are coming.

Vaccine Access: Potential Layers of Loss

  • Step 1: Medicaid Cuts — ~8M people become uninsured, changes to provider taxes mean reduced funds available for services.
  • Step 2: Exchanges — Expiring premium subsidies mean ~8M people uninsured.
  • Step 3: Preventive Services — Changes to first-dollar coverage could decrease access to vaccination.
  • Step 4: DOGE — State budgets will struggle to backfill federal cuts.

Health Insurance Coverage Losses in State Marketplaces without Federal Subsidies
If Congress does not act and renew coverage of federal subsidies, estimates for how many people will lose coverage are seen on this slide. Data from the Urban Institute indicates the 2024 state election results and the estimated number of people who will lose coverage.

  • Texas: ~8.1M people
  • Florida: ~1.1M people
  • Georgia: ~590K people

Four Components of ACA Preventive Services with No Cost Sharing
These four categories shall be provided by insurers and shall not impose any cost sharing:

  • USPSTF Rated A or B: Evidence-based items with these ratings from the USPSTF
  • Immunizations: Those recommended from ACIP
  • Preventive Services: For infants, children, and adolescents, evidence-informed preventive care and screenings from the guidelines supported by HRSA
  • Women’s Health: For women, additional preventive care and screenings from the guidelines supported by HRSA

States have replicated these ACA protections, in many cases, but those states use the same recommendations/guidelines as the federal statute. So, if the recommending entities falter, so will the states because they refer to those same federal statutes. Still, some states have indicated that they will offer state-regulated plans — especially for vaccines — without pointing to the federal entities.

What Immunization Advocates Can Do

  • Make sure your state has some protections in place to ensure state-regulated health insurers must cover preventive services, preferably with no cost sharing.
  • Help your state understand the ramifications if federal agencies, work groups, or entities are eliminated or change focus.
  • Work with your state to make sure local health departments can bill Medicaid and insurers for providing vaccines.

QUESTIONS & ANSWERS

Q: Going back to the state map, [could you talk about] a few of the differences that may occur based on what their current statutes are? You highlighted the boxed ones, but maybe for those in a yellow state or a light green state or gray state, what does that mean?
Brenda Gleason (M2): Any state that doesn’t have a box means they probably don’t have a very clear statute that points to something like the federal ACA preventive statute. I’m going to use Massachusetts as an example. Massachusetts does have a box around it here, but their statute is a little broader. It is great, from our point of view, in that it doesn’t point very directly back to those federal components. In other words, it doesn’t say they must rely on ACIP, or that the Commonwealth of Massachusetts must rely on HRSA. The other states that are colored here [reflect] the kinds of changes that might happen or could have happened in various iterations of the bill. So the gray states just mean they didn’t expand Medicaid. We’re trying to remind people, for instance the states in gray, they didn’t expand Medicaid, so they might not see some of the Medicaid cuts that we’re looking at, but they still also don’t have these preventive services protections. So we’re just trying to overlay the Medicaid issues with the preventive services issues.
Q [follow-up]: But gray doesn’t mean that they’re not impacted by this bill?
Brenda Gleason (M2): Exactly: they’re impacted. They were just not an expansion state. So again, expansion states and non-expansion states are treated a little bit differently in the “one big, beautiful bill.” So we’re highlighting here: The gray states are the states that did not expand Medicaid.
Q [follow-up]: Do you know how states are going to look at some of this with regard to Vaccines for Children (VFC) and administration fee payments? Provider payments clearly is one of those targets. What are your thoughts on that?
Brenda Gleason (M2): I think it’s ripe for advocacy. I think all provider payments are at risk; this will really pit providers against each other. States are going to have to come up with ways to fill these gaps [in funding] that they will [now have to deal with]. Different states will face different funding gaps, both because of their own state budgets, and because of the differential effects of the bill. But that is another sort of whole line of advocacy, that I think in the immunization world is very important. Both Vaccines for Children, and also making sure that pharmacists, for instance, are being reimbursed at rates that are sustainable…FQHCs, state health departments, any entity that is able to provide vaccines both to adults and to kids, it’s imperative that we are out there advocating for those providers, in order to ensure as many access points as possible for people that are choosing vaccines or vaccines for their family members.

Q: Does this mean that HHS’s announcement about taxpayer-funded programs will not affect the medical expansion green states inside a box?
Brenda Gleason (M2): It just means the states are differentially affected. States that did expand Medicaid, for instance, they will have a cap on what they’re allowed to pay providers that is lower than the cap on non-expansion states. For instance, Texas didn’t expand Medicaid, they will be allowed to pay providers more than California, which did expand Medicaid. That’s very simplistic, perhaps an oversimplification, but that’s the general concept. That’s one issue: The way that states are allowed to tax providers is slightly different for expansion states and non-expansion states. So it’s really important [to ask yourself]: Are you in an expansion state or a non-expansion state. And then, from there, think about what policies are in play.

Q: Thinking about the trigger states, in those situations, is the trigger back to zero? What does it mean? Is it very state-specific, as well?
Brenda Gleason (M2): Yes, it’s fairly state-specific. The trigger state concept was…earlier on in the federal bill discussion, the congressional bill discussion, there was some talk about changing the federal match for states. And there are certain states that passed Medicaid expansion, but they put in what was called a trigger provision: if the federal government “meaningfully changed” that match percentage, basically the state would do something to re-review Medicaid expansion. So, in a handful of cases, states said they would have said overnight, “Nope, the feds made this decision, and now we’re changing it.” In some states, they said, “We would go back and review.” It doesn’t appear that there is anything in the bill that is going to trigger any of those states in yellow to actually cut their programs today. So I would put a little asterisk by it, and we continue to monitor those trigger states. And again, because of the way their state legislation that created their Medicaid expansion was put into law, we are watching those carefully, just in case someone steps up and says, “Well, we think this is a reason these federal changes are enough for us to go back and reconsider expansion.” We haven’t heard that yet; if anyone has, I’d love to know. But we’re only six days out.

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Vaccination Quality Measures: Current Landscape & What’s Coming Next

Haley Payne and Shelby Harrington gave an update about vaccination quality measures and implications for future vaccination rates.

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Vaccination Quality Measures: Current Landscape & What’s Coming Next – Haley Payne and Shelby Harrington
There are composite vaccination measures, which aim to reflect immunization delivery across the life course. Four measures from NCQA align directly to the ACIP routine vaccination recommendations (and are representative of the percentage of individuals who have received the routine recommended vaccinations within their patient populations).

  • CIS: Childhood Immunization Status
  • IMA: Immunizations for Adolescents
  • AIS: Adult Immunization Status
  • PRS: Prenatal Immunization Status

Quality measures are an evaluation tool for performance for care delivery or care outcomes; but they get used in various programs as a tool to improve care by driving behavior change. The four measures above were created by NCQA, which runs HEDIS (the most widely reported quality program in the country, with virtually every major health plan participating).

How Major Programs Drive Behavior Change
A group of programs — NCQA HEDIS, Medicare QPP MIPS, MSSP, Medicaid Child Core Set, Medicaid Adult Core Set, and MA Star Ratings — are able to leverage payment incentives and disincentives to improve vaccine uptake.

  • Quality measures can be used as an improvement strategy because they drive behavior change. For example:
    • Paying providers for meeting performance criteria or certain quality metrics has resulted in care improvements.
    • Holding physician networks accountable for quality performance has resulted in systematic changes to improve care through changes to care processes, such as putting automatic orders in their EHR system, implementing additional counseling with patients, care coordination, and outreach.

ACIP Overhaul
The new, replacement ACIP committee appointed by the HHS Secretary stated its intent to revisit existing recommendations, including the full childhood and adolescent immunization schedule. As ACIP recommendations change, measures are updated.

Should the ACIP narrow or remove vaccine recommendations, there are various potential scenarios.

  • NCQA could revise measures and indications to align with the updates.
  • NCQA could look to alternative sources of guidelines.

Shifting Indications for COVID-19 Vaccines
There are also shifting indications for COVID-19 vaccines for adults age 65 and older and others at high risk for severe COVID-19-related outcomes. ACIP has a placeholder on their website for an August or September meeting.

  • The HHS Secretary announced the removal of recommendations for both healthy children and pregnant people to receive the vaccine.
  • Some new COVID-19 vaccine approvals specify older adults and adults in high-risk groups.

Recent proposals could indicate a general de-prioritization of COVID-19 vaccination and, potentially, vaccination more broadly. Specifically, two recent proposed rules were for the removal of a measure assessing COVID-19 vaccination in patients and residents in inpatient rehab facilities and patients in home health, saying the cost of the measure outweighed the benefits of its use. This could indicate a broader trend.

Perceptions & Attitudes about Vaccination and Prioritization
For patients, vaccination measures are a tool to assess and improve vaccination rates, especially among groups whose rates are historically behind targets.

  • NCQA noted that 203M people are covered by a plan that reports to HEDIS and narrower or removed ACIP recommendations could affect vaccination rates.
  • 60K clinicians work in an NCQA-recognized practice and shifting measure specifications aligned with changing guidelines could result in confusion.

QUESTIONS & ANSWERS

Q: Does HEDIS data include uninsured people? And, if not, is there research on the use of HEDIS measures or value-based payment having spillover impacts on outcomes for uninsured people?
Shelby Harrington (Avalere Health): No, [purely HEDIS program data does not include uninsured people]. It is a health plan-based program. They are measuring the health plan’s performance, and therefore people who have health insurance through that plan. When HEDIS measures are adapted for other settings, they could be covering uninsured people. For example, many of the measures in the MIPS program — the Medicare program for evaluating individual providers and physician groups — many of those measures report them for all the patients that they saw, not just the patients with Medicare, so that part alone (with how the measures are used) can apply to uninsured people. But there absolutely is research that shows having measures in a high impact program for one particular plan, or payer or group, does have spillover effects on all the patients being seen. And this makes logical sense.
 I think there are probably a lot of clinicians, [when implementing a change in their practice and how care is being delivered to patients], who are usually not doing that based on, “I’m going to treat this patient differently because they have this insurance. Look at their insurance before they come in and give them a different clinical pathway,” because [they’re] generally trying to orient improvements in the way you deliver care around what is best for that patient, and the clinical pathway, the evidence. And so, we see that with, for example, if [there’s going to be a change to the] order set in the EHR, that’s going to be for everyone who’s being cared for by that provider. So there’s evidence that it does have a spillover effect there and then.
 [To the question of whether] NCQA will wait until the lawsuit about the new COVID-19 vaccination recommendations gets heard or settled, this kind of ties to the question of how NCQA is going to deal with the changing recommendations. Measure development at its highest level is based on evidence: You develop measures based on the evidence for what is high quality care for the vaccination measures to date. The recommendation of ACIP has been the proxy for the evidence base, because the NCQA is like ACIP [and] has a wonderful process, what they are doing is evidence-based. So we will match to their recommendations just like they do with other consensus-based guidelines. If NCQA decides that they no longer feel the ACIP recommendations are evidence-based, they could shift to other methods of designing their specifications, and I think that’s kind of at the core: Do they wait or not?
Haley Payne (Avalere Health): Yes, I would add one caveat: We are not giving legal advice, and we are not lawyers. But that aside, to my understanding, the lawsuit is focused on the removal of COVID-19 recommendations for pregnant people and healthy children. I think as far as [whether] they will wait or not, I can’t make that speculation. But it does not appear that the shift in COVID-19 indications for adults, specifically, is potentially implicated in this, and so that likely won’t be part of the shift. But again, NCQA could wholesale decide, “We are going to look for other sources of guidelines in order to inform our measures going forward.” So hopefully, that helps to start to answer that question. But I think it will be an ongoing scenario.

Q [comment]: Someone from ACOG said the recommendations had changed, but the science has not.
Haley Payne (Avalere Health): We would emphasize that you can make public comments in support of, or arguing against, any changes in these quality measures. HEDIS does a public comment period every year, generally in the spring, when they issue their new measures, specifications, and updates. And the use of quality measures in Medicare programs that would be announced through the IPPS, depending on the program, the PFS, the SNF PPS, anytime there is a substantive change in a measure, or a measure is going to be added or removed from a program, that has to go through rulemaking. So you have the opportunity to comment there.

Q: When will NCQA formalize the determination on COVID-19?
Haley Payne (Avalere Health): We should see that coming out [soon], and we saw it on August 1 last year. It’s something we should see, at the very least, beginning of August — again, barring major complication.
Shelby Harrington (Avalere Health): Yes, they have given all indications it is going to be added. But the final determination will be when it is in the specifications, when those are released.

Q: If NCQA looks to alternative guidelines outside of ACIP, do providers get dinged and less payments tied to the measures if the insurance doesn’t follow suit?
Shelby Harrington (Avalere Health): That is where it gets very confusing and complex and kind of dependent on the health plan’s behavior. So if you’re thinking about purely the HEDIS program or, for example, the Medicare advantage star ratings program, which uses measures from HEDIS…AIS, for example, as used in HEDIA, you are measuring health plans. And so it would be paradoxical if a health plan were to decide to no longer cover vaccines because policy doesn’t require them to; but, at the same time, they are accountable for AIS performance in the HEDIS measures, and so they need vaccination rates to go up, in that sense. So it could be an interesting question in how the health plans are considering their coverage knowing that they could get dinged either way, if the NCQA measures remain as is following the current state of the science.
Haley Payne (Avalere Health): And I think that goes back to a really great point you made earlier, which is how could people use quality measures as a tool in a shifting environment where recommendations might be getting narrower, where insurance coverage doesn’t quite line up with what’s out there. I think, if plans are still accountable for a program like HEDIS, not covering those vaccines but still being accountable to those measures could create a bit of a conflict.

Q: Even if the policy, specifically, doesn’t change — there have been more questions about vaccine safety or necessity that are promoted by certain groups which leads to greater vaccine hesitancy. How does that affect providers’ and health systems’ payments? If you see drops that are not policy-related but, increasingly, vaccine hesitancy-related.
Haley Payne (Avalere Health): That’s an interesting question. And, if they’re not policy related, that’s something that we could probably take a look at. I don’t have data in front of me right now, but let’s take the example of the childhood immunization status measure that includes all of the routine childhood vaccinations that are required, including, say, MMR: We’re seeing MMR rates decline, overall. And so, how does that potentially affect plan payments, for example, for being accountable to HEDIS measures, or how does that affect providers in the incentives that they’re receiving? It would definitely be an interesting question to dig into given the existing environment. I would imagine it’s a scenario in which, if rates are going down, measure scores are going down, therefore payments are at risk.
Shelby Harrington (Avalere Health): Yes, ultimately providers and/or plans do not have 100% control over driving receipt of these services, receipt of immunizations. They can be delivering in the most perfect system and doing absolutely everything right, but, ultimately, it’s up to the patients to decide whether or not to receive the immunizations. So, what’s going on in the public domain, and the information that patients and parents are hearing, is absolutely going to have an effect on whether or not they choose to vaccinate, even if their provider is begging them to and their health plan is offering to cover it and making it widely accessible. When it comes to the actual scores, there will be a bit of a gap and a lag. And how those rates impact payment — because it ends up being a benchmark-based approach — it’s different for each program; but it’s looking at, usually, a historical benchmark of performance and comparing your performance to theirs to determine your penalty, incentive, or star rating, depending on the program. So, if rates are going down, there will be a bit of a time lag when you’re being compared to 2 years ago, a year ago. If rates continue to decline, your benchmark resets as a health plan or as a provider.

Q: There’s been misinformation circulating that physicians, particularly pediatricians, make most of their money through bonuses, giving vaccines either directly or based on quality measure percentages. What can you tell us about this?
Haley Payne (Avalere Health): Just given a lot of the research we’ve done on provider payment for vaccine administration and a lot of the challenges that we’ve heard from various stakeholder groups about that — the misinformation wheel certainly seems to spin.
Shelby Harrington (Avalere Health): It is misinformation. It is taking something that is true, in the sense that there are financial incentives for getting patients vaccinated, that’s what we just presented, but to say that they’re making most of their money through bonuses for giving vaccines, or that a significant percentage of their compensation is based on that, would be misinformation. I think there would probably be a lot more physicians going into pediatrics if that were the case.

Q: We’ve talked a lot about the provider incentives here, but there’s also an issue that’s been mentioned about the provider tax, and how that might impact the Medicaid payments or the match. What does that mean and how is that going to impact our providers and proportion of patients that get covered through Medicaid?
Brenda Gleason (M2): Yes, this is more a big picture issue, so [it’s] not physicians being taxed for participating in Medicaid, it’s more very large providers. The most common entities that are taxed are hospitals, nursing facilities, and intermediate care facilities. This is a way that states…some are calling this financial abuse — I think that is the way that it’s described in the bill — for instance, a hospital takes that money from the hospital into the Medicaid program, and then basically gives the money back to the hospital in the form of a higher payment or a higher reimbursement amount.
 The recently passed bill reaches in and directs states to flatten those provider taxes (so if you’re in a non-expansion state, whatever provider taxes are in place right now, you cannot increase those, they can’t be changed; if you are in an expansion state, they will be systematically reduced from whatever rate they are now down to about 3.5 percent.) So this has to do with fundraising. This has to do with the total budget that Medicaid has to work with in a given state, because, especially in expansion states this means that they — the state — will be able to raise less money to cover Medicaid. They will also, in turn, probably be paying providers less, and it’s possible that they will have to also cut back on services because their total budget in a state is going to go down. So it’s not a one-for-one relationship like, “Oh, I, as a provider, will be taxed on Medicaid.” It’s more that the entire state program will have less to spend.

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Announcements
  • Save the date for the 2026 National Adult and Influenza Immunization Summit in-person meeting: May 19 – 21, 2026 at the Crowne Plaza Atlanta Perimeter at Ravinia in Atlanta, GA.

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