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ROBERT SIEGEL, Host:

This is ALL THINGS CONSIDERED from NPR News. I'm Robert Siegel.

MICHELE NORRIS, Host:

And I'm Michele Norris.

Health officials in California continue to battle what's on pace to be the worst outbreak of whooping cough in 50 years. Six California infants have died of the highly contagious respiratory infection this year. There is a whooping cough vaccine but a number of children are not getting it, and that's not just because some parents are opting out.

As Kelley Weiss reports, an increasing number of doctors in private practice can't afford the vaccine, particularly in rural areas.

KELLEY WEISS: Marsha McKay is a family doctor in a small Sierra foothills town. She says she's used to doing it all at her rural practice in Twain Harte, California, but this is something new.

(SOUNDBITE OF A DIAL TONE)

D: Oof.

WEISS: McKay is on the phone with a loan officer trying to get a $25,000 line of credit.

D: So part of what you do is that you make a business plan for me, right?

WEISS: She says she needs the extra cash so she can buy vaccines, of all things.

D: I'm fairly allergic to high debt and I really would rather not do this.

WEISS: McKay negotiated a contract with Blue Cross insurance to determine her vaccine reimbursement rates. But she says she doesn't get paid for the full price of the vaccines, like for whooping cough.

D: Costs me $46.90 and Blue Cross will pay me $28 for it.

WEISS: In other words, she'll lose money. So, for now, she's not giving the shots. She's worried though. There have been a few whooping cough cases in Twain Harte and McKay is afraid infants in her community could die without the vaccine.

D: The biggest issue for me is I just don't feel like I'm doing everything that I'm supposed to be doing for my patients. And that just makes me feel kind of inadequate as a doctor.

WEISS: So now, along with trying to get a loan, she is shopping online for discounted vaccines. In the meantime, one of McKay's patients, Erica Gianbruno(ph), has three kids who need the vaccines right now. Gianbruno says she'll have to drive 30 minutes to the nearest community clinic to get them. The whooping cough shots are $10 a piece and only available one afternoon a week.

Gianbruno says this is frustrating because she has private health insurance.

NORRIS: It's definitely an inconvenience on the drive. And, you know, then you got to stand in line behind everyone else, and it's only between like one and four on Tuesdays.

WEISS: Plus, she's says, she is reluctant to get vaccines from someone other than her trusted doctor.

NORRIS: But if I go to the clinic and I don't really know them and it's kind of a rush job, it's easier for me to go, maybe I'm not going to do this.

WEISS: Doctors like Marsha McKay in rural areas are one of the groups most likely to drop childhood immunizations. That's according to Gary Freed, a physician at the University of Michigan Health System. In a 2008 article he published in the journal "Pediatrics," he found that about 25 percent of family doctors were seriously considering no longer giving vaccines.

Freed says many were losing money on immunizations.

D: The issue is often that physicians are not good businesspeople.

WEISS: But beyond that, he identified some other surprising issues.

D: We found, interestingly, that there was quite a broad range of what physicians were paying for vaccines. We also found remarkable differences with regard to reimbursement. Some physicians were being reimbursed more than twice as much as other physicians were by their most common insurer, again for the same vaccine.

WEISS: California Association of Health Plans president Patrick Johnston says the private insurance market is a largely unregulated competitive place. So he says doctors have to find good deals on vaccines. And Johnston says that can be difficult if you're in a solo practice in a rural area.

NORRIS: Individual doctors may not have the bargaining power of a big group, but it's their choice to be in a big group or be an individual.

WEISS: Researcher Gary Freed says family doctors need to band together and negotiate better vaccine rates. But for Marsha McKay in Twain Harte, she says it's not that easy. So she's supporting a state bill, sponsored by the California Academy of Family Physicians. If it's passed, the law would make health insurers reimburse doctors for more of their vaccine costs.

For NPR News, I'm Kelley Weiss in Sacramento.

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