Health Equity Focus Needed to Vaccinate Our Way Out of Pandemic

Lorraine Harvey, an in-home care worker, receives her first dose of the COVID-19 vaccine.
Lorraine Harvey, an in-home care worker, receives her first dose of a COVID-19 vaccine from Rudolfo Garcia, RN, at a clinic at Martin Luther King Jr. Community Hospital in South Los Angeles on February 25. Black and Latinx people compose a majority of the South LA community and are dying of COVID-19 at a significantly higher rate than White people. Photo: Mario Tama / Getty Images

The rapid development of COVID-19 vaccines is an opportunity to use modern medical science to end a pandemic, save millions of lives, and make health care delivery more equitable. While the nation’s ambitious vaccination campaign is still in its early phases, we must be intentional about promptly reaching out to communities where the COVID-19 vaccine isn’t readily available and people may be hesitant to get immunized.

According to polls, the share of US adults who want to get vaccinated is increasing as the rollout progresses. This is a welcome trend, but leaders should leverage the ample opportunities to encourage vaccine uptake among many demographic groups, including Black and Latinx adults, people with lower incomes, and younger adults. COVID-19 vaccine inequities already have become apparent as evidenced by lower uptake among Black and Latinx adults, and among people with lower incomes. Immediate intervention is needed.

A recent analysis by the State Health Access Data Assistance Center, which was funded by CHCF, uses influenza vaccination rates among adults to highlight what is known about some of the communities that deserve the particular attention right now.

Evidence for Anticipated Vaccine Disparities

The study analyzed adult flu vaccination data from the Behavior Risk Factor Surveillance System survey and found that only 39% of US adults and 38% of California adults reported getting a flu shot during the survey years of 2017 through 2019 — barely more than half the anticipated 70% target for herd immunity. That rate varied across the 50 states and the District of Columbia, but even the highest rate of 45% in North Carolina fell far short of the goals for a COVID-19 vaccination program.

One positive sign from the research was the relatively high rate of flu vaccination among older adults. This is encouraging because seniors, who are at greatest risk for death or serious complications from COVID-19, appear to be more likely to get vaccinated. The study found evidence that vaccine outreach even among the elderly should be expanded because their flu vaccine rates in both California and the US still fell short of COVID-19 vaccination targets. Flu vaccination rates increased with age, with younger adults reporting the lowest participation. For instance, US adults who have reached age 65 reported a flu vaccination rate of 59%, while the rate for adults age 18 to 39 was only 28%.

If vaccines are available mostly through traditional health care infrastructure, such as clinics and hospitals, people without health insurance, who lack strong ties to those institutions, will be disadvantaged.

US flu vaccination rates for Asians and Pacific Islanders (44%) and for White people (43%) were significantly higher than the rate for the overall population. However, those rates were significantly lower for American Indian and Alaska Native (30%), Black (31%), and Latinx people (31%) — a pattern similar to California’s.

National flu vaccination rates also increased with income. People with incomes below $25,000 reported the lowest rate (33%), while the highest (41%) was for those with incomes of at least $75,000. Again, these patterns were almost identical in California.

Health insurance status, a proxy for access to health care, showed a dramatic disparity. Among people with insurance, 40% reported getting a flu vaccination. People without health coverage reported only 17%. Yet again, California mirrored the national pattern.

Striving for Vaccine Equity

As states and the federal government roll out COVID-19 vaccines, public health professionals and health policymakers should redouble planning and distribution initiatives with an explicit focus on equity. Officials must respond to factually grounded and longstanding concerns held by people of color about the government and health care systems that developed and distribute it. For instance, the Tuskegee study still looms large in the memories of Black Americans. Tangible reasons for distrust of the health care system persist today, as evidenced by such examples as higher rates of pregnancy-related deaths among American Indian and Alaska Native birthing people and Black birthing people.

Public health leaders must ensure that COVID vaccines are readily available to communities that historically have been under-vaccinated. If vaccines are available mostly through traditional health care infrastructure, such as clinics and hospitals, people without health insurance, who lack strong ties to those institutions, will be disadvantaged. If obtaining a vaccination requires people to devote substantial time to scheduling appointments, traveling to inconvenient locations, and taking time off work during business hours, people with lower incomes are far less likely to be immunized.

We need to devote unparalleled efforts in reaching out, especially to communities with fewer health care and economic resources. This means providing information on the vaccines’ benefits, safety, and necessity, persuading individuals and communities to protect themselves, and finding innovative ways to reach people.

Learning from Evidence and Successes

Fortunately, we can borrow approaches that have reduced vaccination disparities in other situations and be guided by research on barriers and potential solutions. Childhood immunizations historically have demonstrated similar inequities to those found in adult flu vaccination rates. However, numerous studies have found clear reductions in many childhood immunization disparities in the past few decades, with some inequities being practically eliminated.

One of the hallmark initiatives credited with increasing childhood vaccination rates and mitigating disparities is the Vaccines for Children program, which was launched in the 1990s to reduce financial barriers to immunization by providing vaccines at no cost to children from lower-income families.

The federal government already has taken some steps in that direction for COVID vaccination by purchasing hundreds of millions of doses to be given at no cost to individuals, although health care providers may still charge service fees for administering the vaccines. The Coronavirus Aid, Relief, and Economic Security (CARES) Act, passed by Congress in 2020, requires coverage of COVID vaccines without cost sharing by most forms of insurance.

If obtaining a vaccination requires people to devote substantial time to scheduling appointments, traveling to inconvenient locations, and taking time off work during business hours, people with lower incomes are far less likely to be immunized.

But the byzantine nature of the US health insurance landscape means that some forms of coverage don’t have to follow that requirement, to say nothing of the potential costs to the millions of people still without health insurance at all. Anecdotal evidence shows that health insurers sometimes fail to make good on that mandate, leaving people on the hook for large bills for services that should have been fully covered. In short, more work is needed to ensure that cost does not become a COVID-19 vaccine barrier and that immunizations can be provided equitably.

Multilingual, culturally relevant educational materials can enhance people’s knowledge about vaccines and could persuade hesitant people to accept a vaccine.

Offering COVID-19 vaccination sites in lower-income neighborhoods and at grocery stores, schools, community centers, and food banks could mitigate vaccination barriers, such as lack of transportation or a medical home. There are further lessons to learn from Affordable Care Act efforts to expand health insurance, which have reduced longtime disparities in health coverage among adults.

Without dedicated efforts to equitably deliver COVID-19 vaccines to underserved communities, we risk prolonging the pandemic by allowing its embers to smolder in segments of society that have been left behind. We can do better, and previous successes in addressing the causes of immunization disparities provide us with a strong foundation to tackle the problem.