COVID-19 Vaccine Access for Uninsured Adults this Fall

The FDA has approved and authorized updated COVID-19 vaccines for the fall, and CDC has recommended them for everyone, ages 6 months and older. This recommendation comes as COVID-19 hospitalizations, and likely cases, are on the rise. The fall will also mark the first time that COVID-19 vaccines will be commercialized – that is, transitioned to the commercial market for their manufacturing, procurement and pricing. Up until this point, the federal government had purchased all COVID-19 vaccines and provided them free of charge to anyone, regardless of insurance coverage or ability to pay.

While the average price paid by the federal government for the most recent COVID-19 booster was about $29/dose, vaccine manufactures have indicated that they will charge $110-$130 per dose, or 3-4 times as much, on the commercial market. This has raised concerns about how those who are uninsured will access COVID-19 vaccines going forward, particularly given the potential for adverse effects on individual and population-level health. While virtually everyone with public and private insurance is guaranteed free access to any CDC recommended vaccine, including for COVID-19, this is not the case for the more than 23 million uninsured non-elderly adults in the United States, a number that may be increasing due to the unwinding of the pandemic-era continuous enrollment policy in Medicaid. Uninsured adults are disproportionately low income, people of color, and in poorer health, including being more likely to be hospitalized for avoidable health conditions and to experience declines in their overall health than those who are insured.

The federal government and vaccine manufactures have announced plans for a temporary approach to support access to the COVID-19 vaccine for uninsured adults. This policy watch provides an overview of how uninsured adults currently access recommended vaccines, how they have accessed COVID-19 vaccines thus far, including what is known about their vaccine uptake, and proposed plans to provide COVID-19 vaccines to uninsured adults this fall and beyond. It does not focus on uninsured and underinsured children who are guaranteed free access to all recommended vaccines through the Vaccines for Children Program.

How do uninsured adults access and pay for recommended vaccines now?

For adults who are uninsured in the United States, there is no guaranteed access to free vaccines recommended for routine use. The federal government does purchase a limited number of recommended vaccines directly for uninsured and other qualifying adults through funding that comes from Section 317 of the Public Health Services Act. Section 317 is a discretionary program, dependent upon annual appropriations from Congress, and its funding is used both for purchasing recommended vaccines and for supporting the nation’s immunization infrastructure. As a discretionary program, funding does not necessarily match need or cost, or take into account the introduction of a new vaccine (such as for COVID-19 or RSV). Because of these limits, some states supplement their Section 317 funds with state funds in order to reach more people. To be eligible to receive free vaccines through the Section 317 program, adults must be uninsured, have no vaccine coverage, or be vaccinated as part of a public health response such as a mass vaccination campaign. Free vaccines are largely distributed through state and local health departments and community health centers. Uninsured adults who are unable to access free vaccines must pay out of pocket for the full cost of the vaccines or receive them on a sliding fee scale at certain safety net providers.

How have uninsured adults accessed COVID-19 vaccines up until this point?

During the COVID-19 pandemic emergency, the federal government spent billions of dollars in emergency funds to purchase COVID-19 vaccines, including boosters, to provide them free of charge to the public. Vaccines were distributed widely, through federal and state public vaccine distribution centers, pharmacies, and health centers, which were instrumental in prioritizing hard to reach communities during this time. In addition, states were given a temporary option to provide Medicaid coverage for COVID-19 vaccines to uninsured individuals and receive 100% federal matching funds to cover the costs of providing care. This coverage option ended when the public health emergency declaration ended in May.

What do we know about uptake of COVID-19 vaccines among uninsured adults?

Among adults between the ages of 18 and 65, and despite COVID-19 vaccines being free to all up until this point, those who are uninsured are much less likely to have been vaccinated compared to those who are insured (54% vs 75%), based on recent KFF polling. This difference in uptake may reflect several factors, including systemic barriers to accessing care among uninsured individuals, different views of vaccination, and other challenges.

What is the ‘Vaccines for Adults’ program proposed by the Biden administration?

The Biden administration has twice proposed to Congress in its annual budget request the creation of a new “Vaccines for Adults” (VFA) program to provide uninsured adults with access to all recommended vaccines, including COVID-19 vaccines, at no cost. Congress has not acted on these proposals. As a result, the administration has proposed a temporary “Bridge Access” program to provide COVID-19 vaccines to uninsured adults on a limited basis (see below).

What is the HHS Bridge Access Program?

To address concerns about COVID-19 vaccine access among uninsured adults this fall, the administration announced a new “Bridge Access Program” earlier this year. It will operate as a “public-private partnership to help maintain uninsured individuals’ access to COVID-19 care at their local pharmacies, through existing public health infrastructure, and at their local health centers.” Financed with $1.1 billion in funds already appropriated during the COVID-19 emergency (funds will be used for both vaccines and treatments), the program is largely managed by the CDC and has two main components:

• Vaccines will be purchased through the CDC’s Section 317 program and distributed through that network of local health departments and health centers. The Health Services and Resources Administration will provide additional support to health centers to ensure equitable access to vaccines and treatments.
• CDC will partner with three pharmacy chains (CVS, Walgreens, and eTrueNorth) and provide them with a per-dose payment to support vaccine administration costs, as was done during the public health emergency. This component of the program relies on vaccine manufacturers providing COVID-19 vaccines at no cost to uninsured people, as they have announced (see below).

CDC has indicated that vaccines under the program will begin to be available within 48 hours of being recommended by CDC. The program is temporary and will run through December 2024.

Will vaccine manufacturers help provide COVID-19 vaccines to the uninsured?

Many vaccine and drug manufacturers offer patient assistance programs to support those without insurance or with limited means in accessing their products; however, these programs vary in terms of eligibility and application process. Both Pfizer and Moderna have announced that they intend to provide their vaccines at no cost to uninsured individuals, though details are not yet available.

Discussion

During the COVID-19 pandemic emergency, the federal government spent billions of dollars in emergency funds to purchase COVID-19 vaccines, including boosters, to provide free of charge regardless of insurance status or ability to pay. As COVID-19 vaccines enter the commercial market for the first time, uninsured adults will no longer be guaranteed access to these vaccines at no cost. To address this in the short term, the federal government announced a “Bridge Access Program” that relies, in part, on vaccine manufacturers providing free vaccines to uninsured individuals. Still, full details on these efforts are not yet available. And, while participating pharmacies will be required to conduct outreach to underserved communities, ensuring eligible people know about the program will be a challenge.  Given that uninsured adults are disproportionately low income and people of color and that COVID-19 vaccine uptake among uninsured adults is already lower than among those with insurance, concerns about cost and lack of awareness about the availability of free vaccines could present additional barriers to vaccination and further exacerbate existing disparities in uptake and health status. Moreover, these temporary approaches do not address access to vaccines beyond COVID-19, such as for flu or RSV, and underscore the broader challenge faced by those who are uninsured in accessing preventive health services.