Estimates of the Initial Priority Population for COVID-19 Vaccination by State
Issue Brief
On December 1, 2020, the Advisory Committee on Immunization Practices (ACIP) of the Centers for Disease Control and Prevention’s (CDC), issued an initial recommendation, adopted by the CDC director, that health care personnel and residents of long-term care facilities should be the first to be offered a COVID-19 vaccine once it is authorized or approved by the FDA (See Appendix A). The ACIP recommendation recognizes that health care workers, who are at higher risk of exposure to people with COVID-19, are essential for preserving health care capacity during the pandemic. Further, it recognizes that long-term care residents are at high risk of serious illness if infected with the virus and account for 40% of all COVID-19 deaths. States have the authority to make their own allocation decisions, although most will likely follow the ACIP guidelines for the initial priority groups.
This analysis provides new national and state-level estimates of the number of health care workers and long-term care residents who are expected to be part of the group first in line to receive the COVID-19 vaccine to gain insight into how this initial priority population varies across states. These estimates are based on our analysis of the 2019 American Community Survey (ACS) and Certification and Survey Provider Enhanced Reports (CASPER) data.
Our health care worker estimates may be lower than others because they are limited to people working in health care settings who are likely to have direct patient contact based on their occupation and who have current ties to the workforce. We include workers providing direct clinical care, such as doctors, nurses, and aides; workers providing direct patient support, such as environmental and food staff; and first-line supervisors and managers of these occupations. Moreover, the estimates are based on state of residence of the health care worker. Some health care workers may work in a different jurisdiction than where they live. For example, many health care workers in the District of Columbia live in Virginia and Maryland. Our national estimates of long-term care facility residents include individuals living in certified nursing facilities and assisted living facilities, but not others who live in other residential settings. Due to data limitations, our state-level estimates do not include people who live in assisted living facilities or in other residential settings.
Findings
Nationwide, there are 19.7 million adults working in health care settings, of which roughly 15.5 million are estimated to have direct patient contact. In addition, there are 1.2 million nursing facility residents and about 800,000 assisted living facility residents. Together, health care workers with direct patient contact and residents in either nursing facility or assisted living facilities account for approximately 17.6 million people or about 7% of the adult population in the U.S.
The number of people in this initial priority group varies widely across states. The number of adults who are health care workers who have direct patient contact or are nursing facility residents ranges from 23,800 who live in Washington, D.C. to nearly 1.7 million who live in California, while the share of adults in these groups varies from roughly 4.4% in DC to at least 8% in 7 states, with North Dakota having the highest share (10%), following by Pennsylvania (8.3%), Minnesota (8.1%) and Rhode Island (8.1%). As noted earlier these estimates do not include people who live in assisted living facilities or in other residential settings.
Discussion
The Department of Health and Human Services (HHS) has announced that about 40 million doses of vaccine could be available by the end of December 2020, enough to vaccinate 20 million people given that two doses are required for the main vaccine regiments that are furthest along in the authorization process. More recent media reports indicate the number of vaccines available for early distribution may be lower than initially projected. HHS plans to allocate vaccinations to states based on each state’s share of the total U.S. adult population but, to date, has not publicly released information on the actual number of vaccines that will be allocated to each state.
Variations in the number of health care workers and long-term care residents across states may result in uneven effects across states in their ability to immunize priority populations using their initial vaccine allotments. While some states may have an adequate supply to vaccinate their priority population, others may fall short and may need to decide who goes first among people in this initial group. Further, as states allocate vaccines down to the local level, the ability of counties, municipalities, and health care systems to vaccinate health care workers and long-term care residents could vary, depending on their supply of vaccines and the demographics of their communities. In instances where supply is insufficient to fully vaccinate the initial priority population, ACIP notes that jurisdictions may consider first offering the vaccine to health care personnel whose duties require proximity (within 6 feet) to other people and that, if vaccine supply remains limited, additional factors might be considered for sub-prioritization of health care personnel. Similarly, ACIP notes that jurisdictions might consider first offering vaccinations to residents and health care personnel in skilled nursing facilities because of the risk of COVID-19 related mortality among residents in those settings.
| Table 1: Estimated Health Care Workers and Nursing Facility Residents by State, 2019 | |||||
| State | Total Adults | Initial Priority Population | |||
| Health Care Workers with Direct Patient Contact | Nursing Facility Residents | Total | Priority Population as a Share of Total Adults | ||
| United States* | 250,235,900 | 15,525,100 | 1,246,100 | 16,771,200 | 6.7% |
| Alabama | 3,697,300 | 225,300 | 22,700 | 248,000 | 6.7% |
| Alaska | 526,200 | 33,000 | 500 | 33,500 | 6.4% |
| Arizona | 5,485,500 | 289,300 | 10,300 | 299,600 | 5.5% |
| Arkansas | 2,237,600 | 145,500 | 17,300 | 162,700 | 7.3% |
| California | 29,920,500 | 1,558,100 | 100,000 | 1,658,000 | 5.5% |
| Colorado | 4,377,800 | 263,500 | 16,000 | 279,500 | 6.4% |
| Connecticut | 2,736,600 | 197,200 | 19,600 | 216,800 | 7.9% |
| Delaware | 742,000 | 54,800 | 3,900 | 58,800 | 7.9% |
| District of Columbia | 544,800 | 22,500 | 1,300 | 23,800 | 4.4% |
| Florida | 16,839,200 | 991,500 | 71,200 | 1,062,700 | 6.3% |
| Georgia | 7,832,000 | 405,700 | 22,900 | 428,600 | 5.5% |
| Hawaii | 1,049,200 | 56,700 | 3,400 | 60,100 | 5.7% |
| Idaho | 1,308,500 | 76,800 | 3,300 | 80,100 | 6.1% |
| Illinois | 9,583,100 | 626,500 | 65,600 | 692,100 | 7.2% |
| Indiana | 4,987,100 | 324,800 | 37,600 | 362,400 | 7.3% |
| Iowa | 2,348,800 | 148,900 | 22,300 | 171,200 | 7.3% |
| Kansas | 2,126,800 | 147,400 | 16,800 | 164,200 | 7.7% |
| Kentucky | 3,342,400 | 215,200 | 21,500 | 236,700 | 7.1% |
| Louisiana | 3,429,500 | 226,300 | 25,900 | 252,100 | 7.4% |
| Maine | 1,064,800 | 75,000 | 5,800 | 80,900 | 7.6% |
| Maryland | 4,569,400 | 294,400 | 16,500 | 310,900 | 6.8% |
| Massachusetts | 5,323,100 | 390,300 | 34,400 | 424,700 | 8.0% |
| Michigan | 7,664,100 | 516,800 | 37,500 | 554,400 | 7.2% |
| Minnesota | 4,233,200 | 319,400 | 23,400 | 342,800 | 8.1% |
| Mississippi | 2,182,700 | 136,300 | 15,900 | 152,200 | 7.0% |
| Missouri | 4,604,900 | 308,900 | 37,300 | 346,200 | 7.5% |
| Montana | 818,000 | 54,700 | 3,800 | 58,500 | 7.1% |
| Nebraska | 1,409,100 | 100,000 | 10,600 | 110,600 | 7.8% |
| Nevada | 2,350,500 | 101,900 | 5,600 | 107,500 | 4.6% |
| New Hampshire | 1,064,100 | 75,400 | 6,400 | 81,800 | 7.7% |
| New Jersey | 6,790,900 | 439,000 | 42,400 | 481,400 | 7.1% |
| New Mexico | 1,576,900 | 101,000 | 5,500 | 106,500 | 6.8% |
| New York | 14,985,700 | 1,103,600 | 89,800 | 1,193,400 | 8.0% |
| North Carolina | 7,886,700 | 472,500 | 36,100 | 508,600 | 6.4% |
| North Dakota | 557,200 | 50,400 | 5,300 | 55,800 | 10.0% |
| Ohio | 8,827,900 | 631,100 | 71,900 | 702,900 | 8.0% |
| Oklahoma | 2,893,300 | 183,000 | 17,200 | 200,200 | 6.9% |
| Oregon | 3,287,200 | 201,300 | 4,700 | 206,000 | 6.3% |
| Pennsylvania | 9,802,200 | 740,100 | 72,500 | 812,600 | 8.3% |
| Puerto Rico | 2,594,600 | 92,300 | Not Available | Not Available | |
| Rhode Island | 817,600 | 58,400 | 7,600 | 66,000 | 8.1% |
| South Carolina | 3,895,400 | 223,000 | 15,600 | 238,600 | 6.1% |
| South Dakota | 642,400 | 45,200 | 5,600 | 50,800 | 7.9% |
| Tennessee | 5,159,400 | 324,700 | 26,600 | 351,400 | 6.8% |
| Texas | 20,987,700 | 1,202,100 | 90,700 | 1,292,800 | 6.2% |
| Utah | 2,234,700 | 124,600 | 5,600 | 130,100 | 5.8% |
| Vermont | 486,800 | 33,000 | 2,400 | 35,400 | 7.3% |
| Virginia | 6,360,800 | 367,100 | 19,600 | 386,600 | 6.1% |
| Washington | 5,795,500 | 327,800 | 15,100 | 342,900 | 5.9% |
| West Virginia | 1,389,500 | 97,600 | 9,300 | 106,900 | 7.7% |
| Wisconsin | 4,434,500 | 299,100 | 21,200 | 320,400 | 7.2% |
| Wyoming | 430,200 | 25,800 | 2,200 | 28,100 | 6.5% |
| NOTE: *Excludes an estimated 800,000 assisted living facility resident; when included, 17.6 million people are part of the priority population nationally, about 7% of the adult population.SOURCE: KFF Analysis of the 2019 American Community Survey and KFF analysis of 2019 Certification and Survey Provider Enhanced Reports (CASPER) data. | |||||
Methods
The estimates of health care workers and the total population are based on a KFF analysis of the 2019 American Community Survey (ACS), 1-year file. The ACS includes a 1% sample of the US population. The health care industry is defined as industry codes 5070 and 7970 through 8290 and does not include the childcare or vocational training industries. Retail pharmacies are included as a healthcare industry. For more information see here. This analysis only includes those individuals who work in health care settings, so does not include professionals working in other care settings, such as school nurses, and does not include individuals who provide other services to clients, such as social services. We exclude individuals in these industries who are not currently in the labor force. For information on how the healthcare workforce has changed during the course of the pandemic see here.
We defined health care workers who likely have direct patient contact by reviewing the occupation codes of workers in healthcare industries. We included workers providing direct clinical care, such as doctors, nurses, and aides; workers providing direct patient support, such as environmental and food staff; and first line supervisors and managers of these occupations. We excluded administrative and managerial staff who are likely able to work remotely and/or not expected to have direct patient contact through their job duties. It is possible that estimate includes some workers who normally have direct patient contact but who can work remotely, for example, through the use of telehealth.
The estimates of nursing facility residents are based on KFF analysis of 2019 Certification and Survey Provider Enhanced Reports (CASPER) data. The CASPER system includes data for all certified nursing facilities in the U.S. See here for more information on these data and methods. The nationwide estimate of residents in assisted living facilities is from the 2016 National Study of Long-Term Care Providers. Note that estimates of residents in nursing facility and assisted living facilities are from different sources, represent different time periods and may include a small number of overlapping residents.
Appendix
Appendix A: ACIP Recommendation and Definitions
On December 1, 2020, ACIP recommended that, when a COVID-19 vaccine is authorized by FDA and recommended by ACIP, both 1) health care personnel and 2) residents of long-term care facilities be offered vaccination in the initial phase of the COVID-19 vaccination program
ACIP defines health care personnel as paid or unpaid persons serving in health care settings who have the potential for direct or indirect exposure to patients or infectious materials. These include people providing clinical care as well as support staff members, such as food and environmental staff.
ACIP defines long-term care facility residents as adults who reside in facilities that provide a variety of services, including medical and personal care, to persons who are unable to live independently. These include adults residing in skilled nursing facilities, nursing homes, and assisted living facilities.