Key Takeaways

The COVID-19 pandemic presented a public health emergency that was unprecedented in its scope and duration and brought new focus to the long-standing unmet need for home and community-based services (HCBS) among seniors and people with disabilities and direct care workforce shortages. Recognizing Medicaid’s role as the primary payer for HCBS, this issue brief presents early findings from the most recent KFF 50-state survey of Medicaid HCBS programs. It focuses on state policies adopted in response to challenges posed by the pandemic, the pandemic’s impact on Medicaid HCBS enrollees and providers, and states’ early plans for the new American Rescue Plan Act (ARPA) 10 percentage point temporary increase in federal Medicaid matching funds for HCBS. We survey states about HCBS provided through state plan authorities and waivers. There were 277 HCBS waivers in FY 2018. Overall, 41 states responded to the survey by mid-July 2021, accounting for 87% of total HCBS spending nationally in FY 2018, though response rates for specific questions varied. We highlight some specific state examples where states provided additional information with their responses. Key finding include the following:

• Important data gaps remain, with just under half of responding states tracking COVID-19 vaccination rates among Medicaid HCBS enrollees. At the same time, state HCBS programs are playing a role in facilitating vaccine access for HCBS enrollees, with most responding states adopting multiple policies in this area. Over one-third of responding states have publicly available data on COVID-19 cases and deaths among HCBS enrollees.
• The Medicaid HCBS provider infrastructure declined during the pandemic, with two-thirds of responding states reporting a permanent closure of at least one provider. Most of these states reported permanent closures among more than one HCBS provider type. States most frequently cited workforce shortages as the pandemic’s primary impact on in-home and group home services, while closures due to social distancing measures was the most frequently reported primary impact on adult day health and supported employment programs.
• Over half of responding states reported early plans for the new ARPA temporary enhanced federal funds for Medicaid HCBS. The most frequently reported activities were provider payment rate increases and workforce recruitment.

Expanding HCBS access and strengthening the direct care workforce would help to improve care as pandemic recovery efforts continue and beyond, while also increasing public spending. While the ARPA enhanced funds are available only for one year, additional federal funding for HCBS is part of the budget reconciliation package proposed by Democratic leaders, though the details will be worked out by Congressional committees. President Biden earlier this year proposed a $400 billion federal investment in Medicaid HCBS, though it is unclear how much of that funding increase will be approved by Congress as it considers competing priorities in the budget package.

Introduction

The COVID-19 pandemic presented a public health emergency (PHE) that was unprecedented in its scope and duration. Key Medicaid populations, including seniors and nonelderly people with disabilities who use long-term services and supports (LTSS), are disproportionately at risk of serious illness or death from COVID-19 compared to the general population. This risk is heightened for people who receive LTSS in congregate settings and for the direct care workers who provide these services. The pandemic’s impact on these populations brought new focus to pre-existing issues, including unmet need for home and community-based services (HCBS) and workforce shortages. Drawing on Medicaid’s role as the primary payer for LTSS, including HCBS, federal and state policymakers have adopted a number of policies to aid pandemic response.

This issue brief presents early findings from the most recent KFF survey of Medicaid HCBS programs in all 50 states and the District of Columbia. It focuses on state policies adopted in response to challenges posed by the pandemic, the pandemic’s impact on Medicaid HCBS enrollees and providers, and states’ initial plans for the new American Rescue Plan Act 10 percentage point temporary increase in federal Medicaid matching funds for HCBS available from April 2021 through March 2022. Additional survey findings and state-level data related to Medicaid HCBS enrollment, spending, and key state policies will be released later. We survey states about HCBS provided through state plan authorities and waivers. There were 277 HCBS waivers in FY 2018.¹  Overall, 41 states responded to the survey by mid-July 2021, though response rates for specific questions varied.²  The 41 responding states account for 87% of total HCBS spending nationally in FY 2018. We highlight specific state examples where states provided additional information with their responses.

COVID-19 Impact on Medicaid HCBS Enrollees

Over one-third of responding states reported having publicly available data on COVID-19 cases and deaths among Medicaid HCBS enrollees.³  Though states are monitoring COVID-19 cases and deaths generally, and some are tracking overall cases and deaths by demographic characteristics such as age, race, and sex, fewer are collecting these data specifically for Medicaid HCBS enrollees. Among the 14 states reporting publicly available data specific to HCBS enrollees, 12 states’ responses to this question varied by waiver program. This suggests that even when states are tracking COVID-19 cases and deaths among HCBS enrollees, tracking may not be uniform across all HCBS programs. For example, Illinois reported that it makes COVID-19 cases and deaths data publicly available for three HCBS waivers serving people with intellectual and developmental disabilities (I/DD) but not for its HCBS waivers serving other populations.⁴  Rhode Island reported that efforts to track COVID-19 cases and deaths among its HCBS waiver enrollees are under development, though data are not yet publicly available.

Just under half of responding states reported tracking COVID-19 vaccination rates for Medicaid HCBS enrollees.⁵  Nearly all of these states indicated that these data are used internally to inform outreach efforts, while two states (Delaware and Indiana) noted that they make these data publicly available. Seven states’ responses to this question varied by HCBS program, again suggesting that tracking may not be uniform across all HCBS enrollees. In addition, Washington reported that it is beginning to track COVID-19 vaccination status among its Section 1115 HCBS waiver enrollees as part of the functional assessment process.

All responding states reported having at least one policy in place to facilitate access to COVID-19 vaccines for Medicaid HCBS enrollees and providers, with 8 in 10 responding states reporting more than one policy.⁶  The most frequently reported policy was partnering with public health agencies on vaccine outreach and education initiatives (Figure 1). For example, West Virginia provided a list of homebound HCBS enrollees to local health departments to arrange for appointments to administer vaccines in enrollees’ homes. Other frequently reported policies included leveraging Medicaid’s non-emergency transportation benefit to provide enrollees with access to vaccination appointments and enlisting HCBS providers in vaccine outreach and education efforts (Figure 1). Additional policies to facilitate vaccine access reported by states included placing certain HCBS populations in higher vaccine access priority groups, having Medicaid managed care plans contact enrollees to provide education and schedule vaccination appointments,⁷  and partnering with pharmacies to provide vaccination clinics for HCBS enrollees.⁸  Washington reported having “strike teams” travel to some HCBS settings to offer vaccinations to staff and enrollees.

The pandemic affected all Medicaid HCBS settings, though the primary impact identified by states varied somewhat by setting type. States most frequently reported that the pandemic resulted in workforce shortages for HCBS provided in an enrollee’s home⁹  and in group homes,¹⁰  while closures due to social distancing measures was the most frequently reported impact for adult day health programs¹¹  and supported employment programs¹²  (Figure 2). For HCBS provided in an enrollee’s home, workforce shortages was closely followed by enrollees declining to have workers in their homes (Figure 2). States reported that some HCBS enrollees and their family members declined services due to fear of coronavirus exposure and had concerns about receiving in-person services until enrollees and providers could be vaccinated. To minimize service interruptions, some states reported using Medicaid emergency authorities to provide HCBS via telehealth where possible to enrollees at home and in adult day health programs. Some states also noted that utilization of supported employment services dropped due to job loss during the pandemic among the enrollees who received these services.

Eight states identified COVID-19 outbreaks as the pandemic’s primary impact in group homes (Figure 2). (Other states also may have experienced outbreaks but did not identify them as the pandemic’s “primary” impact on group homes in their survey response.) Arizona provided additional detail about the pandemic’s impact on group homes, noting that group homes had to increase staffing to support HCBS enrollees during the day when outside day habilitation and supported employment programs became less available. In addition, Arizona noted that its group homes had to identify alternative places to quarantine residents exposed to coronavirus to mitigate the risk of spreading infection to other residents and staff.

COVID-19 Impact on Medicaid HCBS Providers

Two-thirds of responding states reported a permanent closure of at least one Medicaid HCBS provider during the pandemic (Figure 3).¹³  Most of these states (16) reported permanent closures among more than one HCBS provider type. Adult day health programs were the most frequently reported HCBS provider type to have permanently closed, followed by providers of in-home services, supported employment providers, and group homes (Figure 3). Several states indicated that workforce shortages already existed prior to pandemic and worsened during the COVID-19 PHE. For example, Oregon noted that HCBS providers experienced challenges with remaining financially viable due to the pandemic, which will impact their ability to reopen. Specific challenges cited by Oregon related to providers’ ability to maintain leased space, retain trained staff, and provide supported employment services such as job search, placement, and coaching.

About three-quarters of responding states reported that they used CMS-approved authority to provide retainer payments to financially support Medicaid HCBS providers during the pandemic.¹⁴  Retainer payments allow providers to continue to bill and be paid for habilitation and personal care services that are authorized in enrollee service plans, which is intended to help providers maintain capacity when circumstances prevent enrollees from actually receiving those services.¹⁵  For example, some HCBS providers such as adult day health centers had to temporarily close to comply with social distancing orders during the COVID-19 PHE, and some HCBS enrollees may have had to temporarily stop receiving in-home services due to self-quarantine.

Most responding states (20 of 29) reported that the initial federal limit of three 30-day episodes for retainer payments was insufficient to fully support HCBS providers during the pandemic.¹⁶  Some states’ responses to this question varied by HCBS program, indicating that the federal retainer payment limit may have been sufficient to support some service provider types but not others. For example, Pennsylvania reported the federal retainer payment limit was insufficient for I/DD service providers but was sufficient for providers serving enrollees in its waiver for seniors and people with physical disabilities. CMS’s initial guidance allowed states to make up to three 30-day episodes of retainer payments during the COVID-19 PHE.¹⁷  This guidance was in effect when we began fielding our survey in March 2021. Subsequent CMS guidance revised federal policy to allow states to offer retainer payments for up to three additional 30-day periods in calendar year 2021, recognizing the extended duration of the COVID-19 PHE.¹⁸ 

Early State Plans for ARPA HCBS Funding Increase

Nearly six in 10 responding states identified the top initiatives that they were planning to target with the new temporary enhanced federal Medicaid matching funds for HCBS in the American Rescue Plan Act (ARPA).¹⁹  The ARPA increases the federal matching rate for state spending on HCBS by 10 percentage points from April 1, 2021 through March 31, 2022.²⁰  States must maintain their current HCBS spending and use the enhanced funds for activities that expand or strengthen Medicaid HCBS. KFF previously estimated that this ARPA provision could increase federal Medicaid HCBS spending by about $11.4 billion nationally. The increase will be distributed proportional to the size of state HCBS programs, reflecting variation in both state size and optional policy choices. The ARPA was enacted just as our survey went into the field in March 2021, and survey responses reflect states’ early plans. States’ plans for the ARPA funds may change in light of CMS implementation guidance issued in mid-May 2021, and based on stakeholder input as states develop their formal plans to submit to CMS.

The two initiatives most frequently reported by states as potential uses of the new APRA funds were increasing HCBS provider payment rates and workforce recruitment (Figure 4). Other initiatives rounding out the top five included serving additional HCBS waiver enrollees, investing in worker training, and supporting family caregivers (Figure 4). Fewer states reported providing emergency equipment and supplies (4 states), providing worker hazard or overtime pay (3 states), providing retainer payments (3 states), providing services to mitigate enrollee isolation due to the pandemic (2 states), adding or increasing waiver services (2 states), and funding nursing home to community transitions (2 states) among their top anticipated uses of APRA funds. We asked states to identify their top two initiatives, though a number of states’ responses to this question varied by HCBS program with 14 states reporting three or more initiatives across different programs. The May 2021 CMS guidance clarified that states also can use ARPA funds to facilitate access to COVID-19 vaccines, so some states may include this initiative in their final plans.

Looking Ahead

Understanding the pandemic’s impact on Medicaid HCBS enrollees and providers can help to inform ongoing pandemic response and recovery efforts. Important data gaps remain, with most states lacking publicly available data on COVID-19 cases and deaths among HCBS enrollees. While the availability of vaccines has led to substantial decreases in cases and deaths among those in LTSS settings, CMS has noted that ongoing vaccination efforts will be necessary due to workforce turnover and to ensure widespread vaccine access. Our survey results indicate that while some states are tracking vaccination rates among Medicaid HCBS enrollees, tracking is not yet uniform across all states and among all HCBS programs within states. A recent interim final rule adopting requirements for certain LTSS settings to report on, provide education about, and offer the COVID-19 vaccine to residents and staff applies to nursing homes but deferred establishing similar requirements for congregate community-based settings like group homes and adult day health centers. Until data, resource, and oversight gaps across the LTSS continuum are filled, nonelderly people with disabilities may continue to experience disproportionate barriers to vaccine access compared to people in nursing homes, and the full impact of COVID-19 on this population will not be understood completely. Despite limited efforts to track vaccination rates, our survey also found that state HCBS programs are playing a role in facilitating vaccine access for HCBS enrollees, with most states adopting multiple policies in this area. These efforts could be expanded if states choose to direct a portion of their ARPA enhanced HCBS funds to activities supporting COVID-19 vaccine access as permitted in recent CMS guidance.

The pandemic has brought new attention among policymakers and the public to the longstanding unmet need for HCBS and direct care workforce shortage, driven by low wages, high turnover, and limited opportunities for career advancement. Most states reported workforce shortages as the pandemic’s primary impact on HCBS provided in an enrollee’s home  and in group homes. Many states also reported permanent closure of Medicaid HCBS providers during the pandemic, affecting adult day health centers, in-home service providers, supported employment providers, and group homes. Most states that reported provider closures experienced the loss of more than one provider type. Though many states reported using retainer payment authority to financially support providers, the original federal episode limit may have been insufficient to meet some providers’ needs, particularly those with narrow operating margins. Medicaid providers also faced challenges accessing federal provider relief funds, both in the amount of funding received and delays in allocations compared to other provider types.

Maintaining and increasing the HCBS provider infrastructure is key to meeting enrollee need and expanding access to these services as pandemic recovery efforts continue and beyond. The APRA one-year enhanced funds for HCBS represents the first new federal investment in Medicaid HCBS since the Affordable Care Act in 2010. States have adopted a number of policies to expand access to Medicaid HCBS during the PHE, such as expanding eligibility criteria, streamlining enrollment processes, adding services, and increasing provider payment rates, but their ability to continue many of these policies after the PHE ends may be limited by budgetary constraints. Our survey found that states’ initial plans for the new ARPA funds centered on provider payment rate increases and workforce recruitment, two areas which experience during the pandemic has confirmed are crucial to sustaining and expanding access to HCBS. While the ARPA enhanced funds are available only for one year, additional federal funding for HCBS is part of the budget reconciliation package proposed by Democratic leaders, though the details will be worked out by Congressional committees. President Biden earlier this year proposed a $400 billion federal investment in Medicaid HCBS, though it is unclear how much of that funding increase will be approved by Congress as it considers competing priorities in the budget package.

1. The total number of HCBS waivers may differ somewhat for FY 2021. That data will be included in a subsequent report. ↩︎
2. The 10 states that did not respond by mid-July 2021 are Connecticut, District of Columbia, Georgia, Hawaii, Minnesota, New Hampshire, New Mexico, North Carolina, Tennessee, and Utah. ↩︎
3. Thirty-nine states responded to this survey question. ↩︎
4. Illinois reported that the state agencies operating its HCBS waivers for seniors, people with physical disabilities, and people with HIV/AIDS are reporting COVID-19 cases and deaths among those enrollees to local health departments, and managed care plans are tracking COVID-19 cases and deaths across several Illinois HCBS waivers, but this information is not publicly available. ↩︎
5. Thirty-eight states responded to this survey question. ↩︎
6. Thirty-six states responded to this survey question. ↩︎
7. This initiative was reported by five states (Florida, Massachusetts, New Jersey, Ohio, and Virginia). ↩︎
8. This initiative was reported by three states (Illinois, Pennsylvania, and Wisconsin). ↩︎
9. Thirty-nine states responded to this survey question. ↩︎
10. Thirty-seven states responded to this survey question. ↩︎
11. Thirty-eight states responded to this survey question. ↩︎
12. Thirty-four states responded to this survey question. ↩︎
13. Thirty-eight states responded to this survey question. ↩︎
14. Thirty-nine states responded to this survey question. Our survey asked states whether they actually used CMS-approved authority to provide retainer payments. KFF’s Medicaid emergency authorities tracker lists states with CMS-approved authority, without indicating whether states actually used an approved authority. This difference may account for discrepancies in state totals between the two sources. ↩︎
15. Since 2000, CMS Olmstead guidance has permitted states to make retainer payments to personal care and attendant service providers while an HCBS enrollee who usually receives those services is hospitalized or absent from their home. This policy places personal assistance services on equal footing with nursing facility services, for which states are allowed to make bed hold payments in an enrollee’s absence. The 2000 guidance applies to personal assistance services provided through HCBS waivers and allows a retainer payment period of 30 consecutive days or the number of days for which the state allows a nursing facility bed hold payment, whichever is less. CMS’s Section 1115 COVID-19 demonstration waiver template allowed states to request authority to make retainer payments to habilitation and personal care service providers affected by the pandemic in an effort to preserve this provider network. CMS COVID-19 guidance clarified that retainer payment authority also is available as a regular state plan amendment or a disaster state plan amendment for Section 1915 (i) HCBS and Community First Choice attendant services as well as through HCBS waiver Appendix K. CMS, COVID-19 Frequently Asked Questions (FAQs) for State Medicaid and Children’s Health Insurance Program Agencies, at pp. 101-102 (last updated Jan. 6, 2021), https://www.medicaid.gov/state-resource-center/downloads/covid-19-faqs.pdf. ↩︎
16. Twenty-eight states responded to this survey question. One state reported that it used retainer payment authority but did not respond to this follow-up question. ↩︎
17. Consecutive days are those that are eligible for billing, which means that 30 consecutive billing days for services provided Monday through Friday encompasses a 6-week period. CMS, COVID-19 FAQs, supra. n.16 at p. 99. ↩︎
18. The revised policy is retroactive to January 1, 2021. CMS State Medicaid Director letter, SMD #21-003, Implementation of American Rescue Plan Act of 2021 Section 9817:  Additional Support for Medicaid Home and Community-Based Services during the COVID-19 Emergency, at p. 11 (May 13, 2021), https://www.medicaid.gov/federal-policy-guidance/downloads/smd21003.pdf. ↩︎
19. Forty-one states responded to this survey question. ↩︎
20. States have until March 31, 2024 to spend the enhanced funds. ↩︎

The KFF COVID-19 Vaccine Monitor is an ongoing research project tracking the public’s attitudes and experiences with COVID-19 vaccinations. Using a combination of surveys and qualitative research, this project tracks the dynamic nature of public opinion as vaccine development and distribution unfold, including vaccine confidence and acceptance, information needs, trusted messengers and messages, as well as the public’s experiences with vaccination.

Key Findings

• The latest Vaccine Monitor finds the share of adults who say they have either received a COVID-19 vaccine (67%) or say they will get vaccinated as soon as they can (3%) is relatively unchanged from June. The poll, conducted July 15-27th, may not capture any recent uptick in vaccinations after the most recent data from the Centers for Disease Control and Prevention (CDC), citing the increased risk of the Delta variant to both unvaccinated and vaccinated people.
• Three in ten adults remain unvaccinated including one in ten who say they want to “wait and see” how the vaccine works for other people before getting vaccinated and 3% who say they will do so “only if required” (down from 6% in June). An additional 14% say they will “definitely not” get a vaccine, a share that has held relatively steady since December. One-fourth of unvaccinated adults (8% of all adults) say they are likely to get a vaccine before the end of 2021, including nearly half (45%) of those who say they want to “wait and see.”
• Unvaccinated adults, especially those who say they will “definitely not” get a vaccine, are much less worried about the coronavirus, the Delta variant, and have less confidence in the safety and effectiveness of the vaccines compared to those who are vaccinated. Three-fourths of unvaccinated adults, including nine in ten of those who say they will “definitely not” get the vaccine, say they are “not worried” about getting seriously sick from the virus, less than half say they are worried about the Delta variant worsening the pandemic, more than half (including 75% of “definitely not”) say getting vaccinated is a bigger risk to their health than getting infected with coronavirus, and a quarter (just one in ten of “definitely not”) say the vaccines are effective at keeping vaccinated people from dying from COVID-19 or getting seriously ill.
• The increase in COVID-19 cases and news of the Delta variant spreading in the U.S. has made some people say they are more likely to wear a mask in public or avoid large gatherings, though this is mainly driven by vaccinated adults. Majorities of vaccinated adults say news of the variants has made them more likely to wear a mask in public (62%) or avoid large gatherings (61%), while fewer unvaccinated adults say the same (37% and 40%, respectively). However, one in five unvaccinated adults (22%) say news of variants has made them more likely to get vaccinated for COVID-19. This includes one-third (34%) of those who want to “wait and see,” but few (2%) of those who say they will “definitely not” get a vaccine say the news made them more likely to get vaccinated.
• The public is divided on whether the federal government should recommend employers require vaccines among their employees. Half (51%) say the federal government should recommend employers require their employees to get the COVID-19 vaccine unless they have a medical exception while a similar share (45%) say the federal government should not recommend this. Views towards this issue are sharply divided by both vaccination status and party identification, with 68% of vaccinated adults and 75% of Democrats saying the federal government should issue this recommendation, while eight in ten (81%) unvaccinated adults and 67% of Republicans say the federal government should not do this.
• Prior to the CDC issuing the newest guidance encouraging all adults, regardless of vaccine status, to wear masks indoors if they are in an area with higher transmission levels of coronavirus, half of adults said they wore a protective mask at least “most of the time” at an indoor setting like a grocery store, while less than half report wear a mask at least “most of the time” on public transit (44%), at work (42%), outdoors in crowded places (41%), or outdoors with household members or friends (18%). Across most places asked about, vaccinated adults were more likely to report wearing a mask at least “most of the time” than unvaccinated adults. Majorities of Republicans saying they “never” wear a mask outdoors in crowded places, outdoors with friends and household members, at work, or in a grocery store. Democrats, on the other hand, are more likely to report wearing a mask in all of these locations, except when outdoors with household members and friends.

Trends In COVID-19 Vaccination Intentions And Uptake

The latest KFF COVID-19 Vaccine Monitor finds roughly two-thirds of U.S. adults (67%) saying they have received at least one dose of a COVID-19 vaccine with an additional 3% saying they will get vaccinated as soon as they can, as of July 27^th. Three in ten adults (31%) remain unvaccinated. Those who remain unvaccinated include 10% who say they want to “want and see” how the vaccines work for other people before getting vaccinated, 3% who say they will get a vaccine “only if required” to do so for work, school, or other activities (down from 6% in June), and 14% who say they will “definitely not” get the vaccine. The shares of adults who remain unvaccinated is statistically similar to the KFF June COVID-19 Vaccine Monitor and the share who are the most reluctant to get the vaccine has remained relatively unchanged since KFF began tracking vaccine intentions at the end of 2020.

Among unvaccinated adults, one-fourth (8% of all adults) say it is likely they will get the COVID-19 vaccine before the end of the year including 13% who say it is “very likely.” The majority, however, say it is either “somewhat unlikely” or “very unlikely” they will get vaccinated before the end of 2021 (25%), or originally said they will “definitely not” get a vaccine (46%). Nearly half (45%) of those who say they want to “wait and see” say it is likely they will get the vaccine by the end of the year.

At least seven in ten White adults, older adults, Democrats, college graduates, those with serious health conditions, and urban residents say they have received at least one dose of the COVID-19 vaccine. Younger adults (18-29 years old), Republicans, rural residents, and the uninsured still report lower rates of vaccine uptake than other demographic groups. A larger share of Hispanic adults (16%) than Black adults (11%) and White adults (8%) say they want to “wait and see” before getting vaccinated, and at least one fifth of uninsured adults, White Evangelical Christians, rural residents, and 18-29 year-olds say they will “definitely not” get a vaccine.

The gender gap in vaccine uptake that emerged last month is still present with women still eight percentage points more likely to report being vaccinated than men (71% vs. 63%), and a larger share of men saying they will “definitely not” get the vaccine (18% vs. 10%). Yet, this is still largely attributed to the differences in partisan identification between men and women, with larger shares of men than women identifying as Republicans or Republican-leaning independents.

In recent days there has been an increase in calls from Republican lawmakers encouraging people to get a COVID-19 vaccine. The latest data from the KFF COVID-19 Vaccine Monitor (fielded from July 15-27) finds 56% of Republicans saying they either have already gotten a COVID-19 vaccine or plan to do so “as soon as possible,” statistically unchanged from June (54%). While this is the largest share of Republicans reporting this intention since we began the Vaccine Monitor, Republicans lag behind both Democrats (89%) and independents (67%) in their willingness to get a COVID-19 vaccine.

Who Remains Unvaccinated?

A previous KFF analysis examined the demographic groups among the unvaccinated population finding two distinct groups, those who are open to getting a vaccine (“wait and see”) and those who say they will definitely not get a COVID-19 vaccine. The latest KFF COVID-19 Vaccine Monitor finds the key demographic differences between the “wait and see” and the “definitely not” groups still center on racial and ethnic identity and political partisanship. Four in ten of those in the “wait and see” group are people of color, while the most vaccine resistant group, those who say they will “definitely not” get a COVID-19 vaccine, is overwhelmingly made up of White adults (65% of the group compared to 50% of the “wait and see” group). Partisanship also plays a major role with more than half (58%) of the “definitely not” group identifying as Republican or Republican-leaning. In addition, religious identity also plays a role as White Evangelical Christians make up nearly twice the share of the “definitely not” group (32%) as the “wait and see” group.

In addition to key demographics that help explain vaccine intentions, views of the pandemic generally, concerns about getting sick, and views of whether the vaccine or the virus is a greater health risk are also   contributing factors to whether an individual has gotten a COVID-19 vaccine.

Unvaccinated adults, especially those who say they will “definitely not” get a vaccine, are more likely to say they are not worried they personally will get seriously sick from the coronavirus and to believe that getting the vaccine is a bigger risk to their own health than getting the virus. Nine in ten of those who say they will “definitely not” get the vaccine are either “not too worried” or “not at all worried” about getting sick from the coronavirus and three-fourths of this group say getting the COVID-19 vaccine is a greater risk to their health than becoming infected with the coronavirus.

A majority of vaccinated adults (61%) are also not worried about getting sick from the coronavirus, perhaps an indicator of the relief some people are now feeling as a result of getting the vaccine. Unsurprisingly, nine in ten (88%) vaccinated adults say becoming infected with coronavirus is bigger risk to their health than getting the COVID-19 vaccine.

Furthermore, the majority (57%) of unvaccinated adults say they think the news has “generally exaggerated” the seriousness of the coronavirus, while three-fourths of vaccinated adults say the news has been “generally correct” or “generally underestimated” the pandemic’s seriousness. The view that the seriousness of the coronavirus has been “generally exaggerated” is the dominant view among those who say they will “definitely not” get a vaccine (75%).

The Emergence Of The Delta Variant

News about the Delta variant and the recent increases in the number of coronavirus cases in the country has raised concerns only a few weeks after many states and businesses relaxed masking and social distancing guidelines. The vast majority of adults (90%) have heard or read at least “a little” about new strains or variants of the coronavirus, such as the Delta variant. The share of the public who had heard or read about the Delta variant remain unchanged over the field period.

Overall, nearly two-thirds of adults are worried the new variants of the coronavirus will lead to a worsening of the pandemic in the U.S., including 26% who are “very worried.” A majority are also worried that new variants will lead to a worsening of the pandemic in their local area. Fewer are worried they will personally get sick from a new variant of the coronavirus.

Vaccinated people report higher levels of concerns than unvaccinated people about new variants of the coronavirus leading to a worsening of the pandemic in the U.S. (74% vs. 39%), in their local area (65% vs. 34%), and are more worried they will personally get sick from a new variant (40% vs. 27%).

Concerns that new variant of the coronavirus will lead to a worsening of the pandemic in the U.S. increased only slightly over the last week of interviews (starting on July 19^th)¹  during which there was increased media attention on the threat of the Delta variant and more positive vaccine messaging from Republican lawmakers. Nearly two-thirds of adults interviewed during that time period say they are worried (compared to 57% in the week prior). Worries about the pandemic worsening in their local area or that they will personally get sick from a new variant stayed relatively stable over the survey field period.

News of the variants spreading in the U.S. has made some people say they are “more likely” to wear a mask in public or avoid large gatherings. Majorities of vaccinated adults say news of the variants has made them more likely to wear a mask in public (62%) or avoid large gatherings (61%). Unvaccinated adults are much less likely than vaccinated adults to report that the news of the variants has made them more likely to wear a mask (37%) or avoid large gatherings (40%). However, about one in five unvaccinated adults (22%) say the news has made them more likely to get vaccinated for COVID-19. One-third (34%) of those who want to “wait and see” say the news of the variants has made them more likely to get vaccinated for COVID-19 compared to few (2%) of those who say they will “definitely not” get a vaccine.

In addition to news about the variants, six in ten adults have heard or read “a lot” or “some” about the possibility that COVID-19 booster shots might be needed for some vaccinated people to keep them protected, including about a quarter (26%) who have heard “a lot.” While similar shares of vaccinated and unvaccinated Americans have heard “a lot” about booster shots, more than double the percentage of unvaccinated adults report hearing nothing about booster shots (28%) compared to vaccinated adults (12%).

Among vaccinated adults who have heard or read at least a little about boosters for COVID-19, around a quarter (24%) say this news has caused them to worry that they may not be well-protected from coronavirus, even though they are vaccinated. That worry is significantly larger among vaccinated Black and Hispanic adults, with 36% of Black adults and 44% of Hispanic adults reporting concern compared to 17% of White adults. Three quarters of adults who have heard something about the boosters say this news has not caused them to worry about their protection from COVID-19.

Employer mandates

In recent days some cities, states, hospitals, and the federal government have issued requirements mandating some employees be vaccinated against the coronavirus. In addition, some private businesses are requiring employees and patrons to be vaccinated and many colleges are requiring students as well as staff to get vaccinated before the start of the fall semester.

Earlier this month, the U.S. Justice Department issued a statement saying federal law doesn’t prohibit employers from requiring COVID-19 vaccines. The public is split in whether they think the federal government should recommend that employers require employees to get the COVID-19 vaccine unless they have a medical exception with similar shares saying they think the federal government should recommend this (51%) and should not (45%). An additional 3% offer a “don’t know” response.

Views toward this issue are sharply divided by both vaccination status and party identification. Two-thirds of vaccinated adults (68%) and three-quarters of Democrats (75%) say the federal government should issue this recommendation, while eight in ten (81%) unvaccinated adults and 67% of Republicans say the federal government should not do this. Independents are divided in their views with 51% saying the federal government should not make this recommendation and 46% saying it should. Health care workers are also divided with half of health care workers (48%) saying the federal government should recommend employers require COVID-19 vaccinations among their employees.² 

Vaccinated Are Confident In Effectiveness Of Available Vaccines While unvaccinated are not

While most vaccinated Americans view the available coronavirus vaccines as effective against preventing many repercussions of COVID-19, unvaccinated adults are less convinced.

Majorities of vaccinated adults say the COVID-19 vaccines are either “extremely effective” or “very effective” at preventing vaccinated individuals from dying from COVID-19 (75%), at preventing vaccinated individuals from becoming seriously ill or hospitalized if they become infected (71%), and at preventing vaccinated individuals from becoming infected with coronavirus if they are exposed to someone who is sick (64%). Fewer vaccinated adults (50%) say the vaccines are “extremely” or “very” effective at preventing vaccinated individuals from passing coronavirus on to others if they become infected. This survey was fielded before recent data from the CDC, finding that vaccinated people who experience breakthrough infections can transmit the virus.

However, significantly fewer unvaccinated Americans agree about the overall effectiveness of the vaccines. Fewer than one quarter of unvaccinated adults think the available vaccines are “extremely” or “very” effective at preventing death, serious illness, infection, or transmission, and at least one-third say the vaccines are “not too effective” or “not at all effective” at preventing each of these.

Groups that have lower rates of vaccinations also have smaller shares saying the vaccines are effective at preventing death or serious illness among vaccinated adults, as well as preventing vaccinated adults from becoming infected or passing on the virus to others. But even among those groups with lower vaccine rates, including young people, Black and Hispanic adults, and Republicans, at least four in ten report thinking the vaccines are extremely or very effective at preventing hospitalization or death.

Perceived SAFETY OF THE DIFFERENT VACCINES

The percent of adults who say they are “very confident” or “somewhat confident” that each of the COVID-19 vaccines are safe has not changed significantly since April, with 74% believing the COVID-19 vaccines currently available in the U.S. are safe, similar to 71% in April. Similar shares say the same for the Pfizer vaccine (72%) and the Moderna vaccine (68%). A smaller share of the public is confident in the overall safety of the Johnson & Johnson vaccine, but it remains unchanged since April (47%).

Unvaccinated adults are much less confident in the overall safety of the COVID-19 vaccines with majorities saying they are either “not too confident” or “not at all confident” in the safety of each of the available vaccines. One-third of unvaccinated adults say they are “very” or “somewhat” confident in the overall safety of COVID-19 vaccines available in the United States. Confidence is highest among unvaccinated adults when it comes to the safety of the Pfizer vaccine (37%), compared to 31% who are confident in the safety of the Moderna vaccine and 18% who are confident in the safety of the Johnson & Johnson vaccine.

Mask-Wearing Is More Common Among Vaccinated Adults, Democrats

On July 27, 2021 the Centers for Disease Control and Prevention (CDC) issued updated guidance encouraging all adults, regardless of vaccine status, to wear masks indoors if they are in an area with higher transmission levels of coronavirus, which includes nearly two-thirds of all counties in the U.S.. Prior to the CDC issuing the newest guidance, half of adults said they wore a protective mask “every time” or “most of the time” at an indoor setting like a grocery store, while less than half report wearing a mask at least “most of the time” on public transit (44%), at work (42% of those who work outside their home), outdoors in crowded places (41%), or outdoors with household members or friends (18%).

Across most places asked about, vaccinated adults were more likely to report wearing a mask at least “most of the time” than unvaccinated adults including outdoors in crowded places (45% vs. 35%), at work (45% vs. 35%), in a grocery store (53% vs. 44%), or on public transportation (47% vs. 37%). Smaller shares of both vaccinated and unvaccinated adults say they wear masks at least “most of the time” when outdoors with household members or close friends (18% vs. 16%).

Mask-wearing has become a partisan issue during the coronavirus pandemic with majorities of Republicans saying they “never” wear a mask outdoors in crowded places, outdoors with friends and household members, at work, or in a grocery store. Democrats, on the other hand, are more likely to report wearing a mask in all of these locations, except when outdoors with household members and friends.

This KFF COVID-19 Vaccine Monitor was designed and analyzed by public opinion researchers at the Kaiser Family Foundation (KFF). The survey was conducted July 15-July 27, 2021, among a nationally representative random digit dial telephone sample of 1,517 adults ages 18 and older (including interviews from 322 Hispanic adults and 300 non-Hispanic Black adults), living in the United States, including Alaska and Hawaii (note: persons without a telephone could not be included in the random selection process). Phone numbers used for this study were randomly generated from cell phone and landline sampling frames, with an overlapping frame design, and disproportionate stratification aimed at reaching Hispanic and non-Hispanic Black respondents as well as those living in areas with high rates of COVID-19 vaccine hesitancy. Stratification was based on incidence of the race/ethnicity subgroups and vaccine hesitancy within each frame. High hesitancy was defined as living in the top 25% of counties as far as the share of the population not intending to get vaccinated based on the U.S. Census Bureau’s Household Pulse Survey.  The sample also included 28 respondents reached by calling back respondents that had previously completed an interview on the KFF Tracking poll at least nine months ago. Another 118 interviews were completed with respondents who had previously completed an interview on the SSRS Omnibus poll (and other RDD polls) and identified as Hispanic (n =50 ; including 21 in Spanish) or non-Hispanic Black (n=68). Computer-assisted telephone interviews conducted by landline (176) and cell phone (1,341, including 1,015 who had no landline telephone) were carried out in English and Spanish by SSRS of Glen Mills, PA. To efficiently obtain a sample of lower-income and non-White respondents, the sample also included an oversample of prepaid (pay-as-you-go) telephone numbers (25% of the cell phone sample consisted of prepaid numbers) Both the random digit dial landline and cell phone samples were provided by Marketing Systems Group (MSG). For the landline sample, respondents were selected by asking for the youngest adult male or female currently at home based on a random rotation. If no one of that gender was available, interviewers asked to speak with the youngest adult of the opposite gender. For the cell phone sample, interviews were conducted with the adult who answered the phone. KFF paid for all costs associated with the survey.

The combined landline and cell phone sample was weighted to balance the sample demographics to match estimates for the national population using data from the Census Bureau’s 2019 U.S. American Community Survey (ACS), on sex, age, education, race, Hispanic origin, and region, within race-groups, along with data from the 2010 Census on population density. The sample was also weighted to match current patterns of telephone use using data from the January- June 2020 National Health Interview Survey. The weight takes into account the fact that respondents with both a landline and cell phone have a higher probability of selection in the combined sample and also adjusts for the household size for the landline sample, and design modifications, namely, the oversampling of potentially undocumented respondents and of prepaid cell phone numbers, as well as the likelihood of non-response for the re-contacted sample. All statistical tests of significance account for the effect of weighting.

The margin of sampling error including the design effect for the full sample is plus or minus 3 percentage points. Numbers of respondents and margins of sampling error for key subgroups are shown in the table below. For results based on other subgroups, the margin of sampling error may be higher. Sample sizes and margins of sampling error for other subgroups are available by request. Sampling error is only one of many potential sources of error and there may be other unmeasured error in this or any other public opinion poll. Kaiser Family Foundation public opinion and survey research is a charter member of the Transparency Initiative of the American Association for Public Opinion Research.

This work was supported in part by grants from the Chan Zuckerberg Initiative DAF (an advised fund of Silicon Valley Community Foundation), the Ford Foundation, and the Molina Family Foundation. We value our funders. KFF maintains full editorial control over all of its policy analysis, polling, and journalism activities.

1. In order to examine whether vaccine intentions and worries around the Delta variant with the changing news environment, the two samples (interviews conducted July 15-18, interviews conducted July 19-27) were weighted separately to population parameters. We found only a slight uptick in the share of people and Republicans who say they either have already gotten a COVID-19 vaccine or plan to do so “as soon as possible” in interviews conducted beginning on July 19th. The share of total adults and Republicans who said they were “definitely not” going to get a COVID-19 vaccine remained relatively unchanged in the last week (13% and 17%, respectively). The rest of the analysis included in this report uses a single weight for the entire field period. ↩︎
2. For the purpose of this analysis, health care workers are those who identified as working in a health care delivery setting. ↩︎

A previous data note found that weekly deaths and cases in LTCFs dropped to an all-time low in April 2021, largely due to the high rates of vaccination among LTCF residents and staff. Additionally, five states in that previous analysis reported zero deaths per 100,000 state residents in April 2021. This data note examines state reported LTCF data from 42 states plus Washington DC through the end of June 2021 to examine patterns of COVID-19 cases and deaths among LTCF residents and staff. While most states report record low deaths and cases in LTCFs, a handful of states have seen an uptick in deaths, and 12 states report higher cases in June 2021 than a previous period. Ongoing tracking to assess the impact of the Delta variant on long-term care facilities at the state-level can highlight the effect of this recent wave on LTCFs.

LTCFs include a range of facilities, including nursing homes, assisted living facilities, and other congregate care facilities for people with disabilities or older adults. Data in this analysis is as of the week of June 27^th, 2021. See methods for more details.

COVID-19 Deaths in Long-Term Care Facilities

In most states, COVID-19 deaths in LTCFs have continued to fall, with 14 states reporting zero or close to zero weekly LTCF deaths per 100,000 state residents in June 2021. In 11 of these states, zero deaths per 100,000 state residents are rounded values that represent a very small number of LTCF deaths, while Washington DC, Montana, and Rhode Island reported real zero LTCF deaths in June 2021. 21 additional states reported an all-time low LTCF death rate (but not zero) in the most recent month of data available for the state (June 2021 for most states and May 2021 for Florida) (Appendix Table 1). Overall, the average weekly number of COVID-19 LTCF deaths per 100,000 state residents was 0.1 in June 2021, a decline of 96% from December 2020 (when average weekly deaths were 1.6 per 100,000). This decline ranges from 77% in Wisconsin to 100% in six states (California, Connecticut, Washington DC, Massachusetts, Montana, and Tennessee) (Table 1).¹ 

However, five states reported an increase in COVID-19 deaths in LTCFs compared to an earlier period. In June 2021, average weekly deaths were higher than earlier months in Colorado (April 2021), Georgia (May 2021), New York (September 2020), and Wisconsin (July 2020) (Appendix Table 2). Louisiana reported slightly higher deaths in April 2021 (the most recent month available) compared to October 2020. Across all five states, however, LTCF deaths in the most recent month were still substantially lower than their peak.

While LTCF trends largely mirror COVID-19 deaths outside LTCFs, most states report higher death rates outside LTCFs. For example, states that reported zero or near zero LTCF deaths still reported deaths outside of long-term care facilities, ranging from 0.2 deaths per 100,000 in California to 1.2 deaths per 100,000 in Michigan (data not shown). Overall, COVID-19 deaths outside of LTCFs have dropped by 82%, from 3.5 to 0.6 deaths across the 40 states included in this analysis (Figure 2), a smaller decline than among LTCFs.

COVID-19 Cases in Long-Term Care Facilities

Across the 40 states for which we can trend LTCF cases, average new weekly cases in LTCFs were just 0.5 per 100,000 in June 2021, compared to a peak of 19.7 in December 2020, a decrease of 97% (Figure 3 and Table 2). 28 states reported an all-time low case rate in the most recent month of data available for the state (June 2021 for 27 states and May 2021 for Florida) (Appendix Table 2). Nearly all states analyzed have seen a decline of at least 90% in LTCF cases since December 2020, and Vermont and Washington saw declines of 89%.

However, in contrast to deaths, just one state (Rhode Island) reported zero LTCF cases per 100,000 state residents, and 12 states reported higher average weekly LTCF cases in June 2021 compared to an earlier month (Table 2 and Appendix Table 2). Three states reported their lowest LTCF case rate in March 2021 (Colorado, Kansas, and Louisiana), six states reported their lowest LTCF case rate in April 2021 (Arkansas, Mississippi, Montana, New Mexico, Utah, and Wisconsin), two states reported their lowest LTCF case rate in May 2021 (Georgia and Nevada), and Vermont reported its lowest case rate in October 2020. Among the 12 states that report data on new cases among residents and staff separately, it most states reported higher new cases among LTCF staff than LTCF residents  (data not shown), likely reflecting the higher share of unvaccinated staff in LTCFs when compared to LTCF residents. It is unknown whether these new cases are among vaccinated or unvaccinated residents and staff, or whether these cases came from Delta variant infections.

Cases outside of LTCFs have been substantially higher than cases in LTCFs throughout the pandemic, with some state variation. Cases outside of LTCFs have dropped since December 2020, from 390.5 to 26.2 cases, a steep drop of 93% that mirrors the 97% drop in LTCF cases (Figure 3). However, of the six states that reported higher LTCF cases in June 2021 than April 2021 (Arkansas, Mississippi, Montana, New Mexico, Utah, and Wisconsin), only Arkansas reported higher cases outside of LTCFs in that same time period, suggesting faster spread of the virus in LTCFs than the surrounding community in the other 5 states.

Potential Impact of Delta Variant

The highly transmissible nature of the Delta variant may impact this trend of decreased LTCF cases and deaths. Preliminary federal data show a slight uptick in national nursing home cases and deaths in the first weeks of July 2021. Given the steady decline of LTCF cases and deaths since January 2021, additional weeks of data are necessary to understand whether this slight uptick is due to a data anomaly or the rise of the Delta variant in surrounding communities. While current data show that many of the recent hospitalizations and deaths due to COVID-19 are among unvaccinated individuals, many people in these facilities have pre-existing health conditions that could put them at high risk of illness or death if they experience a breakthrough infection, regardless of vaccination status. Ongoing tracking and analysis can shed light on the impact of increased community cases, given the close ties between community spread and LTCF cases and deaths.

Policy Implications

While LTCF cases and deaths have been steadily trending downward since the vaccine rollout, there are still several factors that prevent the long-term care crisis from coming to an end, including the rise of the Delta variant and low vaccination rates in some parts of the country (both in and out of LTCFs). These factors will be important to consider as policymakers use the experience of the pandemic in these settings to inform policy moving forward.

Most notably, the heavy toll that COVID-19 took among staff and residents at LTCFs highlighted the key role that timely, standardized, comprehensive data can play in policy—and the problems that can arise when it is absent. The federal government stood up a new COVID-19 data reporting system for nursing facilities relatively quickly, but there were still gaps in data from the early months of the pandemic, and that data excluded other long-term care settings that also had high rates of cases and deaths. Having robust, comparable data early on could have allowed researchers and policymakers to understand the link between community spread and the spread of the virus in facilities in real-time. In addition, limited data on characteristics of people in LTCFs who were infected or died hindered understanding of those at highest risk. Looking forward, building data systems that can be leveraged during crises to produce timely, detailed, accurate data can be instrumental in targeting policy responses.

The rollout of the long-term care partnership to deliver vaccines to residents and staff, while not perfect, had a nearly immediate effect that was evident in the data. The federal Pharmacy Partnership distributed nearly 8 million doses of the vaccine to LTCF residents and staff from December 2020 – April 2021. Within weeks of the first doses being administered, nursing home cases and deaths dropped while all other cases and deaths increased. Though the partnership experienced challenges (including low rates of staff vaccination and exclusion of some LTC settings), it was ultimately successful in vaccinating a high-risk population to reduce overall mortality due to COVID-19. The success of the partnership can provide a blueprint moving forward for successful public-private partnerships and leveraging pre-existing expertise and infrastructure in large-scale public health efforts.

Lastly, the experience of tracking COVID-19 in LTCFs highlights the importance of targeted or local efforts to understanding data across states. While the federal government eventually published weekly data on cases and deaths in nursing facilities that allowed comparison across all 50 states, data anomalies in this data led to efforts, including those by KFF, to track data directly from state websites. Even this effort yielded inconsistencies. For example, in March 2021, Wisconsin increased its cumulative long-term care death count by over 1,000 deaths with no conceivable explanation. A local news outlet had already reported on this discrepancy and allowed us to understand it was a data correction, and not reflective of what was happening on the ground. This pattern repeated throughout the pandemic: Many states had a few dedicated reporters and news outlets who kept a close eye on their individual state’s long-term care data and, importantly, had contacts in the right state departments. These local news outlets were instrumental in providing insight into data anomalies or state changes that affected data reporting, and effectively created an additional network of data experts for researchers to leverage.

This analysis is based on data as of the week of June 27th, 2021 from 42 states plus Washington DC, for a total of 43 states. The remaining eight states were excluded because they do not directly report data on cases and deaths in long-term care facilities, their data is sourced from sporadically released media reports, or there were data quality or availability issues in trending data over time.

This analysis relies on state-reported data instead of federal data since federal data may exclude cases and deaths prior to May 8th, 2020. This exclusion may miss peaks in states such as New York, New Jersey, and Massachusetts. Additionally, the federal data does not include non-nursing home settings. COVID-19 has disproportionately impacted all types of long-term care settings, such as assisted living facilities and group homes. Thus, the state-reported data is more likely to capture the full burden of cases and deaths in long-term care facilities.

Within the 43 states included in this analysis, we were able to trend long-term care cases in 39 states plus DC and deaths in 39 states plus DC. We included states for which we could reliably trend at least six months of data, using the earliest reliable period reported in the state as the starting point for that state’s trend.

Louisiana’s trend stops at April 2021 due to reporting changes in May and June that prevent data from being trended. Florida’s trend stops in May 2021 due to the state halting their reporting of cumulative long-term care cases and deaths in June 2021.

States vary in which facilities they include in LTCF reporting and whether they include residents and staff in case and death counts. For all states, we trended the subset of facilities and populations that provide the longest reliable trend line. For example, our data for Delaware excludes staff cases because that data was not reported consistently; in Michigan, this analysis excludes cases and deaths in Adult Foster Care facilities since these cases and deaths were only added for recent weeks. For this reason, this analysis should not be used to identify state-level or national data on total long-term care cases and deaths. See below for details on how each indicator in the Tables and Appendix were calculated.

Average Weekly Long-Term Care Deaths/Cases Per 100,000 State Residents:

These data represent trends in long-term care deaths and cases in states overtime in the context of total state population. Total state population data is from 2019 estimates from the US Census Bureau. The first week of available long-term care data for each state was not included in this analysis since the first week of data does not reflect a single week of deaths and cases, but rather all deaths and cases that have occurred up to that point. New deaths and cases were calculated for each week thereafter, and then averaged for all of the weeks within the month. Weeks where states reported large increases or any decreases due to reporting changes or data reconciliation were not included in the calculations of monthly averages. These average new deaths and cases were converted to represent deaths and cases per 100,000 state residents to allow for easier comparison across states. Totals for each table were calculated by dividing total new deaths and new cases per month by the total state populations for the states represented in each month of data and converting values to represent totals per 100,000 state residents.

Percent Change In LTCF Deaths/Cases Since December 2020:

Percent change is calculated by taking the difference between average weekly deaths in December 2020 and average weekly deaths in June 2021 and dividing that difference by the average weekly deaths in December 2020.

1. Florida and Louisiana reported lower declines between December 2020 and the most recent month of data available (58% and 69%); however, these declines were calculated using earlier months of data since they did not report data in June 2021 (see methods for more detail). ↩︎