The coronavirus pandemic’s disproportionate impact on seniors and people with disabilities and chronic illnesses has brought heightened focus on the unmet need for home and community-based services (HCBS). Medicaid serves as the primary source of coverage for HCBS, which help these populations to live independently outside institutions by assisting with daily needs. In addition to determining whether to retain Medicaid HCBS policy changes adopted during the pandemic, states are currently developing plans to access an increased federal matching rate (“FMAP”) for Medicaid HCBS spending established in the American Rescue Plan Act (ARPA) of 2021. In the future, states may also be able to access increased HCBS funds proposed in the Biden Administration’s American Jobs Plan and the Better Care Better Jobs Act recently introduced in Congress.

To provide context for state considerations of policy options for the post-pandemic period and the potential use of new federal funds, this brief highlights examples of Medicaid HCBS policy changes authorized through Section 1115 demonstration waivers in seven states (Arizona, Delaware, New Jersey, New York, Rhode Island, Vermont, and Washington). Where available, we discuss waiver evaluation findings and reports that assess the impact of these policy changes. Key waiver provisions seeking to expand HCBS include the following (and are summarized in a state-by-state table in the Appendix):

• Streamline processes for determining eligibility and providing services.
• Expand financial eligibility rules to help certain enrollees afford to live in the community.
• Serve additional populations by expanding financial and/or functional eligibility rules.
• Offer new services through alternative benefit packages.

States may be unlikely to pursue new 1115 waivers to use the ARPA HCBS funds because these funds are available for states to claim for one year only (though states have until March 2024 to spend the enhanced funds). However, these examples from 1115 waivers identify policy areas that states may consider targeting through existing state plan or HCBS waiver authorities, particularly where state evaluations and experiences have found that policy changes seeking to expand HCBS access have achieved their goals.

Streamlining eligibility and enrollment processes

To provide faster access to HCBS, states have used 1115 authority to streamline processes for determining eligibility and providing services, including by authorizing benefits during a presumptive eligibility period and accepting self-attestation as verification for financial eligibility.

Authorizing benefits during a presumptive eligibility period. Presumptive eligibility is a longstanding option that allows states to authorize certain qualified entities to enroll individuals who appear likely eligible for coverage while the state processes the full application and makes a final eligibility determination. Presumptive eligibility can facilitate access to coverage and services when individuals in need of critical services also may need extra time to collect documents needed to complete a full eligibility determination. While states may allow hospitals to determine presumptive eligibility for Medicaid pathways based on old age or disability without an 1115 waiver, several states have used 1115 authority to provide presumptive eligibility (determined by non-hospital entities) for more limited populations and/or benefits to provide faster access to HCBS. For example:

• Washington uses 1115 authority to provide presumptive eligibility for both its Tailored Support for Older Adults (TSOA) and Medicaid Alternative Care (MAC) programs, which provide supportive services to older adults and their caregivers (see Appendix for program details). An interim evaluation Quarterly progress reports from 2020 indicate high proficiency for appropriate determinations of nursing facility level of care, performed primarily by local Area Agencies on Aging, for those enrolled presumptively and low percentages of enrollees determined ineligible after the presumptive eligibility period. In a recent pending waiver amendment requesting to further extend presumptive eligibility for LTSS, Washington noted that the high accuracy rate of presumptive eligibility determinations for TSOA “exemplifies the minimal risk to the state and [] federal partners.”
• Rhode Island’s waiver also authorizes HCBS benefits to new long-term care (LTC) applicants during a presumptive eligibility period while final financial eligibility determinations are pending.

Accepting self-attestation as verification for financial eligibility. States may simplify the Medicaid application process by allowing applicants to self-attest to certain financial eligibility criteria. During the COVID-19 public health emergency (PHE), some states are using Medicaid emergency authorities to allow self-attestation of eligibility requirements for applicants to Medicaid pathways based on old age or disability. States may also use 1115 authority to allow more limited populations to self-attest to financial eligibility requirements. For example,

• New Jersey’s 1115 waiver eliminates state review and instead accepts self-attestation of no asset transfers during the five-year look-back period for applicants below 100% FPL seeking LTC and HCBS. The look-back period delays the date of Medicaid eligibility for applicants who transferred assets for less than fair market value, which instead could have been used to meet long-term care needs. New Jersey conducted electronic asset verification of randomly selected applications in 2015 and 2016 and found a 0% error rate on these sampled self-attestations, concluding that “the often burdensome five year lookback process can be safely eliminated for many low-income applicants.”

Expanding financial eligibility rules

To help enrollees maintain community residence, states have used 1115 authority to modify financial eligibility rules for limited populations (though states may more generally expand financial eligibility without waiver authority). These expanded eligibility rules enable enrollees to more easily afford to live in the community rather than in nursing facilities and include:

• Establishing an income disregard that accounts for average rent (in New York). New York’s 1115 waiver applies a special income disregard that accounts for average rent when determining financial eligibility for individuals moving from institutional to community settings. An evaluation of New York’s waiver has found positive impacts among individuals transitioning out of institutional settings, including that high percentages of enrollees remained in the community.
• Increasing the asset limit for certain HCBS beneficiaries (in Vermont). Vermont uses 1115 authority to increase the asset limit for certain high-need beneficiaries receiving HCBS. Evaluation results suggest positive impacts for this population, including an increase in the percentage of participants living in home and community settings versus in nursing facilities.
• Increasing the personal needs allowance for certain HCBS beneficiaries (in Rhode Island). For enrollees transitioning from nursing facilities to the community, Rhode Island’s 1115 waiver increases the personal needs allowance, which is the amount of funds not considered available to contribute to the cost of LTC services.

Serving new populations by expanding eligibility rules

Several states use 1115 authority to expand financial and/or functional eligibility rules to serve additional populations, such as:

• Elderly and near-elderly adults (in Washington). Washington’s TSOA program creates a new eligibility pathway and benefit package for otherwise ineligible adults older than 55 who require nursing facility level of care. By serving these adults with and without unpaid caregivers, TSOA aims to delay or avoid the need for more intensive LTSS. An interim evaluation of the program suggests that TSOA has met this goal: while 24-35% of TSOA participants enrolled in regular Medicaid within 6 months of TSOA enrollment, only a very small percentage used traditional LTSS. Both TSOA caregivers and recipients expressed high satisfaction with the program, with 86-90% of recipients indicating that the TSOA program would help keep them from moving to a nursing home or adult family home.
• Young adults with disabilities (in Rhode Island). Rhode Island’s 1115 waiver covers young adults age 19 to 21 who age out of the Katie Beckett group (which provides coverage to children with significant disabilities without regard to family income) and are in need of services for behavioral health or medical/developmental diagnoses. This new pathway aims to enable children with disabilities to maintain continuity of care and remain in the community as they age into young adulthood. Issues related to continuity of care for young adults with disabilities are widespread beyond Rhode Island: for example, a recent New York Times article details how in New York, the change from “medically fragile child” to “medically fragile adult” includes lower pay rates for nurses that could result in young adults with disabilities losing care and being forced to move into nursing homes.
• Children with disabilities (in Delaware). Delaware’s 1115 waiver creates a new eligibility pathway for children with disabilities who do not meet institutional level of care criteria for the Katie Beckett pathway, but are at risk of institutionalization absent the provision of services. By providing benefits to serve these children with disabilities in the community, this new pathway could help delay or avoid the use of more costly LTSS. States may use Section 1915 (i) state plan authority to serve enrollees with functional needs that are less than an institutional level of care; however, Delaware uses 1115 authority in order to limit this population to children with incomes at or below 250% of Supplemental Security Income (SSI) ($1,985 per month in 2021).

Offering new services

While states may add services to existing benefit packages without 1115 authority, they instead may use 1115 waivers to design alternative benefit packages. For example, the MAC program created by Washington’s 1115 waiver provides an alternative benefit package to support unpaid caregivers for older adults who are otherwise Medicaid eligible. This provision supports these enrollees and their caregivers by providing additional HCBS benefits not available in the standard Medicaid benefit package (though not the full Medicaid benefit package in other respects), which in turn may help the clients they care for remain in the community. An interim evaluation report shows that MAC enrollment has been lower than anticipated (with just 251 caregiver/care-receiver pairs enrolled in MAC as of October 2020, compared to initial projections of 4,673 MAC enrollees in that month) and suggests that further outreach may be necessary to reach eligible populations. Of those who did enroll, however, both caregivers and care recipients reported high satisfaction with the MAC services provided. The report also suggests that MAC participation has reduced the occurrence of adverse health outcomes and helped enrollees delay or avoid the use of more intensive traditional Medicaid LTSS.

Looking Ahead

As the primary source of coverage for HCBS, Medicaid plays a significant role in helping states meet community integration obligations under the Americans with Disabilities Act and the Supreme Court’s Olmstead decision. While the unmet need for HCBS for seniors and people with disabilities pre-dates the COVID-19 pandemic, during the PHE states have taken a number of emergency Medicaid LTSS actions, such as HCBS benefit expansions and provider payment rate increases for HCBS. In guidance on considerations for the end of the PHE, CMS specifically encourages states to identify temporary authorities that increase access to HCBS and to consider making these changes permanent. Further, the American Rescue Plan Act provided a time-limited increase in the Medicaid FMAP for HCBS spending to fund activities beyond what is currently available in states’ Medicaid programs. States must develop plans to use these funds for expanded HCBS activities such as streamlining eligibility/enrollment processes, increasing covered services, and supporting family caregivers. The existing HCBS policy changes in Section 1115 waivers summarized in this brief may provide useful examples of areas that states could target, particularly where state evaluations and experiences have found that policies seeking to expand HCBS access have achieved their goals.

Appendix

• In many low- and middle-income countries, PEPFAR and the Global Fund are significant funders of commodities to diagnose, treat, and prevent HIV, along with country governments. But, information on their relative contributions, which is important for assessing the HIV response, is not readily available. We analyzed data from PEPFAR documents on funding for key HIV commodities in 34 PEPFAR countries to better understand the funding landscape.
• Overall, we find that funding for HIV commodities in these countries was estimated to total more than $3 billion among PEPFAR countries required to submit 2019 Country and Regional Operating Plans. Almost two-thirds was for antiretroviral drugs (ARVs) (64% or $1.95 billion), followed by lab and diagnostic products (26% or $779 million). Funding for each of the other commodity types was 6% or less.
• While PEPFAR is the largest funder of HIV efforts in the world, it was not the dominant funder overall for HIV commodities in PEPFAR countries. Country governments were the largest funder of HIV commodities (44% or $1.3 billion), followed by the Global Fund (31%), and PEPFAR (24%). Overall, South Africa’s domestic government funding accounted for 56% of all country government commodity support. When commodity funding for South Africa is removed from the analysis, the Global Fund was the top funder and PEPFAR was second.
• The main funder varied by commodity. For example, PEPFAR accounted for the largest share of funding for voluntary medical male circumcision (VMMC)-related commodities in countries with a VMMC program, and the Global Fund accounted for the largest share of funding for condoms and lubricants. While country governments accounted for the largest overall share of ARV funding, the Global Fund was the top ARV funder when South Africa was removed.
• The main funder also varied somewhat by country. The Global Fund provided the largest share of commodity funding in most PEPFAR countries (21 of 34), followed by country governments (8 of 34) and PEPFAR (5 of 34).
• As we find here, PEPFAR is not the dominant funder of HIV commodities in most of the countries where it works, although PEPFAR often funds many of the associated services needed to support the delivery and use of commodities and, as the main donor to the Global Fund, indirectly funds a larger share of commodities in PEPFAR countries. These findings could help to inform assessments of the sustainability of HIV efforts, decision-making about the most effective division of commodity funding between purchasers, and opportunities for better coordination and synergy in the future, particularly given concerns about overall HIV funding in low- and middle-income countries.

Introduction

Global HIV/AIDS programs depend on having a reliable supply of health commodities, including essential medicines and other products, to prevent, diagnose, and treat HIV. Key commodities in the HIV/AIDS response include: antiretroviral drugs (ARVs), condoms and lubricants, laboratory and diagnostic products (including rapid test kits and viral load commodities), and voluntary medical male circumcision (VMMC) supplies, among others. PEPFAR, along with the Global Fund, to which the U.S. is the largest donor, is a critical source of funding for key commodities, as well as associated services, in low- and middle-income countries (LMICs), sometimes supplementing country government funding or supporting most of a country’s effort.¹  However, information on their relative roles is not readily available. Such data are important for assessing the HIV response, particularly given concerns about overall global funding for HIV, which has declined in recent years.² 

We sought to better understand PEPFAR’s role, relative to the Global Fund and country governments, in directly funding HIV-related commodities in PEPFAR countries (as the largest donor to the Global Fund, PEPFAR indirectly funds a larger share of commodities in the countries in which it works). To do so, we analyzed data from PEPFAR’s 2019 Country and Regional Operating Plan (COP and ROP) Strategic Direction Summaries (SDS) (“COP19”).³  These are documents submitted by PEPFAR country teams, as part of their larger COP/ROP submission, which describe a country’s strategic plan for the coming year, as well as provide a framework for how the country will measure progress. The SDS includes data on funding for commodities by source. We used these data to assess the relative shares of funding by source and by commodity in the 34 countries required to develop a COP or ROP in 2019, and which provided data on commodity funding distribution (an additional 20 countries were required to submit a COP or ROP in 2019 but did not provide these data).⁴  These 34 countries represented 67% of all people living with HIV and over half (approximately 54%) of new infections globally in 2019.⁵ 

Data extraction and cleaning were conducted jointly by KFF and amfAR, and the final dataset is housed on amfAR’s site here. Data were extracted as reported in the 2019 COP/ROP SDS documents, but not validated beyond these sources. In some cases, data were presented in dollar amounts and in others, as percentages of total funding. We computed both percent and dollar values where needed; percent totals may not sum to 100%.⁶  We grouped commodities into six broad categories: ARVs; condoms and lubricants; lab and diagnostic products; other commodities; other drugs; and VMMC products (see Box). All 34 countries provided data on ARVs; 33 for lab diagnostic and products; 29 countries for condoms⁷  and lubricants; 28 for other drugs; 19 for other commodities;⁸  and 13 for VMMC commodities.⁹ 

Key Findings

Funding for HIV commodities in 34 PEPFAR countries was estimated to total more than $3 billion ($3,051,168,558) from all sources in the 2019 COP/ROPs.

• Funding ranged from $709,000 in Tajikistan to $762 million in South Africa (See Figure 1).
• 10 countries accounted for 76% of all funding for commodities.

Almost two-thirds of commodity funding was for ARVs (64%), followed by lab and diagnostic products (26%). Funding for each of the other commodity types was 6% or less. 

• Overall, ARVs accounted for 64% ($1.95 billion) of funding for all commodities in 2019 (See Figure 2). Lab and diagnostic products represented the second largest share (26% or $779 million), followed by other drugs (6% or $177 million), and condoms and lubricants (2% or $59 million).
• ARVs represented the largest share of commodity funding in almost all (29 of the 34) PEPFAR countries included in this analysis (See Figure 3).

While PEPFAR is the largest single funder of HIV efforts in the world, it was not the dominant funder overall for HIV commodities in these 34 countries. Rather, in aggregate, country governments provided the largest share of commodity funding (44%), followed by the Global Fund (31%) and then PEPFAR (24%). Excluding the South Africa program, whose funding accounts for nearly a quarter of total funding for commodities across the 34 countries and almost exclusively from domestic resources, the Global Fund was the top funder and PEPFAR was second.

• Funding from country governments totaled an estimated $1.3 billion (44%), followed by the Global Fund ($935 million or 31%), PEPFAR ($735 million or 24%), and other sources ($39 million or 1.3%) (See Figure 4).
• This is primarily due to the significant role played by the South African government in funding HIV-related commodities. In 2019, the South African government’s commodity contribution ($746 million) accounted for almost all of the country’s commodity funding (98% of $762 million), 56% of total country government commodity funding ($1.3 billion), and nearly a quarter (24%) of funding for all commodities across the 34 countries ($3 billion). With South Africa removed from the analysis, PEPFAR was the second largest funder of commodities ($729 million or 32%), after the Global Fund ($924 million or 40%) (See Figure 5).

The main funder varied by commodity. For example, PEPFAR was the largest funder of VMMC-related commodities in the group of countries with VMMC programs and the Global Fund was the largest of condoms and lubricants. In most cases, though, the order changed when South Africa was removed.

• ARVs. The largest funder of ARVs was country governments, which accounted for 45% of all ARV funding, followed by the Global Fund (33%), PEPFAR (21%), and other sources (<1%) (See Figure 6). With South Africa removed, the Global Fund becomes the largest funder (45%), followed by PEPFAR (29%) (See Figure 7).
• Condoms and Lubricants. The Global Fund was the largest funder of condoms and lubricants (38%), followed by country governments (24%), PEPFAR (22%), and other sources (15%) (see Figure 6). With South Africa removed, PEPFAR was the second largest funder (See Figure 7).
• Lab and Diagnostic Products. Country governments were the largest funder of lab and diagnostic products (44%), followed by PEPFAR (30%), the Global Fund (24%), and other sources (2.5%) (See Figure 6). Without South Africa, PEPFAR moves to the top (See Figure 7).
• VMMC Commodities. Among the 13 countries that reported funding on VMMC commodities,¹⁰  PEPFAR was by far the largest payer of VMMC-related commodities (75%), followed by the Global Fund (19%), and country governments (6%) (See Figure 6). The shares, but not order, of the distribution shifts slightly without South Africa (See Figure 7).
• Other Commodities and Other Drugs. Among the 19 countries that specified funding for other commodities in 2019,¹¹  the Global Fund was the largest funder of other commodities (48%), followed by country governments (27%), PEPFAR (22%), and other sources (3.3%) (See Figure 6). The largest funder of other drugs was country governments (54%), followed by the Global Fund (25%), PEPFAR (19%), and other sources (2.6%) (See Figure 6). (South Africa did not report funding in these areas).

• The Global Fund was the largest funder of commodities in 21 of the 34 countries, followed by country governments (8 of 34), and PEPFAR (5 of 34) (See Figure 8). The Global Fund accounted for more than half of all commodity funding in 15 of the 34 countries.
• The Global Fund also was the largest funder for each commodity type in the majority of countries, with the exception of VMMC commodities, where PEPFAR was the largest funder in most countries that had a VMMC program (See Figures 8 and 9). For example, for ARVs, the Global Fund was the dominant funder in 18 countries and PEPFAR in 7 countries. For lab and diagnostic commodities, the Global Fund was the dominant funder in 18 countries and PEPFAR in 9 countries.

Looking Ahead

HIV-related commodities play a key role in the prevention, diagnosis, and treatment of the disease. As shown above, the commodity landscape varies greatly in PEPFAR countries. This variation is likely due to a range of factors, including the context of local HIV epidemics, the evolution of the HIV response in each country, availability of funding from different sources, and the priorities of funders, including of country governments. Given the lack of a cure or vaccine for HIV and millions of people with or at risk for HIV, the importance of funding currently available commodities will continue for some time but may be more challenging in an environment of flat or declining funding.

While PEPFAR is the single largest HIV funder in the world, as we find here, it is not the dominant funder, at least not directly, of HIV commodities in most of the countries in which it works. Rather, the Global Fund and country governments play the main role. At the same time, PEPFAR often funds many of the associated services (e.g., supply chains, laboratory facilities, and health care personnel) that are needed to support the delivery and use of commodities. In addition, given that PEPFAR is the largest donor to the Global Fund, it plays a more significant indirect role in the Global Fund’s support for commodities in PEPFAR countries. Going forward, these findings could help to inform policymakers, implementers, and others as they make decisions about future directions for the HIV response, including assessments of: the appropriate balance of funding for commodities between PEPFAR and the Global Fund; coordination of commodity procurement and provision at the global and country levels; whether current arrangements are best from a sustainability perspective; and how changes in overall funding for commodities or the current payer mix, might affect continuity of services.

1. KFF, u201cThe U.S. Presidentu2019s Emergency Plan for AIDS Relief (PEPFAR)u201d fact sheet, May 2020. PEPFAR, PEPFAR 2019 Country Operational Plan Guidance for all PEPFAR Countries. ↩︎
2. Global HIV funding in LMICs has been largely flat over the years and declined between 2017 and 2019. KFF. Donor Government Funding for HIV in Low- and Middle-Income Countries in 2019, July 2020. ↩︎
3. Funding totals represent amounts reported in countriesu2019 PEPFAR 2019 COP/ROPs (u201cCOP19u201d) for implementation in FY 2020. All references to 2019 throughout this analysis refer to data presented in 2019 COP/ROP documents. The underlying source of these data varies considerably. In some cases, countries used data from previous years, while in others, the data are a result of planning and negotiations with national stakeholders and the Global Fund. ↩︎
4. Zimbabwe reports total funding need, which includes the percent covered by each funding source as well as the gap in funding. For the purposes of this analysis, we removed the percent gap in funding; consequently, Zimbabweu2019s total expenditure on key commodities is lower than what is reported in its SDS. Eswatini only reports 75% of expenditures for condoms, all of which is supported by PEPFAR. We categorized the remaining 25% as u201cOther Funder,u201d as Eswatiniu2019s SDS states u201cit is not expected that there will be a gap in condom supply because PEPFAR will continue to support the optimization of access to low-cost condoms for clients who can afford to pay for condoms while ensuring that the no-cost condoms are distributed according to mapped need.u201d Nepal only reports 66% of its expenditures for u201cOther Drugs.u201d Given that there were no further details provided about the remaining 33%, the data is considered missing and not included in the analysis. ↩︎
5. UNAIDS. AIDSinfo database, accessed May 2021. ↩︎
6. Countries whose percentage totals do not sum to 100% include Burma, Cambodia, Eswatini, Jamaica, Lesotho, Nepal, Zambia, and Zimbabwe. ↩︎
7. Most PEPFAR countries order condoms through USAIDu2019s Commodity Fund. It is possible that there may be inconsistency among countries on how condoms procured through USAIDu2019s Commodity Fund are accounted for in the SDSs; for instance, some countries may call them PEPFAR-supported procurement and others may categorize them as u201cOther.u201d We interpret the funding amounts reported in the SDSs at face value. PEPFAR, 2019 Country Operational Plan Guidance for all PEPFAR Countries. ↩︎
8. Numerous countries did not report data for u201cOther Commoditiesu201d. In some cases, the lack of data might indicate $0 expenditures. As it was not clear, we assumed that any data denoted by a u201c-u201c or u201cN/Au201d in the SDSs were true u201cN/Au201d and noted it as such in this analysis. We applied this assumption to u201c-u201c and u201cN/Au201d in other categories as well. ↩︎
9. According to the 2019 COP Guidance, PEPFAR concentrates its VMMC programs in 14 priority countries. Also, data for PEPFAR-supported VMMC procedures in these countries for 2019 is included in PEPFARu2019s online Panorama Spotlight Dashboard. Twelve of these countries provided VMMC commodity funding data in their 2019 SDSs; two countries, Kenya and Ethiopia, did not provide data on VMMC commodity funding in their 2019 SDSs. According to Ethiopiau2019s SDS, Ethiopia used non-COP resources for its VMMC program. South Sudan, while not noted as one of the 14 priority countries where PEPFAR concentrated its VMMC efforts in 2019, provided funding data on VMMC in its 2019 COP. We included South Sudanu2019s data as reported in the analysis. ↩︎
10. According to the 2019 COP Guidance, PEPFAR concentrates its VMMC programs in 14 priority countries. Also, data for PEPFAR-supported VMMC procedures in these countries for 2019 is included in PEPFARu2019s online Panorama Spotlight Dashboard. Twelve of these countries provided VMMC commodity funding data in their 2019 SDSs; two countries, Kenya and Ethiopia, did not provide data on VMMC commodity funding in their 2019 SDSs. According to Ethiopiau2019s SDS, Ethiopia used non-COP resources for its VMMC program. South Sudan, while not noted as one of the 14 priority countries where PEPFAR concentrated its VMMC efforts in 2019, provided funding data on VMMC in its 2019 COP. We included South Sudanu2019s data as reported in the analysis. ↩︎
11. Numerous countries did not report data for u201cOther Commoditiesu201d. In some cases, the lack of data might indicate $0 expenditures. As it was not clear, we assumed that any data denoted by a u201c-u201c or u201cN/Au201d in the SDSs were true u201cN/Au201d and noted it as such in this analysis. We applied this assumption to u201c-u201c and u201cN/Au201d in other categories as well. ↩︎

Introduction

The COVID-19 pandemic has taken a stark disproportionate toll on people of color, including the Hispanic population. These disparate impacts of the COVID-19 pandemic have exposed and exacerbated longstanding underlying disparities in health and health care facing Hispanic people. Prior to the pandemic, these disparities had already been compounded by immigration policies implemented during the Trump administration that increased fears among immigrant families and made some more reluctant to access programs and services, including health coverage and health care. Although the Biden administration has since reversed many of these policies, they likely continue to have lingering effects.

This report provides insights into the health care experiences of Hispanic adults amid the current environment and examines how they vary by key factors, including insurance and immigration status. A prior report examined the health and economic impacts of COVID-19 for Hispanic adults and their attitudes, experiences with, and barriers to getting COVID-19 vaccinations. This report from the KFF COVID-19 Vaccine Monitor is based on interviews with 778 Hispanic adults in the U.S., including 334 conducted in Spanish, 392 with adults born outside the U.S., including 185 who indicated that they do not have lawful permanent resident status (referred to in this report as “potentially undocumented”).¹ 

Employment and Income

Individuals’ employment and income affect access to health insurance and ability to afford health care. People in lower wage jobs are less likely to be offered health insurance by their employer and may have more difficulty affording it when it is offered due to their limited incomes. Moreover, people with limited incomes may face more challenges paying for health care costs.

Although Hispanic adults are as likely as White adults to say they are employed, they are more likely to report living in a lower income household. Over half (54%) of Hispanic adults say they are employed, similar to the shares of Black (52%) and White (54%) adults (Figure 1). Among Hispanic adults, nearly six in ten (57%) potentially undocumented Hispanic adults say they are employed, similar to the shares among Hispanics who are U.S.-born (54%) and who are lawful permanent residents (50%). Employed Hispanic adults are more likely than employed White adults to say they currently work solely at a location outside their home (69% vs. 57%), contributing to increased risk of exposure amid the COVID-19 pandemic, particularly for those who are unvaccinated. Among employed Hispanic adults, those who are potentially undocumented are more likely to say they are currently working outside the home—84% of potentially undocumented employed Hispanic adults say they work only outside the home compared to 60% of employed U.S.-born Hispanic adults.

Despite being as likely as White adults to report being employed, about half (52%) of Hispanic adults say their annual household income is less than $40,000 compared to 29% of White adults (Figure 2). Nearly eight in ten (78%) potentially undocumented Hispanic adults report annual household income of less than $40,000, compared to 60% of lawful permanent residents and 40% of U.S.-born Hispanic adults.

Health Coverage and Program Participation

Health insurance makes a difference in whether and when people get necessary medical care, where they get their care, and ultimately, how healthy they are. Uninsured adults are far more likely than those with insurance to postpone health care or forgo it altogether. Hispanic people have faced longstanding disparities in health coverage. They were more likely than their White counterparts to be uninsured prior to the pandemic and faced widening gaps in coverage between 2018 and 2019. These coverage declines may, in part, reflect changes to immigration policy, particularly the “public charge” policy under the Trump administration, which contributed to growing fears among immigrant families about participating in public programs, including health coverage. Although the Biden administration has since reversed many of these policies, they may continue to have lingering effects. Further, the economic impacts of the COVID-19 pandemic have likely contributed to additional coverage losses that may further widen disparities in coverage for Hispanic people.

Three in ten nonelderly Hispanic adults (31%) say they are uninsured compared to 15% of Black adults and 9% of White adults (Figure 3). The share reporting they don’t have health insurance is much higher among nonelderly Hispanic adults who are potentially undocumented (71%) and somewhat higher among those who are lawful permanent residents (31%) compared to U.S.-born Hispanic adults (18%).

These patterns likely reflect more limited access to employer-sponsored coverage among foreign-born Hispanic adults, due to higher rates of employment in low-wage jobs that are less likely to offer health coverage, as well as more limited access to and barriers to enrolling in public coverage options. Lawfully present immigrants may qualify for Medicaid and the Children’s Health Insurance Program, but many, including most lawful permanent residents, must wait five years after obtaining a qualified immigration status before they may enroll. Lawfully present immigrants can purchase coverage through the Affordable Care Act (ACA) marketplaces and may receive subsidies for this coverage, including those who are not eligible for Medicaid or CHIP because they are in the five-year waiting period. Although lawfully present immigrants are eligible for coverage, they face a range of potential enrollment barriers, including fear, confusion about eligibility policies, difficulty navigating the enrollment process, and language and literacy challenges. Undocumented immigrants are not eligible to enroll in Medicaid or CHIP or to purchase coverage through the ACA marketplaces.

Some Hispanic adults, particularly those who are potentially undocumented, report that they have avoided seeking assistance for food, housing, and/or health care due to immigration-related fears. One in ten Hispanic adults (11%) say there was there a time in the past 3 years when they or a family member decided not to apply for or stopped participating in a government assistance program because they were afraid it might negatively affect their or a family member’s immigration status (Figure 4). Across Hispanic adults overall, 6% say they did not apply for or stopped participating a program to help with food, 4% say assistance for housing, and 3% say a health care program. The share saying they or a family member did not apply for or stopped participating in a program in the past 3 years due to immigration-related fears increased to 13% among lawful permanent residents and 26% among potentially undocumented Hispanic adults. Overall, 21% of potentially undocumented Hispanic adults say they did not apply for or stopped participating in a program to help with food, 12% say assistance for housing, and 11% say a health care program.

Access to and Experiences Obtaining Health Care

Beyond health coverage, other factors such as having a usual source for health care, accessibility of health care provider locations, and affordability of care have implications for individuals’ access to and use of care, including preventive and primary care as well as care for chronic conditions. Further, individuals’ experiences and relationships with health care providers, including patient-provider communications, can affect the quality of care they receive, their satisfaction with care, and health outcomes.

Usual Source of Care

A usual source of care is a health care provider where people usually go when they are sick or need advice about their health. Research finds that people with a usual source of care are more likely than those without a usual source to get care and less likely to have difficulty obtaining care or to go without receiving needed services.

Hispanic adults, particularly those who are potentially undocumented and uninsured, are more likely than their White counterparts to say they do not have a usual source of care other than the emergency room. Nearly one in four (24%) Hispanic adults overall report no usual source of care other than an emergency room, higher than the share of White adults (12%) and similar to the share of Black adults (28%) (Figure 5). Among Hispanic adults, roughly three in ten potentially undocumented (32%) and lawful permanent resident (29%) adults say they have no usual source of care other than the emergency room, compared to about one in five (19%) U.S.-born adults. Similarly, among nonelderly Hispanic adults, those who are uninsured are more likely than those with insurance to say they do not have a usual source of care other than the emergency room (37% vs. 20%).

Hispanic adults are also more likely than White adults to say a neighborhood clinic or health center is their usual source of care (33% vs. 16%). The shares relying on a clinic or health center as their usual source of care are even higher among lawful permanent resident (42%) and potentially undocumented (40%) Hispanic adults. In contrast, Hispanic adults are less likely than White adults to say their usual source of care is a private doctor’s office (34% vs. 64%). The share saying a clinic is their usual source of care is similar for both uninsured (36%) and insured (33%) nonelderly Hispanic adults, but those who are uninsured are less likely to say they use a private doctor’s office as their usual source of care than their insured counterparts (22% vs. 38%).

Access to and Affordability of Care

About one in five (21%) Hispanic adults say it is somewhat or very difficult to get to a location for health care versus 12% of White adults (Figure 6). The remaining nearly eight in ten Hispanic adults (78%) say it is very or somewhat easy to find health care at a location that is easy to get to, compared to 86% of White adults. Less than half of Hispanic adults say it is very easy (46%) compared to 62% of White adults. Among Hispanic adults, those who are foreign-born are less likely to say it is very easy to get to a location for health care, with 39% of lawful permanent residents and 35% of potentially undocumented adults saying it is very easy compared to 53% of those who are U.S.-born. Similarly, among nonelderly Hispanic adults, those who are uninsured are less likely to say it is very easy (34%) compared to those with health insurance (50%). Nearly three in ten uninsured Hispanic adults (28%) say it is very or somewhat difficult to find care at a location that is easy to get to.

Overall, the share of Hispanic adults who say it is very or somewhat difficult to find health care they can afford is similar to the share of White adults (37% vs. 32%) (Figure 7). However, Hispanic adults are less likely than White adults to say it is very easy to find affordable care (29% vs. 42%). Further, among nonelderly Hispanic adults, those who are uninsured are twice as likely as those with insurance to say it is very difficult to find health care they can afford (24% vs. 12%). There are no major differences in the reported ease of finding affordable care by immigration status. The reliance on community health centers as a usual source of care by a high share of Hispanic adults may mitigate potential challenges finding affordable care among Hispanic adults even though they are more likely to be uninsured and have lower incomes than White adults, since health centers provide free or low-cost care regardless of insurance status. Other data also show that Hispanic adults are less likely to utilize care than their White counterparts.² 

Provider Communications and Linguistic Access to Care

Communication plays a key role in the delivery of health care and affects patient–provider relationships and the health care people receive. Studies have found that language barriers between providers and patients may result in excessive ordering of medical tests, lack of understanding of medication side effects and provider instructions, decreased use of primary care, increased use of the emergency department, and inadequate follow-up.

Some Hispanic adults, particularly those who are foreign born or uninsured, say it is difficult to find a doctor who explains things in a way that is easy to understand (Figure 8). Overall, three-quarters (74%) of Hispanic adults say it is very or somewhat easy to find a doctor who explains things in a way that is easy to understand, but nearly one-quarter (24%) say it is very or somewhat difficult, higher than the share of White adults (16%) and similar to the share of Black adults (23%). Foreign-born Hispanic adults are more likely than those born in the U.S. to say it is difficult to find a doctor who explains things in a way that is easy to understand, with 34% of potentially undocumented adults and 31% of lawful permanent resident adults saying it is somewhat or very difficult compared to 16% of those who are U.S.-born. Having a usual source of care also makes a difference in the ability to find a doctor who explains things in a way that is easy to understand, as Hispanic adults without a usual source of care are more likely to report it is somewhat or very difficult than those with one (30% vs. 21%). There are no significant differences in the share of nonelderly Hispanic adults who say it is difficult by insurance status, but those who are uninsured are less likely to say it is very or somewhat easy compared to those who are insured (65% vs 77%). Linguistic access to care is also a challenge for some Spanish-speaking adults. Among Hispanic adults who completed the survey in Spanish, one-third (33%) say it is very or somewhat difficult to find a doctor who speaks their preferred language or provides an interpreter when needed.

Experiences with Providers

Most Hispanic adults (83%) say it is very or somewhat easy to find a doctor who treats them with dignity and respect, similar to the share of White adults (84%) who say so (Figure 9). However, about one in four (24%) potentially undocumented Hispanic adults say it is somewhat or very difficult, compared to 14% of U.S. born Hispanic adults and 11% of lawful permanent residents. Among nonelderly Hispanic adults, there are no significant differences in reported ease of finding a doctor who treats them with dignity and respect by insurance status. However, among Hispanic adults overall, those without a usual source of care are more likely to say it is very/somewhat difficult compared to those with a usual source of care (20% vs. 12%).

Just over half (52%) of Hispanic adults say it is easy to find a doctor with shared background and experiences to them versus over two-thirds (67%) of White adults (Figure 10). The share who say it is very or somewhat easy to find a doctor with shared background and experiences falls to 42% among potentially undocumented Hispanic adults compared to 56% of those who are U.S. born. Similar differences are observed among Hispanic adults based on whether they have a usual source of care, with 42% of those without a usual source of care saying it is very or somewhat easy compared to 56% of those with a usual source of care. Ease of finding a doctor with the same background and experiences does not vary by insurance status among nonelderly Hispanic adults.

Implications

Overall, these findings show that, consistent with research from prior to the pandemic, Hispanic adults are more likely to be uninsured than their White counterparts. They also are less likely to have a usual source of care other than an emergency room and to rely on community health centers as their source of care. Further, they are more likely than their White counterparts to say it is difficult to get to a location for health care. The findings further show that these access challenges generally are amplified among Hispanic adults who are foreign-born and uninsured. Beyond increased barriers to accessing care, the findings also highlight some challenges communicating with providers among Hispanic adults, particularly among those who are foreign-born and those without a usual source of care. These challenges include increased difficulty finding a doctor who explains things in a way that is easy to understand, finding a doctor with shared background and experiences, and linguistic access challenges for Spanish-speaking adults.

Despite having a higher uninsured rate and being less likely to have a usual source of care, Hispanic adults are not more likely than White adults say it is difficult to find affordable care. This finding may, in part, reflect the primary role community health centers play as a source of care among Hispanic adults. Community health centers provide comprehensive primary care as well as supportive services such as health education, translation, and transportation to patients who are disproportionately low-income, people of color, uninsured, or publicly insured. They provide these services regardless of patients’ ability to pay or immigration status and charge for services on a sliding fee scale. As such, health centers facilitate access to affordable, culturally and linguistically competent care and can help mitigate challenges to accessing care. This finding may also reflect that Hispanic adults are less likely than their White counterparts to utilize care. For example, other federal survey data show that a quarter of Hispanic adults have not seen a doctor in the past year, compared to less than one in five White adults.³ 

The overall findings on Hispanic adults’ reported experiences and perceptions of care may reflect certain cultural norms, including an emphasis on politeness and conflict avoidance, and variations in expectations and experiences with the U.S. health care system. For example, research suggests that Hispanic people may give higher ratings to physicians and health plans despite worse health care experiences due to a cultural disposition to be deferential to those who are presumed to be of higher status. Moreover, immigrants may have lower expectations of the healthcare system based on prior experiences with health care in their countries of origin and less experience interacting with the U.S. health care system. Similarly, uninsured individuals’ reported experiences and perceptions of health care and health care system may reflect less interaction with the health care system.

Together these findings highlight the importance of addressing disparities in coverage, access to care, as well as in patient-provider communications for improving health and well-being of Hispanic adults. Further, they highlight the variation of experiences and needs within the Hispanic population which can help inform these efforts going forward. Addressing disparities in health and health care among the Hispanic population is of increasing importance given their growing share of the nation’s population and that they have been disproportionately affected by the COVID-19 pandemic.

1. The survey used questions to determine the likely immigration status of respondents by asking those who were born outside the U.S. whether they were a permanent resident (i.e. had a green card) when they came to the U.S. or if their status had been changed to permanent resident since arriving. In the current survey, 18 percent of Hispanic adults said they have not been granted permanent resident status, indicating that they are likely to be undocumented immigrants, although this group may also include a small number of temporary lawful residents. ↩︎
2. KFF analysis of 2019 National Health Interview Survey Data ↩︎
3. Ibid. ↩︎

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 hesitancy, trusted messengers and messages, as well as the public’s experiences with vaccination.

Key Findings

At the beginning of 2021 as vaccine distribution began in the U.S., KFF conducted interviews with a nationally representative sample of adults using open-ended questions to better understand public concerns around receiving a COVID-19 vaccine. Six months later, we recontacted these individuals to find out whether they chose to receive a COVID-19 vaccine, their reasoning behind their decisions, and how they are feeling about their choice.

• The vast majority (92%) of those who planned to get vaccinated “as soon as possible” in early 2021 have received at least one dose of a COVID-19 vaccine, as have slightly more than half (54%) of individuals who had previously said they wanted to “wait and see” before getting vaccinated. On the other hand, a majority (76%) of people who had previously said they would “only get vaccinated if required” or said they would “definitely not” get a COVID-19 vaccine remain unvaccinated.
• One-fifth of adults (21%) now report being vaccinated after saying in January they planned on waiting to get vaccinated, would only get it if required, or would definitely not get vaccinated. Many of these individuals noted the role of their friends and family members as well as their personal doctors in persuading them to get a vaccine. Seeing their friends and family members get vaccinated without serious side effects, talking to family members about being able to safely visit, and conversations with their personal doctors about their own risks were all persuasive factors for these individuals. A small but meaningful share also say the easing of restrictions for vaccinated people was a factor in their decision to get a vaccine.
• When asked to name the feeling that best describes how they feel now that they have been vaccinated, nearly a quarter of vaccinated adults offer responses around feeling safe (24%) and relieved (22%). Other positive feelings reported were freedom, confidence, and more certainty that if they did get COVID-19 it would be less serious or they were less likely to die from it. And while most respondents react with some positive emotion, one in ten said they felt the same or neutral. This feeling was more common among those who initially said they would “wait and see” in January or who said they would only get vaccinated if required or would not get vaccinated.
• Conversations with family members and friends have played a major role in persuading people to get vaccinated. Two-thirds of vaccinated adults say they have tried to persuade their friends and family members to get a COVID-19 vaccine, and 17% of adults who are now vaccinated after saying in January they planned on waiting to get vaccinated, would only get it if required, or would definitely not get vaccinated, say they were persuaded to do so by a family member and 5% say they were persuaded by a friend. In addition to this, others cite protecting friends and family members as the main reason for getting vaccinated and others offer being able to see their friends and family members as well as family pressure or encouragement as the main reasons why they chose to receive a vaccine.
• About one-fourth of those who previously said they planned on getting vaccinated “as soon as possible” or were wanting to “wait and see” before getting a vaccine, remain unvaccinated six months later. Some of these individuals either have an appointment to get a vaccine or still plan on getting it as soon as they are able, but one in ten (6% of total) now say they either will “only get vaccinated if required” or say they will “definitely not” get a vaccine. When asked what changed their mind, many offer concerns about the side effects of the vaccine as the reasons why they now do not plan on getting vaccinated.
• Being concerned about side effects is the top reason offered by unvaccinated people for why they haven’t gotten a COVID-19 vaccine. When asked what would motivate them to get vaccinated against COVID-19, most in the “wait and see” group say they just want more time to see how the vaccine affects others who have already gotten it.

Vaccine Behavior Largely Matches Previous Intentions

Nine in ten (92%) of those who said back in January 2021 they would get vaccinated as soon as they were able now report, six months later, that they have received at least one dose of a COVID-19 vaccine. In addition, slightly more than half (54%) of those who were in the “wait and see” group back in January, say they have received a COVID-19 vaccine while 46% of adults in this group report not being vaccinated against COVID-19. A smaller share, one-fourth (24%) of those who said they would “only get vaccinated if required” or they would “definitely not” get vaccinated now report receiving at least one dose, while the majority (76%) of adults in this group say they remain unvaccinated.

Three-fourths (72%) of the most vaccine enthusiastic group (those who said they would get vaccinated as soon as they could back in January) say they received a COVID-19 vaccine more than two months ago, compared to a majority of vaccinated adults from the “wait and see” group who say they received their vaccine either less than one month ago (10%) or between one and two months ago (46%).

Overall nearly half of adults either were already vaccinated in January (8%) or had said they planned to get vaccinated as soon as possible and have now received at least one dose (39%). An additional one in five adults (21%) are now vaccinated after saying in January they planned on waiting to get vaccinated, would only get it if required, or would definitely not get vaccinated. One-third of adults remain unvaccinated after either planning to get it as soon as possible or were going to wait and see back in January (17%) or had said they were only going to get vaccinated if required or were definitely not getting a COVID-19 vaccine (16%).

What Made Some People Decide to Get vaccinated?

When the 21% of adults who are now vaccinated after saying in January they planned on waiting to get vaccinated, would only get it if required, or would definitely not get vaccinated are asked in their own words what they learned or heard that persuaded them to get vaccinated, many discussed the role of their friends and family members as well as their personal doctors in their decision.

A common response mentioned by one-fourth of these individuals was that seeing others, especially friends and family, get vaccinated without side effects made them decide to get a vaccine.

Others said they chose to get vaccinated either due to pressure from friends and family (8%), or they wanted to be able to safely visit with their friends and family members (3%).

Another common response was that conversations with their doctors or health providers encouraged them to get vaccinated (11%).

Half (52%) of those who were initially vaccine hesitant or resistant (saying in January they planned on waiting to get vaccinated, would only get it if required, or would definitely not get vaccinated) and have now received a COVID-19 vaccine say they heard or read something that persuaded them and more than one-third (36%) say they spoke with someone who persuaded them to get vaccinated.

Most commonly, people reported talking to and being persuaded by a family member (17% of all previously vaccine hesitant or resistant individuals) or their own doctor or health care provider (10%), followed by a close friend (5%) or a co-worker or classmate (2%).

Many of those who said they were persuaded after talking to their own doctor mentioned their doctor encouraging them due to their own or a family member’s medical condition.

A small but meaningful share said the easing of restrictions for vaccinated people made them decide to get a vaccine.

Two-thirds (65%) of vaccinated adults, including many of those who were previously vaccine hesitant, say they have tried to persuade close friends or family members to get vaccinated.

What Made Some People Decide to Not Get vaccinated?

One-third of adults remain unvaccinated, including a quarter of adults who previously had said they planned on getting vaccinated “as soon as possible” or wanted to “wait and see” before getting a vaccine and remain unvaccinated six months later. Some of these individuals (3%) either have an appointment to get a vaccine or still plan on getting it as soon as they are able, but one in ten (6% of total) now say they either will only get vaccinated if required or say they will “definitely not” get a vaccine.

When asked what changed their mind, many of these individuals offer concerns about the side effects of the vaccine as the reason why they now do not plan on getting vaccinated.

For some, others’ views of the pandemic influenced their decisions to not get vaccinated, with several people offering responses about the pandemic being exaggerated and no longer feeling that a vaccine was necessary.

The Experiences Of Vaccinated Adults

When adults who have received at least one dose of a COVID-19 vaccine were asked how they feel now they have been vaccinated, the most common responses were about feeling safe and relieved. One-fourth (24%) of vaccinated adults say they felt “safe” or some variation after being vaccinated, with a similar share (22%) offering responses that they felt relieved. Other positive feelings reported were those of freedom, confidence, and more certainty that if they did get COVID-19, it would be less serious, or they were less likely to die from it.

While most respondents reacted with some positive emotion, another one in ten said they felt the same or neutral. Others offered responses about not experiencing any or only mild side effects as a result of the vaccinations, while some were excited about the “return to normal.” A much smaller share expressed a negative emotion (about 1% of vaccinated adults).

Those who initially said they would “wait and see” in January were less likely than those most enthusiastic about the vaccine (“as soon as possible” in January) to say they felt relief (14% vs. 29%), and more likely to express feeling the same or neutral about getting vaccinated (19% vs. 5%).

More than a quarter of vaccinated adults say the main reason they chose to get vaccinated was to protect themselves or reduce their own risk (27%), while another 16% mentioned they were afraid of getting COVID-19 and wanted to avoid getting sick. One in ten respondents cited being at risk of getting sick due to their age or other health condition as their reason for getting vaccinated. Others wanted to protect their family members (7%) or protect others around them and help with herd immunity (6%).

Those who previously had said they were going to “wait and see” offer similar reasons for getting vaccinated as the vaccine enthusiastic group but were slightly less likely to say they got vaccinated to protect themselves (21% vs. 33%), and slightly larger shares offer reasons related to not having to wear a mask anymore (5% vs. 0%) and because of encouragement or pressure from family members (6% vs. 1%).

One of the most common responses among the more vaccine resistant group who have received a vaccine were about getting vaccinated in order to travel or being required to due to a job.

Why Some Adults Remain Unvaccinated

When those who remain unvaccinated were asked about their main reason for not getting a COVID-19 vaccine, the most commonly offered reasons are around concerns about side effects (21%), followed by concerns that the vaccine was too new, too unknown, or not tested enough (16%). One in ten (12%) offer they haven’t gotten vaccinated because they don’t think they need the vaccine. Smaller, but still significant shares, say they haven’t gotten vaccinated because they just want to wait and see (7%), they don’t trust the vaccine and don’t normally get vaccines (7%), have a medical condition which prevents them from receiving a COVID-19 vaccine (7%), or think COVID-19 is not that bad or that the vaccine is worse (7%).

Being concerned about side effects was also the top reason back in January why people said they may not get vaccinated. The latest report finds one-fifth of unvaccinated adults still offer concerns over possible side effects as the main reason why they haven’t gotten a COVID-19 vaccine.

Another one of the most commonly offered reason for not getting vaccinated were concerns that the vaccine was too new, too unknown, or not tested enough. This was one of the top reasons offered across vaccine intention groups.

Some unvaccinated people say they don’t see the benefit of getting vaccinated either because they do not think they are at risk of getting sick from the virus, or that they already had COVID-19.

many unvaccinated Adults Just Want to Wait and See

As millions of adults in the U.S. have received a COVID-19 vaccine and access to vaccines has increased throughout the country, the share of adults who say they either will get vaccinated “as soon as possible” or want to “wait and see” before getting vaccinated has decreased to about one in eight adults. Few adults (9%) say they are now “more motivated” to get vaccinated than they were six months ago while most (65% of all unvaccinated adults and 60% of those in the “wait and see” group from January) say they have the same level of motivation now to get vaccinated as they did six months ago. About a quarter across groups say they are “less motivated” to get vaccinated than they were six months ago.

Among those who are still unvaccinated but are not resistant to getting vaccinated (now say they either plan to get it ASAP or are wanting to wait and see), about four in ten say they plan on waiting more than a year before getting a COVID-19 vaccine, while about three in ten (28%) say they plan on getting vaccinated within the next three months and an additional third say they will get vaccinated between 4 months and a year. Many adults in this group (unvaccinated adults who say they either plan to get it ASAP or are wanting to wait and see) offer side effects as the main reason why they have not gotten vaccinated yet.

When those who say they want to “wait and see” before getting vaccinated are asked what, if anything, would motivate them to get vaccinated against COVID-19, few tangible motivations are mentioned. Most of these individuals say they just want more time to see how the vaccine affects others who have already gotten it. A few individuals explicitly mention wanting full FDA approval, a motivation found in previous KFF COVID-19 Vaccine Monitor reports.

This KFF COVID-19 Vaccine Monitor: In Their Own Words, Six Months Later was designed and analyzed by public opinion researchers at the Kaiser Family Foundation (KFF). The survey was conducted June 15-23, 2021 using the SSRS Opinion Panel, a nationally representative panel of U.S. adults age 18 or older recruited using probability-based sampling techniques. For the Kaiser Family Foundation, SSRS re-invited adult panelists in the U.S. who previously participated in a survey in January 14-18, 2021. The original sampling targeted panel respondents by gender, age, race, education, and region. SSRS regularly monitored data collection to check for demographic composition of the sample and data quality. Cases determined to be poor-quality, as defined by surveys with a length of interview of less than 33% of the mean length of interview and with invalid text responses were removed from the final data. In total, 1,009 panelists were invited to participate in this follow-up survey and 878 respondents completed the full questionnaire online on June 15-23, 2021 with additional follow-ups conducted on July 2,2021. 859 surveys were completed in English and 19 surveys were completed in Spanish. Panelists were compensated for their participation, with incentives distributed by the SSRS Opinion Panel through their standard procedures.

The margin of sampling error including the design effect for the full sample is plus or minus 4 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. Note that sampling error is only one of many potential sources of 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.