For months, the main challenge with COVID-19 vaccine roll-out in the U.S. was that demand greatly outstripped supply. Indeed, limited supply, coupled with restricted eligibility in many parts of the country, meant that most people couldn’t get vaccinated if they wanted to. Now, with supply having increased significantly and eligibility fully open to adults in all states as of April 19, the main question has become, when will supply outstrip demand? While timing may differ by state, we estimate that across the U.S. as a whole we will likely reach a tipping point on vaccine enthusiasm in the next 2 to 4 weeks. Once this happens, efforts to encourage vaccination will become much harder, presenting a challenge to reaching the levels of herd immunity that are expected to be needed.

Our polls, and others, have shown that the share of adults who have either received one vaccine dose or want to get vaccinated as soon as they can has continually increased. As of March 21, it was 61% (up from 55% the month before). This increase reflects a shift from those saying they want to “wait and see” into the vaccine enthusiasm group. In fact, the share saying they want to “wait and see” has consistently fallen, as more people become enthusiastic about getting vaccinated.

If we use 61% as a current “outer edge” of vaccine enthusiasm, it translates into about 157 million adults. The latest data from the CDC indicate that almost 131 million adults (or 50.7% of all adults), had received at least one vaccine dose as of April 19. That leaves an additional 27 million adults to go before we hit up against the “enthusiasm limit”. At the current rate of first doses administered per day (using a 7-day rolling average, as of April 13) – or approximately, 1.7 million per day – we would reach the tipping point in about 15 days.  Of course if the pace of vaccination picks up, it could be sooner.  However, if those who say they want to get vaccinated right away face challenges in accessing vaccination, it could take longer.

We also know that, over time, people have moved from the “wait and see” group to the vaccine enthusiasm group, suggesting that the 61% may be a floor, not a ceiling.  If about a third of the “wait and see” group moves into the enthusiasm group (comparable to what happened last month), the “outer edge” of vaccine enthusiasm would increase to 170 million people (or 66% of all adults); at the current rate of vaccine doses administered per day, it would take 22 days to reach the point at which supply outstrips demand.  If half of the “wait and see” group move, it would take about 28 days to reach the tipping point.

Thus, on average across the country, it appears we are quite close to the tipping point where demand for rather than supply of vaccines is our primary challenge. Federal, state, and local officials, and the private sector, will face the challenge of having to figure out how to increase willingness to get vaccinated among those still on the fence, and ideally among the one-fifth of adults who have consistently said they would not get vaccinated or would do so only if required. Now that supply has increased and eligibility has expanded, it will take a concerted effort to reach a sufficient level of vaccination for herd immunity, and to do so in a way that achieves equity goals as well.

A new KFF analysis finds that a relatively small share of drugs, mainly those without generic or biosimilar competitors, accounted for a disproportionate share of prescription drug spending in Medicare in 2019. This finding suggests that recent proposals that focus on prices for a limited number of high-cost drugs could achieve significant savings.

The 250 top-selling drugs in Medicare Part D with one manufacturer and no generic or biosimilar competition – or roughly 7 percent of the more than 3,500 Part D covered drugs — accounted for 60 percent of the net total Part D spending of $145 billion in 2019, the analysis finds. Part D is Medicare’s voluntary benefit that covers retail prescription drugs for 46 million enrollees in 2020.

Similarly in Medicare Part B, the top 50 covered drugs – or 8.5 percent of all Part B covered drugs — accounted for 80 percent of total Part B drug spending of $37 billion in 2019. Medicare Part B pays for prescription drugs administered by physicians and other providers in outpatient settings for conditions such as cancer and rheumatoid arthritis.

The findings inform ongoing policy debates about policies to rein in prescription drug prices, such as proposals to allow the government to negotiate drug prices (Part D) or peg payments to international prices (Part B), if such changes were applied to a limited number of drugs. Focusing drug price negotiation or reference pricing on a subset of high-priced drugs could leave some savings on the table, but might also be a more efficient use of administrative resources.

For more data and analyses related to Medicare and prescription drugs, visit kff.org.

Note: An updated analysis with more recent data is available here. 

Policymakers are once again focusing attention on proposals to lower prescription drug costs. During the previous session of Congress, the House passed legislation (H.R. 3) to allow the federal government to negotiate drug prices for Medicare Part D, Medicare’s outpatient prescription drug benefit, and private insurers. Under H.R. 3, the HHS Secretary would negotiate prices for up to 250 brand-name drugs lacking generic or biosimilar competition with the highest net spending. In contrast, other drug price negotiation proposals placed no limit on the number of covered drugs subject to negotiation. In a similar vein, the Trump administration issued a final rule to establish a model through the CMS Innovation Center  that would base Medicare’s payment for the 50 highest-spending Part B drugs (i.e., drugs administered by physicians in outpatient settings) on the lowest price paid by certain other similar countries. (In light of pending litigation, the Biden Administration has stated that it will not implement this model without further rulemaking.)

These drug pricing proposals raise the question of whether limiting the number of drugs subject to government price negotiation or international reference pricing might leave substantial savings on the table, even if this approach is more administratively feasible than subjecting all drugs to negotiation or reference pricing. This analysis provides context for this question by measuring the share of total Medicare Part D and Part B drug spending accounted for by top-selling drugs covered under each part. For this analyses, we ranked drugs by total spending in 2019, based on data from the Centers for Medicare & Medicaid Services’ Medicare Part D and Part B drug spending dashboards. For Part D, we calculated estimates of net total spending, taking into account average rebates reported by the Congressional Budget Office. (See Data and Methods for details.)

Takeaways

Our analysis finds that a relatively small number and share of drugs accounted for a disproportionate share of Medicare Part B and Part D prescription drug spending in 2019 (Figure 1).

• The 250 top-selling drugs in Medicare Part D with one manufacturer and no generic or biosimilar competition (7% of all Part D covered drugs) accounted for 60% of net total Part D spending.
• The top 50 drugs covered under Medicare Part B (8.5% of all Part B covered drugs) accounted for 80% of total Part B drug spending.

Medicare Part D

In 2019, Medicare Part D covered more than 3,500 prescription drug products, with total spending of $183 billion, not accounting for rebates. Because drug-specific rebate data are not publicly available, we applied average rebates from a CBO analysis of prices for top-selling brand-name drugs to derive an estimate of net Medicare Part D spending of $145 billion in 2019. For specialty drugs (which we identified as drugs with prices at or above $670 per claim, based on the amount of the Part D specialty tier threshold ]in 2019), we applied a rebate of 12%, and for non-specialty brand-name drugs, we applied a rebate of 47%. We assumed no rebate for lower-cost generic drugs.

Our analysis shows that Part D drug spending is concentrated among a relatively small number of drugs with only one manufacturer and no generic or biosimilar competition.

• The top-selling 250 drugs with one manufacturer and no generic or biosimilar competitors accounted for 60% of net total Part D spending in 2019 (Figure 1). In contrast, the remaining 2,208 drugs with one manufacturer accounted for 13% of net total Part D spending in 2019, and all other covered Part D drugs (1,078) accounted for 27% of net total spending.
• The average net cost per claim across the top 250 drugs with one manufacturer and no generic or biosimilar competitors was substantially higher than the average net cost per claim of other covered Part D drugs. For the top 250 drugs, the average net cost per claim was $5,750, more than twice as much as the average net cost per claim for the remaining 2,208 drugs with one manufacturer ($2,555), and more than 13 times greater than the average net cost per claim for all other covered Part D drugs ($422) (primarily generic drugs).
• The 10 top-selling Part D covered drugs with no generic or biosimilar competition in 2019 accounted for 0.3% of all covered products but 16% of net total Part D spending that year (Figure 2). These 10 top-selling drugs include three cancer medications, four diabetes medications, two anticoagulants, and one rheumatoid arthritis treatment (Table 1). Our estimate of net total spending on each of these drugs ranged from around $1 billion to $4 billion in 2019, based on average rebates for specialty and non-specialty brand drugs derived from CBO’s analysis.

Medicare Part B

Medicare Part B covers prescription drugs administered by physicians and other providers in outpatient settings. Part B covers a substantially smaller number of drugs than Part D – fewer than 600 drug products in 2019, with total spending of $37 billion – but many Part B covered drugs are relatively costly medications. As is the case under Part D, drug spending under Part B is highly concentrated among a handful of medications:

• The top 50 drugs ranked by total spending accounted for 80% of total Medicare Part B drug spending in 2019, while the top 100 drugs accounted for 93% of the total (Figure 3). In contrast, the remaining 485 covered Part B drugs accounted for only 7% of total Part B drug spending in 2019.

• The top 10 Part B covered drugs in 2019 accounted for 2% of all covered products but 43% of total Part B drug spending that year. The top 10 drugs include four cancer medications, two medications for macular degeneration, two rheumatoid arthritis treatments, one osteoporosis drug, and one bone marrow stimulant. Total spending on these drugs ranged from $2.9 billion for Eylea, a treatment for macular degeneration, to $0.9 billion for Remicade, a treatment for rheumatoid arthritis (Table 2)

Conclusion

Some recent proposals to lower prescription drug prices have limited the number of drugs subject to price negotiation and international reference pricing. This analysis shows that Medicare Part D and Part B spending is highly concentrated among a relatively small share of covered drugs, mainly those without generic or biosimilar competitors. Focusing drug price negotiation or reference pricing on a subset of drugs that account for a disproportionate share of spending would be an efficient use of administrative resources, though it would also leave some potential savings on the table. In considering whether to broaden these proposals to focus on all prescription drugs, policymakers may want to consider whether doing so would achieve sufficient savings to justify the added administrative burden and associated costs.

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.

KFF launched the COVID-19 Vaccine Monitor in December 2020 to track the dynamic nature of the U.S. public’s attitudes and experiences with COVID-19 vaccination as distribution efforts unfold across the country. As many states have opened up eligibility to everyone ages 16 and over and the remainder of states are poised to do so soon, this brief summarizes some of the key findings and themes from this research based on interviews with more than 11,000 adults across the nation to date.

Key takeaways

• Broadly, the COVID-19 Vaccine Monitor has found that vaccine confidence in the U.S. has increased as more and more people have seen their friends and family members get vaccinated, and now a majority of the public has either already gotten vaccinated or is ready to get the vaccine as soon as they can. Yet with a small but persistent group opposed to getting the vaccine and many others still on the fence, the U.S. may soon hit a point where vaccine supply exceeds demand, a situation that is already the case in certain communities.
• While some media narratives have focused on which groups are most “vaccine hesitant,” our research finds that no group is monolithic in their vaccine attitudes, and in every demographic segment there are large shares of people who are ready to get the vaccine, others who are in “wait and see” mode, and some who are more resistant. Even though certain demographics (for example, Republicans) have a higher share than other groups saying they don’t intend to get vaccinated and others (for example, Black adults) have a higher share saying they want to “wait and see,” we’ve found that majorities across all demographic groups are at least somewhat open to getting the vaccine.
• Those who are not ready to get vaccinated for COVID-19 right away have a range of questions and concerns about the vaccine that require different strategies to address. The top concern across groups has been the potential side effects of the vaccine, including a substantial share who are worried about missing work due to side effects. Other concerns reflect a lack of access to accurate information; for example, many are concerned that they might get COVID-19 from the vaccine (which is not possible) or that they will have to pay out-of-pocket costs to get vaccinated (when in fact, vaccination is free). And other concerns reflect issues with vaccine access, including needing to take time off work to get vaccinated, issues with transportation, or concern about not being able to get the vaccine from a trusted place. Rather than a single messaging strategy, these concerns point to the need for a combination of information, outreach, and policies to both bolster confidence in COVID-19 vaccines and make vaccination accessible across communities.
• Individual health care providers are the most trusted messengers when it comes to information about the COVID-19 vaccines. With trust in national public health messengers eroding and becoming increasingly partisan over the past year, local doctors, nurses, health care providers, and other trusted community figures have an important role to play in supplementing any national campaigns to increase COVID-19 vaccine confidence and uptake.
• It is too early to know what effect the recent announcement about the pause in distribution of the Johnson & Johnson vaccine will have on COVID-19 vaccine confidence. Prior to this announcement, our research found that the one-shot vaccine was an appealing option for a large share of those in the “wait and see” group. However, the potential side effects of the vaccine are a top concern for those who have not yet been vaccinated, so if the public perceives blood clots as a potential side effect (regardless of whether a link is proven), this news does have the potential to increase concerns about getting the Johnson & Johnson vaccine. In the meantime, messages about the effectiveness of the existing vaccine options at preventing serious illness and death from COVID-19 are likely to be the most effective at bolstering confidence among those who are on the fence about getting the vaccine.

Vaccination intentions: trends and demographics

• The share of the public that is eager to get the COVID-19 vaccine has been increasing over time, including across subgroups by race/ethnicity, partisanship, and urbanicity. As of March, six in ten adults said they had already gotten at least one dose of the vaccine (32%) or would get it as soon as it was available to them (30%), a share that has increased steadily since December, when 34% said they would get the vaccine as soon as possible. The share saying they want to “wait a while and see how it’s working for others” before getting vaccinated themselves declined steadily from 39% in December to 17% in March. Where we have not yet seen much movement is in the shares saying they definitely won’t get the vaccine (13% in March) or will do so only if required for work, school, or other activities (7%).
• People at higher risk for serious complications and death from COVID-19 tend to be more enthusiastic about getting the vaccine. For example, in March, 82% of adults ages 65 and older and 70% of individuals with a serious health condition say they’ve already been vaccinated or will get the vaccine as soon as they can, compared to smaller shares of younger adults and those without serious health conditions. This at least partially reflects early access these groups had to the vaccine compared to others, but also the fact that larger shares of younger and healthier adults say they want to wait and see, will get the vaccine only if required, or will definitely not get vaccinated.
• While enthusiasm for getting the vaccine increased dramatically among Black adults between February and March (from 41% to 55% saying they’d already gotten vaccinated or intended to do so as soon as possible), Black adults remain somewhat more likely than White adults to say they want to “wait and see” (24% vs. 16%). In earlier months, Hispanic adults were also somewhat more likely to say they wanted to “wait and see,” but by March the share among Hispanic adults decreased to 18%.
• Education is also a dividing factor in vaccination intentions, with college-educated adults more likely than those without college degrees to say they’ve already gotten vaccinated or will do so as soon as they can (73% vs. 56% in March).
• Vaccination intentions have also divided along party lines since December, reflecting the broader partisan dialogue about the pandemic over the past year. About eight in ten Democrats (79%) are eager to get the vaccine or say they have done so already, compared to nearly six in ten independents (57%) and just under half of Republicans (46%). About three in ten Republicans (29%) say they will “definitely not” get vaccinated, a share that has not changed substantially over time.
• In addition, 28% of White Evangelical Christians say they will definitely not get the vaccine, reflecting the fact that two-thirds (66%) of this group either identifies as Republican or leans towards the Republican party. One in five rural residents also say they will definitely not get vaccinated, about twice the share as in urban areas, a gap largely explained by the concentration of Republicans and White Evangelical Christians who live there.

Challenges and opportunities that cross demographic groups

Concerns and messages

• The potential side effects and the newness of the vaccine seem to be driving a lot of the concern among people who have not yet been vaccinated. Among the 37% of adults in March who were not yet convinced to get the vaccine as soon as possible, seven in ten said they were concerned they might experience serious side effects from the vaccine, and over six in ten were concerned the effects of the vaccine might be worse than getting COVID-19. In addition, when those who say they will definitely not get the vaccine are asked to state their main reason in their own words, the most common response is that the vaccine is too new and/or that not enough is known about the long-term effects.
• Different groups respond to messaging and information at different levels, but of the messages we’ve tested, emphasizing the effectiveness of the vaccine at preventing serious illness and death is the most effective across groups (two-thirds of those in the “wait and see” group and four in ten in the “only if required” group say they’d be more likely to get vaccinated after hearing the vaccines are nearly 100% effective at preventing hospitalizations and death from COVID-19).
• The “wait and see” group is an important target for outreach and messaging, since they express some concerns about getting vaccinated, but will likely be much easier to convert from vaccine-hesitant to vaccine-acceptant than those who say they will “definitely not” get the vaccine or will get it “only if required” to do so. Other messages/information that are effective at persuading many in the “wait and see group” include that scientists have been working on the technology used in the new COVID-19 vaccines for 20 years; that more than 100,000 people from diverse backgrounds took part in the vaccine trials; that the vast majority of doctors who have been offered the vaccine have taken it; and that there is no cost to get the vaccine.
• Separate from concerns about the effects of the vaccine itself, about six in ten of those who are not yet convinced to get the vaccine right away are concerned that they might be required to get the vaccine even if they don’t want to.

Information and misinformation

• Reaching people with information about how to access vaccines is an ongoing challenge. As of March, many people say they still don’t have enough information about when (46%) and where (33%) they’ll be able to get the vaccine, and three in ten are not sure if they are currently eligible in their state (rising to four in ten among Hispanics, young adults, and those with lower incomes).
• Many are unaware of some basic facts about the vaccines and how they work. As of January, 34% of all those who had not been vaccinated had heard and believed or were unsure about several common “myths” about the vaccine (that it contains the live virus that causes COVID-19, that it causes infertility, or that one must pay out-of-pocket to get vaccinated), rising to 41% among the “wait and see” group and 53% among those who say they will “definitely not” get vaccinated. Around four in ten of those who are not yet convinced to get the vaccine right away (rising to half among Black and Hispanic adults) are concerned that they might get COVID-19 from the vaccine.
• Health care providers are the top source people say they will turn to for information when making decisions about whether to get vaccinated (79%, far outranking other sources in January). However, just one-quarter of those who had not yet been vaccinated said they have asked a provider about the vaccine as of February. Regardless of the sources they trust or say they will turn to, the media is a more prominent source where people are actually getting information. Asked where they have gotten information about the vaccine in recent weeks, cable (43%), network (41%), and local TV news (40%) are top sources, along with family and friends (40%). However, social media, most notably Facebook, is among the most prominent sources of information for those who want to “wait and see” about the vaccine (37%) as well as those who say they “definitely won’t” get vaccinated (40%).

Vaccine access and experiences

• While most of those who were vaccinated as of February say they were able to find or schedule a vaccine appointment on their own, about four in ten say someone else helped them, including larger shares of those with lower incomes and without college degrees. Among those who believe they are eligible but had not yet been vaccinated as of March, about a third have tried to schedule a vaccination appointment including 16% who did so successfully and 17% who say they tried but were unable to make an appointment.
• Making access to vaccines more convenient may improve uptake among some groups. Among the “wait and see” group, half say they’d be more likely to get vaccinated if their doctor offered it during a routine appointment, and four in ten of those with jobs say they’d be more likely to get it if their employer arranged for them to get vaccinated at work. Employer incentives could also play a role (38% of the employed “wait and see” say they’ be more likely to get vaccinated if their employer paid them $200), as could airline travel requirements (almost half in both the “wait and see” and “only if required” groups say they’d be more likely to get vaccinated if it was required to fly).

Challenges and opportunities for key subgroups

Despite the demographic differences in vaccination intentions noted above, no group is monolithic in their attitudes towards the COVID-19 vaccines. In each demographic group, there are many who are eager to get the vaccine right away and some who say they won’t get it under any circumstances. Importantly, across all the groups we’ve analyzed, a large majority is at least somewhat open to getting the vaccine and no more than one-third say they will “definitely not” get it. Still, our in-depth survey work has revealed some insights that may be helpful for those looking to understand vaccine attitudes and increase confidence in specific populations, and those are outlined in the sections below.

Black and Hispanic adults

• Concern about getting sick with COVID-19 is high among Black and Hispanic adults who want to wait and see before getting vaccinated, but concern about experiencing serious side effects of the vaccine is also high. Given this, messages focused on protecting individuals and families from illness, while also acknowledging and/or addressing concerns about serious side effects may be most successful.
• People express a range of other concerns about the vaccine that can be addressed with better access to information and policies that make it easier for people to get the vaccine from trusted places, and many of these concerns are expressed at higher rates among people of color. In particular, among those who are not convinced to get the vaccine as soon as possible, at least half of Black and Hispanic adults are concerned that they might get COVID from the vaccine or that they might have to miss work if they have side effects. Addressing these misperceptions in conversations and outreach may be helpful.
• For Black adults in particular, reluctance to get vaccinated may be related to mistrust of the health care system that reflects both historical mistreatment and personal experiences with racism and discrimination. In fact, 38% of Black adults and 27% of Hispanic adults who are not yet convinced to get the vaccine are worried they won’t be able to get it from a place they trust.
• Black and Hispanic adults say they will turn to a wide range of information sources when making vaccine-related decisions, including individual health care providers, pharmacists, friends and family, and government health agencies. While religious leaders rank lower on the list of overall sources of information, among those who want to “wait and see,” Black adults (35%) and Hispanic adults (28%) are more likely than white adults (14%) to say they’ll turn to them for information, indicating a possible effective messenger to reach some the Black and Hispanic communities.

Republicans

• While about a third of Republicans say they will “definitely not” get the vaccine or will get it “only if required,” another 19% are in “wait and see” mode and may be receptive to messages and information aimed at increasing vaccine uptake. However, even within the “wait and see” group, partisan differences emerge that suggest different messaging strategies will be required. For example, two-thirds (67%) of Republicans and Republican-leaning independents in the “wait and see” group view vaccination as a personal choice, and half (51%) believe the seriousness of COVID-19 is being exaggerated in the news, according to the January Monitor. This suggests that messages focused on helping people make the right choice to protect their own health are more likely to resonate with Republican audiences than those that emphasize the seriousness of the pandemic or the need to get vaccinated for the collective good.
• Government sources of information (including the CDC and state and local health departments) are less trusted by Republicans than by Democrats in the “wait and see” group, so individual health care providers, pharmacists, and friends and family are a better conduit for messaging/information to Republicans.
• Republicans – who tend to be particularly concerned about personal liberty – are more likely to be concerned about being required to get vaccinated against their will. Among those who are not convinced to get vaccinated right away, a larger share of Republicans (71%) compared to independents (57%) and Democrats (53%) say they are concerned that they might be required to get the vaccine even if they don’t want to.
• Two-thirds (66%) of White Evangelical Protestants identify as Republicans or independents who lean toward the Republican Party, so there is a lot of overlap between their attitudes toward the COVID-19 vaccine and the attitudes of Republicans in general.

Rural residents

• In a large survey of over 1,000 adults living in rural areas, we found signs of strong early uptake and access to vaccines in rural areas. A slightly larger share of adults in rural areas compared to urban and suburban areas reported having received at least one dose of the vaccine (39% vs. 31%), and an additional 16% of rural residents want to get the vaccine as soon as they can. In addition, most adults living in rural areas feel their community has enough vaccination locations and vaccine supply to serve local residents. However, Black adults living in rural areas are less likely than White or Hispanic adults to say their community has adequate supply of these things.
• While one in five rural residents say they will “definitely not” get vaccinated, this is largely due to the disproportionate share of Republicans and White Evangelical Christians living in these areas. The concerns that rural residents have about the vaccine and the messages that resonate most to convince them to get vaccinated mirror the concerns and effective messages for the public at large.

The “definitely nots”

• Those who say they will “definitely not” get the vaccine (13% of the overall public) have a very different view of the overall pandemic compared to the rest of the population. For example, 75% of this group believes the seriousness of coronavirus has been exaggerated by the media (compared to 32% of the public overall), and 82% are not worried about themselves or a family member getting sick from COVID-19 (compared to 50% of the public overall).
• This group not only views the vaccine differently, but they also hold different views on other protective measures. For example, 96% of those in the “definitely not” group say getting vaccinated for COVID-19 is a personal choice rather than part of everyone’s responsibility to protect others (compared to 46% of the public overall who say this), and 65% believe that wearing a mask does not prevent the spread of coronavirus (compared with 20% of the public overall).
• This group is highly distrustful of government sources of information; 83% say they trust the U.S. government “not too much” or “not at all” to look out for the interests of people like them, and 71% say they do not trust the CDC for reliable information about COVID-19 vaccines.
• Of the messages and incentives we’ve tested to see what might make people more likely to get the vaccine, none are effective at moving more than a very small share of the “definitely not” group. For example, fewer than one in ten among this group say they’d be more likely to get vaccinated after hearing the vaccines are nearly 100% effective at preventing hospitalization and death from COVID-19 or that scientists have been working on the technology used in the vaccines for 20 years. A similarly small share say they’d be more likely to get vaccinated if airlines required it or if it was offered to them during a routine medical visit.

Frontline health care workers

• A KFF/Washington Post survey of frontline health care workers, including those who work in various functions such as treating patients, performing administrative duties, or assisting with patient’s daily activities and housekeeping, found that half (52%) of all frontline health workers reported receiving at least one dose of a COVID-19 vaccine as of early March and another one in five (19%) had scheduled or were planning to receive the vaccine. Another nearly one in five (18%) said they did not plan to get vaccinated and 12% had not made up their mind.
• As among the general public, COVID-19 vaccination intention among health care workers divides by race/ethnicity and education, as well as by work location and type of job duties. For example, while the large majority of those working in hospitals have been gotten the vaccine or intend to do so, almost half of those working in patients’ homes say they won’t get vaccinated or are undecided. And among physicians (and nurses with graduate degrees), nearly nine in ten report either already being vaccinated or plan to get a vaccine.
• Health care employers have a role to play in making sure their employees can get vaccinated. The share of health care workers who were offered a COVID-19 vaccine from their employer was much lower among those working in patients’ homes compared to those working hospitals and other settings.
• The potential side effects of the vaccine – a top concern among the public – are also a top concern for health care workers who have not yet been vaccinated; 82% say worry about possible side effects is a major factor in their decision about whether to get vaccinated.

With nearly all states poised to allow anyone at least 16 years old to get a COVID-19 vaccine, this week’s announcement pausing the distribution of the Johnson & Johnson vaccine to investigate a rare side effect is raising questions about whether and how it will affect the public’s eagerness to get vaccinated.

A new report summarizes key insights about vaccine confidence, messages and messengers from the KFF COVID-19 Vaccine Monitor project, which has interviewed more than 11,000 adults nationally since December to track the public’s shifting attitudes and experiences with COVID-19 vaccinations.

Among its key takeaways:

• Among those who are not ready to get a COVID-19 vaccination right away, their top concern consistently has been the potential side effects, including many who worry they will have to miss work due to side effects. The news about the Johnson & Johnson vaccine could heighten those worries for people on the fence about getting vaccinated.
• Prior to the pause in the Johnson & Johnson vaccine, it was an appealing option for a large share of those in the “wait and see” group because it requires only a single shot, while the other available vaccines (Moderna and Pfizer) require two shots several weeks apart.
• Some people’s concerns about vaccination are based on lack of access to accurate information. For example, many are concerned that they might get COVID-19 from a vaccine, which is not possible, or that they will have to pay out-of-pocket even though the COVID-19 vaccinations are free.
• No group is monolithic in their vaccine attitudes. While some demographics such as Republicans have a higher share saying they don’t intend to get vaccinated, and others such as Black adults have a higher share saying they want to “wait and see,” majorities across all demographic groups are at least somewhat open to getting a vaccine.
• Individual health care providers are the most trusted messengers when it comes to information about the COVID-19 vaccines.

Available through the Monitor’s online dashboard, the report looks at common messages and messengers that apply across demographic groups, as well as challenges and opportunities related to the views of specific groups such as Black and Hispanic adults, Republicans, rural residents, frontline health workers and those who say they will “definitely not” get vaccinated.

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 unfolds, including vaccine confidence and acceptance, trusted messengers and messages, as well as the public’s experiences with vaccination.

As COVID-19 vaccination rolls out in parts of the world, many countries have started to implement or are considering the use of COVID-19 “vaccine passports” – paper or digital forms certifying that a person has been vaccinated against COVID-19 – for purposes of international travel. In addition, some countries are using them for domestic travel and/or access to certain establishments, activities, and events. Such certifications are separate from but related to the issue of vaccine mandates. Where COVID-19 vaccines are mandated, there will be a need to certify vaccine status, and a vaccine passport is a potential tool for that purpose.

The U.S. government is exploring COVID-19 vaccine certifications for use internationally and domestically. The administration has said that a vaccine passport may be required in the future for international travelers entering the U.S., but it will not impose a federal requirement for domestic purposes. However, it is working with the private sector to develop standards around such certifications. Within the U.S., states are landing on different sides of what has quickly become a partisan issue with several states moving to implement passports while others have come out strongly against the idea.

This brief provides an overview of what vaccine passports are, how they are being used, and identifies a number of outstanding policy issues facing the U.S. in both the international and domestic contexts.

What are COVID-19 Vaccine Passports?

A vaccine passport is a paper or digital form certifying that a person has been vaccinated against a particular disease. There is a long history of the use of vaccine certifications for international travel, with many countries currently requiring travelers to present proof of yellow fever vaccination to enter, for example. A COVID-19 vaccine certification for international travel could be used by governments in a number of ways, such as allowing an individual to move across borders more freely by potentially bypassing travel restrictions like testing or quarantine requirements upon arrival. In addition, vaccine passports may be used for domestic purposes, such as to permit individuals access to certain businesses, locations or activities within countries.

Where are COVID-19 Vaccine Passports Being Used Now?

Several countries have already begun to use COVID-19 vaccine passports, with wide variation in policies and implementation. Israel began issuing ‘green passes’ in February 2021 to their vaccinated citizens to allow for less restricted internal movement and access to businesses such as to gyms or theaters. Other countries, such as China and Bahrain, have begun issuing digital vaccine passports to their vaccinated citizens to equip them to travel internationally. Lastly, in several countries, including Georgia, Estonia, Poland, and Seychelles, proof of COVID-19 vaccination allows incoming travelers to avoid certain travel restrictions, such as testing or quarantining. Numerous other countries are considering the use of COVID-19 vaccine passports, either for internal or international movement, including the United Kingdom, Malaysia, Singapore, Greece, Denmark, the EU, and the U.S.

Multiple international organizations have already launched efforts to set standards and coordinate the design and implementation of vaccine passports for international travel, including the World Health Organization, World Economic Forum, International Chamber of Commerce, and the International Air Travel Association. The WHO is undertaking this effort as part of its mandate under the International Health Regulations (IHR) to coordinate among member states to provide a public health response to the international spread of diseases; it is possible that COVID-19 vaccination could be included in an updated version of the IHR (at this time, yellow fever is the only disease listed in the IHR for which countries can require proof of vaccination as a condition of entry).

Will the U.S. Use COVID-19 Vaccine Passports?

There is likely to be growing demand for vaccine certifications for use in the U.S., for international travel as well as domestic purposes. Airlines and tourism groups have already called for vaccine certifications as a way to ease the process of pandemic-era travel; the CDC recently released guidance saying fully vaccinated individuals can resume non-essential travel safely within the U.S. and stating that fully vaccinated persons can consider international travel if they maintain recommended precautions. Federal officials have also indicated that vaccination may in the future be required for entry into the U.S. for incoming travelers; the U.S. currently requires all air passengers coming to the U.S. to have a negative COVID-19 test.¹   Domestically, proof of vaccination may be required for entry into certain federal facilities in the U.S., including military bases and other federal buildings, and a number of U.S. companies and universities have already announced vaccinations will be required for their employees, students, and staff, which will require some kind of certification (see this recent KFF analysis for more discussion of vaccine mandates in the U.S.). Indeed, as stated at a recent meeting of the federal Office of the National Coordinator for Health Information Technology (ONC), “Proof of individual COVID-related health status is likely to be an important component of pandemic response” and “As more of the population becomes vaccinated, proof of immunization will likely become a major, if not the primary, form of health status validation”.

The Biden administration has made it clear it will not be the role of the federal government to issue vaccine passports or to collect and store individuals’ vaccination data at the federal level, but the government is taking on a coordination role and working with many of the international and domestic vaccine passport initiatives being developed by other parties. For example, President Biden issued an Executive Order directing the State Department to work with the World Health Organization, the International Civil Aviation Organization, the International Air Transport Association, foreign governments and others to establish international travel standards. Further, the order directs the Secretaries of the State Department, Department of Health and Human Services, and Department of Homeland Security, in coordination with relevant international organizations, to assess the feasibility of linking vaccination status with digital certificates for international travel. On the domestic side, the Administration is working with a number of privately-led vaccine passport initiatives already underway, to develop guidelines and address issues such as accessibility, privacy, and other access barriers. There are at least 17 such U.S.-based initiatives involving companies and institutions including Microsoft, IBM, MasterCard, the Mayo Clinic, and MIT. So far, these efforts remain in the development stage and none of these organizations has yet launched a vaccine passport for widespread use in the U.S. In the absence of a widely used vaccine passport system, the Centers for Disease Control and Prevention (CDC) “vaccination report card”, which is issued to each vaccinated individual, is being used as proof of vaccination in many cases for access to some activities and facilities. However, these cards can be falsified and lack a digital counterpart, upping the stakes on the need to develop standards and implement security measures.

Individual states are landing on different sides of the issue. Several have launched or are actively exploring the use vaccine certificates with New York being the first state to introduce a COVID-19 vaccine certification pass that would allow individuals to certify their vaccination status in order to access certain social activities. Other states, including Hawaii, are considering similar efforts. At the same time, several governors have come out strongly against vaccine passports, with some issuing executive orders banning their use, as has been done in Florida and Texas, or supporting legislation to prevent them, as in Tennessee. In the absence of a federally issued or sanctioned vaccine passport, and no nationwide private sector initiative yet being adopted, the U.S. may see more state or local level certification initiatives, which may or may not be coordinated across jurisdictions.

What are Key Implementation Issues to Consider?

There are a host of challenges and questions surrounding the design and use of vaccine passports, including issues of equity and access, a lack of uniform standards, and privacy and security.

Equity and access: There have already been significant equity challenges in vaccine roll out and access. Globally, most people in low and middle income countries (LMICs) do not have access to COVID-19 vaccines and may not until 2023 or later, and within the U.S. our analyses show that Black and Hispanic people have been vaccinated at lower rates than White people, and that high poverty and uninsured rates are associated with lower vaccination rates in many U.S. counties. In addition, non-citizen immigrants in the U.S. who, while eligible for free COVID-19 vaccination, may be reluctant to access the vaccine and/or to sign up for a vaccine passport that would require sharing of personal or other information with authorities. Further, it is still an ongoing question as to how populations that are either ineligible or unable to receive the COVID-19 vaccine, such as children under the age of 16, people with medical exceptions and those with religious objections, will be included in a COVID-19 vaccine passport system. Lastly, the process to sign up for a vaccine passport itself may present additional access issues, particularly for some groups. Given these inequities, some have cited concerns that proof of vaccination as a condition to access certain activities, such as travel or specific venues, has the potential to be discriminatory. For this reason, the World Health Organization’s Emergency Committee on the COVID-19 Pandemic officially cautioned countries against the use of requiring COVID-19 vaccine passports for international travel at this time, stating that COVID-19 vaccination should not exempt individuals from other risk-reduction measures while traveling and noting that vaccination as a requirement to travel would inequitably impact individuals in LMICs. Likewise, a coalition of travel organizations recently expressed concerns about imposing a travel-related vaccine requirement, recommending that vaccinated individuals be exempt from international testing requirements but that vaccination not be a “prerequisite to travel.” The EU, in its proposal for a Digital Green Certificate, has said that to ensure freedom of movement with the EU, it would include COVID-19 test certificates and certificates for those who have recovered from COVID-19 as part of its plan, in addition to certification of vaccination. New York state’s Excelsior Pass also allows for the use of a negative COVID-19 test (instead of vaccine certification).

Mutual recognition of passports: Countries that have begun or are considering issuing COVID-19 vaccine passports will need to establish agreements with other countries in order to have these passports recognized for international travel. Already, some of the initial passport proposals demonstrate limitations in this regard. For example, the EU’s proposal would allow for any vaccinated EU citizen to travel freely across all EU member states² , but not outside of the EU. Israel has signed an agreement with Cyprus and Greece to allow for international travel, while Malaysia and Singapore are considering an agreement for reciprocal recognition. The U.S. has not yet weighed in on an international standard or indicated what form of passport the government would accept for international arrivals, though such standards are being discussed and developed but have yet to be applied. This has created confusion, and a fragmented approach across countries so far. It is also likely to be an issue within the U.S. as different jurisdictions take varying approaches.

Lack of uniform digital standards: Related to the issue of mutual recognition is that of digital standards. Currently, there is no standardized guidance related to the design of COVID-19 vaccine passports, including any standards for issues such as data privacy or interoperability. One report has identified at least 12 issues that will require international guidance in order to create a universally recognized COVID-19 vaccine passport system. The WHO’s Smart Vaccination Certificate Working Group is currently working to provide such international guidance and standards. The group released its first round of guidance addressing several digital standards issues, including interoperability and minimum data standards, in March 2021. A complete set of recommendations in expected in June 2021, though in the meantime, countries are moving ahead with individual efforts. Within the U.S., the interoperability of individual organization or jurisdiction passport efforts also presents a domestic challenge.

Diverse vaccine authorization and approval landscape: Across countries, different combinations of vaccines have been authorized and administered. Some of the vaccines used in one country may not be recognized or accepted by another country, raising questions about whether and how to certify different vaccines across this landscape for purposes of a vaccine passport. For example, Iceland has stated that only vaccines approved for use by the European Medicines Agency or the WHO will be recognized in order to waive certain screening and quarantine requirements for incoming travelers, which would exclude persons who have been vaccinated with the Russian Sputnik V vaccine or one of the Chinese-developed COVID-19 vaccines. Similarly, the EU’s Digital Green Certificate proposal would also only include vaccines that have received EU-wide authorization. So far, the U.S. has not stated which vaccines it might accept for the purposes of a vaccine passport.

Scientific considerations: The WHO has stated there is a need for further scientific investigation into COVID-19 vaccine products to understand in more detail the extent vaccines reduce transmission, and the strength and duration of immunity provided. For example, Israel’s green passes are only valid for six months starting the week after vaccination, to take into consideration the potential for waning immunity over time. COVID-19 passports may need to consider each vaccine product’s unique immunity profile when issuing certification of vaccine-induced immunity over a certain period of time, a process which becomes even more complicated in the presence of variants with unknown effects on vaccine effectiveness.

Privacy and security: Among the concerns raised in the lack of uniform digital standards and COVID-19 vaccine passports is the issue of privacy and data security. Combining and storing individuals’ vaccination data in a centralized database could expose this information to data breaches and raises questions about oversight and control of that data. In fact, some vulnerabilities have already been detected in COVID-19 vaccine passports under development. Individuals and organizations are less likely to want to participate if these concerns about security and privacy are not adequately addressed.

Conclusion

There are a large number of as-yet uncoordinated efforts underway already to develop vaccine passports. It is not yet clear if or when the U.S. might adopt a vaccine passport standard for cross-border travel or for domestic purposes, and what form such a credential will take or what restrictions it might place on individuals. It is likely that attention to, and calls for, vaccine passports for both international and domestic use will increase over time, as more people are vaccinated and governments and employers seek to find ways to balance public health concerns while also easing a return to some level of normalcy. However, there a number of significant issues to consider related to the design, use, and ethics of vaccine passports, and many questions about how they can and should be implemented in the U.S. and elsewhere.

1. For incoming travel to the U.S., individuals are currently required to either provide proof of a negative COVID-19 test within three days of departure or proof of recovery within the last 90 days. As of April 13, vaccination status does not exempt incoming travelers from these requirements. ↩︎
2. The proposal would also allow Iceland, Liechtenstein, Norway, and Switzerland to opt-in to the program. ↩︎

Around the country and in parts of the world, COVID-19 vaccination efforts continue to grow, leaving people wondering about vaccine requirements and ways to certify vaccine status. “Vaccine passports,” a paper or digital form certifying that a person has been vaccinated, have garnered increased interest in recent months, especially as countries roll out plans to reopen international and domestic travel. A new issue brief takes a closer look at what vaccine passports are, how other countries are using them, and what implementation issues to consider.

Several countries have already begun using COVID-19 vaccine passports, with policies varying across countries. For example, several countries are beginning to require proof of vaccination for incoming travelers to avoid testing or quarantining; many other countries, including the U.S., are considering implementing similar travel requirements. In the U.S., airlines have already called for vaccine certifications as an option for domestic and international travel.

The Biden administration stated it will not be the role of the federal government to issue COVID-19 vaccine passports, however individual states are exploring vaccine passport options. New York is the first state to introduce vaccine certification to access certain social activities, with other states expressing interest in doing so. Alternatively, several governors have strongly discouraged vaccine passports, with states such as Florida and Texas issuing executive orders banning the use of vaccine passports.

There are a number of implementation issues to consider surrounding vaccine passports, from equity and access to lack of uniform digital standards. The brief covers key challenges and questions about vaccine passports within the U.S. and globally.

It is likely that calls for vaccine passports will grow over time as vaccine efforts increase. Still, it remains unclear if or when the U.S. might adopt standards for a vaccine passport system for both domestic and international travel, and how extensive the use of these certifications will be.

A new brief from the Peterson-Kaiser Health System Tracker looks at how the pandemic affected the excess mortality rate in 2020 and estimates how many potential years of life were lost. “Excess deaths” represent the number of deaths beyond what is expected in a typical year. “Premature” excess death measure accounts for age at excess death to estimate potential years of life lost up to age 75 over a typical year, using the OECD methodology. Overall, the U.S. had more than 500,000 excess deaths in 2020 compared to prior years, losing an estimated 3.6 million potential years of life.

Relative to similarly wealthy countries, the U.S. had the highest overall premature excess mortality rate in 2020 with 1,171 excess potential years of life lost per 100,000 people (compared to an average of 126 excess potential years of life lost per 100,000 people in comparable countries). Among excess deaths in 2020, the average person lost 14 years of life in the U.S. compared to an average of 8 years in peer countries before the age of 75.

The higher premature excess death rate in the U.S. compared to peer nations was driven in part due to racial disparities. People of color under age 75 were more likely to have died in the U.S. during the pandemic in 2020 than white non-elderly individuals, as shown in the chart below. Among people under the age of 75, American Indian and Alaska Native, Black, Native Hawaiian and Other Pacific Islander, and Hispanic people had over 3 times the premature excess death rate in the U.S. in 2020 than the rate among White and Asian people. Of the potential years of life lost in the U.S., 30% were among Black people and another 31% were among Hispanic people, disproportionate to their share of the U.S. population.

The higher premature excess mortality rate among people of color in the U.S., and in the U.S. as a whole compared to similar countries, is likely due in part to higher COVID-19 risk factor rates and broader racial inequities. For more data and discussion of the gaps in premature excess mortality within the U.S. and among peer countries, please visit the Peterson-Kaiser Health System Tracker.

Source

COVID-19 Pandemic-Related Excess Mortality and Potential Years of Life Lost in the U.S. and Peer Countries