Summary

Even as the COVID-19 vaccine roll-out is accelerating across the country, the public health and economic effects of the pandemic continue to put pressure on Medicaid spending and enrollment. In mid-February 2021, the Kaiser Family Foundation (KFF) and Health Management Associates (HMA) fielded a two-part rapid, mini-survey of Medicaid directors in all 50 states and the District of Columbia as a follow-up to the annual Medicaid Budget Survey conducted last summer. This brief provides insights into the current status of Medicaid enrollment and spending trends in FY 2021 and state projections for FY 2022. See separate brief for findings from Part II of this mini-survey, related to state Medicaid agency involvement with the COVID-19 vaccination roll-out. A total of 38 states responded to the Part I enrollment and spending survey, although not all of these states answered all of the survey questions. These states accounted for over three-quarters of total Medicaid enrollment.¹  For most states, the state fiscal year begins on July 1. Key findings include the following:

• Most states with updated Medicaid enrollment projections expect overall FY 2021 enrollment to exceed original projections (30 of 37 states). Most states reported that expansion adults and other adults had the highest rates of growth. Two-thirds of states with updated Medicaid expenditure projections for FY 2021 (24 of 37 states) also expect total FY 2021 Medicaid expenditures to exceed original projections.
• Looking ahead to FY 2022, just under half of responding states (12 of 29) are projecting a higher total Medicaid expenditure growth rate in FY 2022 compared to FY 2021, while just over half (14 of 29) are expecting the growth rate to be lower. While fewer states reported specific FY 2022 spending growth rate percentages, the median rate for 21 reporting states was 5.6% while the median projected enrollment growth rate for 17 reporting states was 5.5%. Most states with updated projections assumed that the public health emergency (PHE) would remain in effect through CY 2021, part-way through the state fiscal year.

Medicaid spending and enrollment trends will continue to depend on the trajectory of the pandemic and the economic downturn as well as the duration of the PHE. In particular, the expiration of the PHE and the enhanced FMAP will have implications for state spending during the 2022 fiscal year.

Background/Context

The coronavirus pandemic has generated both a public health crisis and an economic crisis, with major implications for Medicaid, a countercyclical program. During economic downturns, more people enroll in Medicaid, increasing program spending at the same time state tax revenues may be falling. To help support states as Medicaid enrollment grows and ensure continuous coverage for enrollees, the Families First Coronavirus Response Act (FFCRA) authorized a 6.2 percentage point increase in the federal match rate (“FMAP”) for states that meet certain “maintenance of eligibility” (MOE) requirements. The additional funds were retroactively available to states beginning January 1, 2020 and continue through the quarter in which the PHE period ends. While the current PHE declaration expires on April 21, 2021, the Biden Administration has notified states that the PHE will likely remain in place throughout CY 2021 and that states will receive 60 days-notice before the end of the PHE to allow states time to prepare for the end of emergency authorities and the resumption of pre-PHE rules.

After relatively flat Medicaid enrollment growth in FY 2020 (0.4%), states responding to KFF’s annual Medicaid Budget Survey conducted in June-August 2020, projected, on average, that Medicaid enrollment would increase 8.2% in FY 2021 (over FY 2020) and total spending would increase by 8.4%. Preliminary national data show that total Medicaid and CHIP enrollment grew to 77.3 million in September 2020, an increase of 6.1 million, or 8.6%, from February 2020. This growth likely reflects both changes in the economy, as more people experience income and job loss and become eligible and enroll in Medicaid coverage, and the FFCRA MOE provisions that require states to ensure continuous coverage for current Medicaid enrollees through the end of the month in which the PHE ends. This growth represents a reversal of recent Medicaid enrollment trends in 2016 through 2019, when the rate of total Medicaid and CHIP enrollment growth was declining or negative.

All states are experiencing fiscal stress tied to the pandemic, although individual state experiences vary. The impact of the pandemic on states depends on a variety of factors including the composition of state economies, tax structures, and virus transmission levels, among other factors. For example, states that are more dependent on tourism and the energy sector have seen larger economic and state revenue impacts. Overall, however, state revenues declined in FY 2020 and greater declines are expected in FY 2021. As a result, states’ enacted budgets for FY 2021 reflect the first general fund spending decrease in more than ten years as states make reductions to meet balanced budget requirements. While the state fiscal relief provided by FFCRA has undoubtedly helped states avoid more severe budget cuts, some states still face budget gaps that they must address. While states often turn to provider rate and benefit restrictions to constrain Medicaid spending during economic downturns, these cost containment approaches may not be as viable with providers facing revenue shortfalls and enrollees facing increased health risks due to the pandemic.

KEY FINDINGS

Enrollment

Most states with updated Medicaid enrollment projections expect overall FY 2021 enrollment to exceed original projections (30 of 37 states) with higher growth rates reported for expansion and other adults. We asked states to identify the eligibility group (children, parent/caretakers, expansion adults, persons with disabilities, or seniors) that has experienced the highest rate of enrollment growth in FY 2021 (Figure 1). A majority of responding states that had implemented the ACA Medicaid expansion as of February 2021 (22 of 28) indicated “expansion adults” have experienced the highest rate of enrollment growth in FY 2021 while four expansion states identified “parent/caretakers” and two expansion states identified “children.” Among the 10 responding non-expansion states, seven states indicated “parent/caretakers” have experienced the highest enrollment growth in FY 2021 while three states indicated “children.” No states reported seniors or persons with disabilities as groups experiencing the highest rate of enrollment growth. Nonelderly adults are more likely to be affected by changes in the economy and more likely to experience churn on and off the program that the FFCRA MOE has eliminated during the PHE.

The median growth rate for the 17 states reporting Medicaid enrollment growth projections for FY 2022 over FY 2021 is 5.5%. We asked states whether their projections accounted for the likelihood that the PHE and continuous coverage requirements would remain in place through CY 2021 as indicated in a January 2021 Biden administration letter to Governors. More than half of the responding states indicated that their projections reflect the PHE remaining in place throughout 2021, followed by a gradual enrollment decline beginning in CY 2022 after the expiration of continuous coverage requirements (during the second half the state fiscal year for most states). Several states indicated that their projections did not assume that the PHE and continuous coverage requirements would remain in place through the end of CY 2021 suggesting that the projections were developed prior to the release of the Biden Administration letter or that some states may not consider the letter to reflect enough certainty. Based on these assumptions, these states generally reported lower expected enrollment growth for FY 2022 than states that assumed the PHE would continue through CY 2021. To the extent that the PHE remains in place longer, actual enrollment could be higher than projected. In addition to uncertainty regarding the PHE end date, states cited other currently unknown factors that could significantly affect the accuracy of current FY 2022 enrollment projections such as future trends in unemployment and the Medicaid enrollment impacts of the ACA special enrollment period.

Expenditures

Almost two-thirds of states with updated Medicaid expenditure projections for FY 2021 (24 of 37) expect total FY 2021 Medicaid expenditures to exceed original projections (Figure 2). Nearly all of these states (23 of 24) indicated higher enrollment as the most significant driver of FY 2021 Medicaid expenditures so far. States attributed increases in enrollment to both the economic downturn and to the FFCRA MOE requirements. In contrast, about one third of states with updated FY 2021 projections expect total Medicaid expenditures to be lower than (7 of 37) or about the same as (6 of 37) earlier projections. Four states expecting lower FY 2021 total Medicaid expenditures attribute decreases to net decreases in utilization; three of these states deliver Medicaid services to enrollees through fee-for-service delivery systems where net decreases in utilization immediately result in lower Medicaid expenditures. While utilization may have been initially depressed in FY 2021 due to enrollees foregoing or providers limiting non-urgent care, some states commented that utilization was starting to rebound. Decreases in utilization in heavily capitated managed care states may not result in lower expenditures unless states adjust capitation rates.

Although many states’ updated FY 2021 total Medicaid expenditure projections exceed the projections originally made at the beginning of the state fiscal year, nine of 38 states reported mid-year cost containment policy actions. Three states indicated implementing mid-year provider rate cuts, and although not specifically asked about provider taxes, one state reported that they implemented a new provider tax in 2021. Eight states indicated making mid-year managed care plan rate adjustments. However, several states also commented that MCO contracts were amended to add risk mitigation strategies (e.g., risk corridors). One state reported implementing mid-year benefit restrictions, and one state reported several benefit expansions passed by the state legislature in 2020 were removed before implementation. The survey did not ask about the effects of the federal fiscal relief, but states had reported in an earlier survey that the fiscal relief helped to mitigate Medicaid cuts and address Medicaid shortfalls.

Of the 29 states with expenditure projections for next fiscal year, half anticipate that total Medicaid expenditure growth in FY 2022 will slow down compared to FY 2021 while just under half expect the rate to accelerate (Figure 2). Three states expect the rate of spending growth to be “about the same.” The median growth rate for the subset of states (21) reporting actual growth rates for FY 2022 is 5.6% (over FY 2021). While we only asked about total spending projections, state spending growth is likely to accelerate in FY 2022 when the PHE and enhanced FMAP expire, as states will need to replace the expiring federal funds with state funds.

About one-third of responding states (12 of 38) reported plans to introduce cost containment policy actions in FY 2022. Six states plan to introduce provider rate cuts in FY 2022, seven states plan to make MCO rate adjustments, and three states plan to introduce benefit restrictions. Other planned FY 2022 cost containment strategies/actions reported by states include expansion of value-based payment initiatives, new utilization management strategies, and the introduction of risk-based managed care. Similar to the mid-year cost containment strategies reported for FY 2021, several states reported plans to introduce (or continue) capitated managed care plan risk mitigation strategies (e.g., risk corridors) and at least one state plans to implement revenue generating provider fees. Fourteen states reported that no cost containment policy actions are planned for FY 2022, nine states reported that FY 2022 actions are undetermined, and three states responded, “don’t know.”

Looking Ahead

As states approach the end of FY 2021 and adopt budgets for FY 2022 (that begins in July for most states), they must account for the ongoing impacts of the pandemic and resulting economic downturn on Medicaid spending and enrollment trends. While substantial enrollment growth has already occurred across all states, more growth is possible as individuals continue to struggle with the economic downturn and due to the decision to open enrollment in the federal ACA Marketplaces from February 15 through May 15, combined with $50 million in federal spending on outreach and education about ACA coverage options. This outreach has the potential to reach millions of people who became uninsured prior to or during the pandemic and will likely result in more eligible low-income people enrolling in Medicaid. State spending and enrollment projections must also account for the expiration of the PHE. At that time, states will resume eligibility renewals and redeterminations, possibly leading to slower enrollment growth and decreased total spending growth. The end of the PHE, however, will also end the enhanced FMAP requiring states to increase state spending to replace the expiring federal funds. Finally, even if total Medicaid spending growth is lower in FY 2022 relative to 2021, median growth rates in excess of 5 percent may difficult to absorb, depending on how quickly the economy and state revenues recover.

1. The 13 states that did not respond were: Arkansas, the District of Columbia, Georgia, Hawaii, Idaho, Louisiana, New Hampshire, New Jersey, New Mexico, Ohio, Texas, Utah, and Vermont. ↩︎

As of February 2021, there are three COVID-19 vaccines approved for emergency use in the U.S. and states are playing a central role in their timely distribution and prioritizing eligible populations. Because Medicaid covers for over 77 million enrollees, including groups disproportionately at risk of contracting COVID-19 as well as hard-to-reach groups, Medicaid agencies can be important partners for the public health agencies that are typically leading the state COVID-19 vaccination efforts. In mid-February 2021, the Kaiser Family Foundation (KFF) and Health Management Associates (HMA) fielded a two-part rapid, mini-survey of Medicaid directors in all 50 states and the District of Columbia. Of the 32 states that responded to Part II of the survey, 29 reported that Medicaid agencies were involved in at least one vaccine roll-out activity (Figure 1). This brief provides insights regarding how state Medicaid agencies are assisting with the COVID-19 vaccine roll-out including specific actions taken. (See separate brief for findings from Part I of the mini-survey related to Medicaid enrollment and spending trends.)

Three-quarters of responding states (24 of 32) reported partnering with public health or other agencies to plan and implement the vaccine roll-out. Several states indicated close coordination with their state departments of public health that are taking the lead on vaccine distribution and roll-out. For example, one state commented that it amplifies the public health department’s messaging and communications, but also periodically relays back concerns from key Medicaid stakeholders (e.g., behavioral providers not included in the Phase 1a priority group for health care workers). Fewer states, however, reported being involved with determining state vaccination priority lists (11 of 32).

Over three-quarters of responding states indicated their state Medicaid agencies are providing technical assistance to providers (25 of 32). States reported communicating directly with Medicaid providers regarding the roll-out of COVID-19 vaccinations through, for example, provider bulletins and dedicated webpages that include information on COVID-19 vaccination coverage, reimbursement, and billing and a dedicated email address/inbox for provider questions. One state also reported that it has worked to ensure that there is an expedited process for vaccinators to enroll in Medicaid (if not already enrolled).

Over half of responding states reported conducting outreach to Medicaid enrollees to encourage COVID vaccination take-up (19 of 32). Several states discussed working with Medicaid managed care plans on vaccine roll-out activities including: messaging to address member vaccine hesitancy; clarifying the availability of MCO care coordination and transportation services that could reduce vaccine access barriers; coordinating COVID vaccine appointments; calling high-risk members, and making vaccination appointment reminder calls. Over half of responding states (17 of 32) are expanding services to assist with vaccine roll-out. For example, a few states specifically mentioned authorizing nonemergency medical transportation (NEMT) services for vaccine appointments. A number of states (12 of 32) also reported planning or authorizing new or expanded Medicaid administrative supports. One state, for example, commented that its existing nurse advice line will provide general information to callers regarding vaccine administration.   

The majority of responding states reported that the Medicaid agency is involved with specific activities to assist with vaccine roll-out to groups disproportionately covered by Medicaid. About two-thirds of responding states (22 of 32) reported that their state Medicaid agencies are involved with specific activities to assist with vaccine roll-out to HCBS recipients. About half of responding states also reported assisting with vaccine roll-out efforts for residents of non-nursing home institutions, communities of color, and people in rural areas (Figure 2). Several states commented on a number of specific activities underway including:

• Data sharing with the public health agency on seniors receiving HCBS who are not in a nursing facility or alternative living facility. The public health agency matched the data provided against its vaccine registry and is now conducting outreach to those not yet vaccinated.
• Developing quality measures focused on closing vaccination disparities between whites and communities of color.
• Proactively outreaching to NEMT drivers to get vaccinated and drive to vaccination events.
• Requesting federal approval to provide COVID-19 vaccines to populations who are in limited benefit programs (e.g., family planning program, COVID-19 uninsured group, and restricted scope programs where only emergency and pregnancy related services are offered).
• Partnering with Rite Aid to provide vaccinations to long-term care facilities not covered by the federal pharmacy partnership program.
• Encouraging MCOs to utilize community health workers to conduct outreach to individuals that are transient or difficult to reach, including individuals experiencing homelessness, people with disabilities, or individuals with substance use disorders.

More than three-quarters of states (26 of 32) indicated at least one way in which partnerships between public health and Medicaid had been or could be further developed to assist with vaccine roll-out efforts. The most common areas of opportunity reported were coordinating outreach, data sharing, and holding daily or weekly meetings between agencies. States described other activities that could assist in vaccine roll-out efforts including: creating opportunities to have staff work across agencies; coordinating to assist individuals without internet access and individuals whose first language is not English in scheduling vaccination appointments, and working to help ensure and promote equity regarding the vaccine roll-out.

Early data suggest significant racial disparities in COVID-19 vaccinations, with higher vaccination rates among White people compared to Hispanic and Black people as of early March, based on available state-reported data. The Biden administration has identified equity as a key priority in its national COVID-19 response strategy. One action the administration is pursuing to advance equity in vaccinations is to increase distribution through community health centers.

Community health centers are a national network of safety net primary care providers and are a primary source of care for many low-income populations and people of color. This analysis examines the extent to which early vaccination efforts through community health centers are reaching people of color using data from the federal government’s weekly Health Center COVID-19 Survey. We include data from the survey weeks of January 8 through February 26, 2021, largely before the start of the federal health center COVID-19 vaccination program.

Just over half (54%) of people who received their first dose of the COVID-19 vaccine from health centers were people of color, including 26% who were Hispanic and 12% who were Black. These shares are higher than the shares of nationwide vaccinations; show that 9% of people receiving one more dose of vaccine as of March 7, 2021 were Hispanic and 7% were Black. The shares of vaccinations received by people of color at community health centers increased in more recent weeks compared to vaccinations in January 2021.

The shares of people receiving the first dose of the COVID-19 vaccine at health centers who were Black, Hispanic, and Asian generally matched or exceeded their shares of the total population. However, their shares of vaccinations were similar or slightly lower than their shares of the overall health center patient population. Patterns of health center vaccinations by race/ethnicity compared to their population distributions varied widely by state.

While vaccinations at health centers represent a relatively small share of total vaccinations administered nationally to date, further ramping up health centers’ involvement in vaccination efforts at the federal, state, and local levels will likely be a meaningful step in reaching people of color and advancing equity on a larger scale.

Source

Community Health Centers’ Role in Delivering Care to the Nation’s Underserved Populations During the Coronavirus Pandemic

The latest report from the KFF COVID-19 Vaccine Monitor examines how the COVID-19 pandemic has impacted the lives of lesbian, gay, bisexual and transgender (LGBT) people and finds that larger shares of LGBT adults report economic losses and mental health struggles than their non-LGBT counterparts.

Based on data gathered on self-identified LGBT and non-LGBT individuals over two months, some of the key differences include:

• Economic impact. Most LGBT adults say that they or a household member lost a job or income due to the pandemic (56%), which compares to 44% of non-LGBT adults.
• Mental health. Three quarters (74%) of LGBT people say worry and stress from the pandemic has had a negative impact on their mental health, compared to half (49%) of non-LGBT people. LGBT people are also more than twice as likely to say this negative impact has been major (49% to 23%).
• Vaccine intentions. LGBT people are about as eager to get vaccinated as other Americans but more view it as a part of everyone’s responsibility to protect the public health (75%) rather than a personal choice (24%). Non-LGBT individuals are about as equally likely to say it is part of everyone’s responsibility (48%) and a personal choice (49%).

Differences in the experiences of LGBT and non-LGBT individuals likely reflect a number of factors. Other research has found that LGBT individuals are more likely to work in health care, restaurants and other industries highly impacted by the pandemic; have lower average incomes; and may experience discrimination and stigma, including in accessing health care.

The new report is available through the Monitor’s online dashboard.

This analysis is based on interviews conducted in December and January among a nationally representative random digit dial telephone sample of 3,239 adults, including 174 who identified as lesbian, gay, bisexual, or transgender. The margin of sampling error is plus or minus 9 percentage points for the full LGBT sample and 2 percentage points for the non-LGBT sample. For results based on subgroups, the margin of sampling error may be higher. Detailed methodology can be found in the toplines for the December and January KFF COVID-19 Vaccine Monitor.

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

Key Findings

There has been little data on how the coronavirus pandemic has impacted the lives of lesbian, gay, bisexual, and transgender individuals (LGBT) in the U.S. Drawing on previous research indicating that LGBT individuals are at greater risk of both COVID-19 health and economic outcomes, this analysis examines the reported experiences from self-identified LGBT individuals from two months of the KFF COVID-19 Vaccine Monitor and finds that LGBT people have experienced the COVID-19 pandemic differently than non-LGBT people, including being harder hit in some areas:

• Economic: A larger share of LGBT adults compared to non-LGBT adults report that they or someone in their household has experienced COVID-era job loss (56% v. 44%).
• Mental health: Three-fourths of LGBT people (74%) say worry and stress from the pandemic has had a negative impact on their mental health, compared to 49% of those who are not LGBT, and are more likely to say that negative impact has been major (49% v 23%).
• Views: One-third (34%) of LGBT adults say the news has generally underestimated the seriousness of the pandemic (compared to 23% of non-LGBT adults). Three-fourths of LGBT adults (74%) are either “very worried” or “somewhat worried” that they or someone in their family will get sick from the coronavirus, similar to responses from, non-LGBT adults (67%). A large share of LGBT adults report being willing to take CDC recommend steps to avoid acquisition/transmission of the virus.
• Vaccine: While LGBT people report wanting to get vaccinated at a similar pace as non-LGBT people, a greater share of LGBT adults see doing so as part of everyone’s responsibility to protect the health of others (75% v. 48%), while greater shares of non-LGBT people see vaccination as a personal choice (49% v 24%).

Why Examine COVID-19 Views and Experiences of LGBT Populations?

Limited early data available on how LGBT people have experienced the COVID-19 pandemic in the United States (U.S.) has suggested that this group may be disproportionately impacted. The reasons are far-reaching and may include: LGBT individuals being at greater risk of worse COVID-19 outcomes due to higher rates of comorbidities; working in highly affected industries such as health care and restaurants/food services; living on average on lower incomes than non-LGBT people; experiencing stigma and discrimination related to sexual orientation/gender identity, including in accessing health care; and, for transgender individuals, being less likely to have health coverage. As the pandemic continues to take a toll nationwide, our analysis from the KFF COVID-19 Vaccine Monitor explores self-identified LGBT people’s COVID-19 experiences and offers comparisons to the non-LGBT population. We find that LGBT adults have experienced the pandemic differently than non-LGBT people in some key domains including with respect to their risk of COVID-19, mental health, employment loss, vaccine attitudes, and willingness to engage in risk-reduction behavior such as social distancing.

The analysis is based on findings from the December and January KFF COVID-19 Vaccine Monitor and building on previous research conducted early on, offers a new look at experiences nearly a year into the pandemic.

COVID-19 Economic and Health Impacts

Echoing previous research conducted earlier on in the pandemic, we find that LGBT adults and their household members report facing COVID-era job loss at higher rates than non-LGBT adults. Since February 2020, 56% of LGBT people report that they or another adult in their household have lost a job, been placed on furlough, or had their income or hours reduced because of the coronavirus outbreak, compared to 44% of non-LGBT people. Separate research has found that LGBT people are more likely to work in industries hard hit by the pandemic, such as restaurants or food services, than their non-LGBT peers.

In addition to personal or familial experience with job loss, the COVID-19 pandemic has been hard hitting for LGBT people in terms of mental health. Prior to the pandemic, LGBT people experienced certain mental health conditions at higher rates than non-LGBT people. In this analysis, we find three-fourths of LGBT people (74%) say worry and stress from the pandemic has had a negative impact on their mental health, compared to 49% of non-LGBT people. In addition, LGBT people more than twice as likely to say this negative impact has been major (49% compared to 23%).

Views Of the COVID-19 Pandemic

LGBT people have a different perspective on some aspects of the pandemic compared to non-LGBT people, including regarding the media’s portrayal and their own level of concern. They also have different views on COVID-19 risk mitigation efforts.

One-third (34%) of LGBT adults say the news has generally underestimated the seriousness of the pandemic (compared to 23% of non-LGBT adults).  A much smaller share of LGBT people say the seriousness of coronavirus is exaggerated in the news compared to non-LGBT people (15% vs 34%). Previous KFF COVID-19 Vaccine Monitor analysis finds that these views are largely driven by partisanship, with larger shares Republicans saying the seriousness of the pandemic has been “generally exaggerated” compared to Democrats and independents.

Three-fourths of LGBT adults (74%) say they are either  “very worried” or “somewhat worried” that they or someone in their family will get sick from the coronavirus. While this share is not statistically different than those of non-LGBT adults (67%), it demonstrate the high level of concern among LGBT individuals which may be correlated to taking more precautions to protect themselves and family members.

In addition to worry surrounding the virus, large shares of LGBT people report being willing to take CDC recommend steps to avoid acquisition/transmission of COVID-19. Larger shares of LGBT people say they could follow social distancing guidelines for more than six months or until there is a vaccine widely available than non-LGBT people (85% v 69%). Conversely, larger shares of non-LGBT people say they could follow social distancing guidelines for only up to six months compared to LGBT people (28% v. 14%). Additionally and similarly to non-LGBT people, vast majorities of LGBT people also say they wear a mask every time or most of the time when they leave the house (97%) and accurately believe masks limit the spread of coronavirus (90%).

While LGBT people report wanting to get vaccinated at the same rate as non-LGBT people, LGBT people hold different views on whether getting vaccinated is public health imperative or individual choice. LGBT people report wanting to get the vaccine as soon as possible (40%) or take a wait and see approach (39%) at similar rates as non-LGBT people (36% and 36%, respectively). One in ten LGBT people (10%) say they definitely do not plan to get the vaccine, statistically similar to 15% of non-LGBT people.

However, a larger share of LGBT people believe getting vaccinated is part of everyone’s responsibility to protect the health of others (75% v. 48%) and a smaller share sees it as a personal choice (24% v. 49%) compared to non-LGBT people.

Implications

Compared to non-LGBT adults, larger shares of LGBT people report experiencing COVID-era job loss, say the pandemic has had a negative impact on their mental health, and report being worried about getting COVID-19. As such it may not be surprising that smaller shares believe the media has overstated the seriousness of the pandemic and with more saying it has been understated. The greater levels of concern and negative experiences with the pandemic in certain domains may also play a role in LGBT people’s willingness to take recommend steps to avoid acquisition/transmission of the virus. Finally, a larger share of LGBT people view COVID-19 vaccination as a collective responsibility than as an individual choice, potentially reflecting the community’s experience with HIV, another infectious disease that requires community level buy-in of public health strategies to curb. While sexual orientation and gender identity may drive some of the differences we find between LGBT and non-LGBT adults, it is also important to note the two populations differ markedly in other key areas. Compared to non-LGBT adults, larger shares of LGBT adults are younger, live on lower incomes, and identify as Democrats, factors that may also contribute to the difference observed. Targeted vaccine outreach to LGBT people could be helpful in reaching a group that has high rates of comorbidities that place them at elevated risk for COVID-19 but has traditionally faced barriers to accessing medical care.

Methods

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.

Designed and analyzed by researchers at KFF, this analysis is based on interviews conducted in December and January among a nationally representative random digit dial telephone sample of 174 adults who identified as lesbian, gay, bisexual, or transgender. The margin of sampling error is plus or minus 9 percentage points for the full LGBT sample and 2 percentage points for the non-LGBT sample. For results based on subgroups, the margin of sampling error may be higher. Detailed methodology can be found in the toplines for the December and January KFF COVID-19 Vaccine Monitor. Methods for the qualitative “in their own words” findings can be found at KFF COVID-19 Vaccine Monitor: In their Own Words.

KFF has updated its 2021 Health Insurance Marketplace Calculator to reflect the expanded premium tax credits available to people who purchase their own coverage through their state’s health insurance exchange as passed by Congress in the American Rescue Plan Act and expected to be signed into law soon.

The calculator allows users to enter their age, income, family size, and zip code to assess their eligibility for tax credits and how much they can expect to spend on premiums for coverage purchased through the Affordable Care Act’s marketplaces. It reflects the actual cost of health plans in the region and the changes to how the tax credits are calculated under the legislation’s provisions.

The American Rescue Plan Act increases the premium tax credits available both to people previously eligible and to those at higher incomes who had been ineligible before but face high premiums. The enhanced tax credits will expire after two years and are projected to increase federal deficits by $34.2 billion.

A previous KFF analysis found that the changes would result in premium savings for the vast majority of the nearly 14 million people already insured through the individual market, while millions of uninsured Americans would become eligible for new or bigger tax credits that could make marketplace coverage more affordable.

Those likely to see the biggest drop in what they pay in premiums include those who make just above 400% of the federal poverty rate ($51,040 for an individual), who were not previously eligible for tax credits and would have had to pay the full cost of coverage.

Some examples from the calculator:

• A 50-year-old in Franklin County, Nebraska making $51,500 annually is newly eligible for tax credits under the legislation that would lower what they would pay in premiums for a benchmark plan from $1,127 per month to $365 per month.
• A 50-year-old in Jefferson County, Oklahoma making $18,000 annually is now eligible for a benchmark plan with significant help to lower deductibles. Previously, they would have had to pay $54 per month for that plan, or enroll in a less generous plan with a large deductible for no premium.

HealthCare.gov, the federal health insurance marketplace serving 36 states, last month began a special enrollment period that runs through May 15. All state-based marketplaces also launched their own special enrollment periods, though the exact dates vary.

More than half of those who received their first dose of a COVID-19 vaccine through a community health center were people of color, suggesting that health centers appear to be doing a better job of reaching people of color than are overall vaccination efforts, finds a new KFF analysis.

People of color accounted for 54 percent of people who got their first dose of the vaccine through a health center, the analysis finds, including 26 percent who were Hispanic and 12 percent who were Black. The analysis is based on weekly surveys of health centers by the Health Resources and Services Administration starting the week of January 8 through February 26.

In contrast, Centers for Disease Control data show that, as of March 7, just 9 percent of people receiving one or more doses of a COVID-19 vaccine nationally were Hispanic and 7 percent were Black.

As part of an effort to increase vaccination rates among people of color, the Biden administration recently announced an initiative to provide health centers with direct access to vaccine supply. The more than 1,300 health centers in the U.S. are a national network of primary care providers serving nearly 30 million patients annually, many of them low-income and living in underserved communities.

The analysis finds that, among those receiving the 1st dose of the vaccine, health centers appear to be vaccinating people of color at similar or higher rates than their shares of the total population. However, their shares were similar or slightly lower than that of the health center patient population. It also finds that patterns of health center vaccinations by race/ethnicity and population distributions varied widely by state. People of color appear to be receiving a larger share of vaccinations at health centers in recent weeks compared to vaccinations at health centers in January.

Also newly available from KFF is the brief, How are States Addressing Racial Equity in COVID-19 Vaccine Efforts?. For more data and analyses on COVID-19 and vaccination efforts, including KFF’s Vaccine Monitor project, visit kff.org.

Introduction

As COVID-19 vaccine distribution continues and expands to larger segments of the population, early KFF analysis of state-reported data raise concerns about disparities in vaccinations for Black and Hispanic people. Ensuring equitable access to the vaccines will be important to mitigate the disproportionate impacts of the pandemic for underserved populations, prevent widening disparities going forward, and achieve broad population immunity. The Biden administration’s national COVID-19 response strategy outlines equity as a key priority, including as part of vaccine distribution efforts. Some states have also emphasized equity as a priority in their vaccine distribution plans and, in some cases, have taken responsive action to address disparities in vaccinations revealed by early data.

This brief reviews information available through state websites and publicly available vaccine distribution plans as of February 2021 to provide greater insight into how states are addressing equity through vaccine allocation and distribution strategies, outreach and communications efforts, and data collection and reporting. The review seeks to provide a snapshot and examples of state efforts in these areas. However, this review does not provide a fully exhaustive summary of all state actions, and given the rapidly evolving nature of state vaccination efforts, it may not reflect the latest developments in state approaches. Beyond the state-level strategies highlighted in this review, efforts to advance equitable access to the vaccines are also underway at the city and county level, among health systems and providers, and in the private sector. Moreover, the federal government is implementing a range of approaches to expand vaccine access and uptake — including direct distribution through community health centers — with a particular focus on reaching underserved areas and communities hardest hit by the pandemic.

Vaccine Allocation and Distribution

Where and how people can sign-up for and access vaccines has direct implications for who will receive them. People living in underserved and disproportionately affected areas may face increased challenges accessing vaccines due to more limited resources available to navigate online sign-up systems, lack of transportation, and other access challenges. States are employing a range of strategies to increase the availability and accessibility of vaccines for disproportionately affected areas and people.

Some states are allocating additional vaccine doses to enhance vaccine supplies in underserved and disproportionately affected areas. About half the states indicated in their vaccine distribution plans that they planned to use the Center for Disease Control and Prevention’s (CDC’s) Social Vulnerability Index (SVI) or similar indices to inform their vaccine allocation strategies. States varied in the level of detail they provided in their plans on how they would use these resources to inform their allocation approach, although some states have provided more specific implementation details. For example, in December, Governor Baker of Massachusetts pledged to allocate 20% additional vaccines to communities with high social vulnerability to help address the pandemic’s disproportionate impact on people of color. New Hampshire has indicated that it will reserve 10% of its vaccine supply for allocation to communities that have been hard hit by the pandemic. Connecticut reports providing an additional roughly 10% of the state’s allocation to areas that have high vulnerability based on the SVI. North Carolina also reports allocating additional doses to counties with larger older populations and historically marginalized populations. They indicate that vaccines will be invested into projects and events that promote increased access and partnerships in the community, with a particular focus on achieving equitable access to the vaccine. California will begin reserving 40% of vaccines for residents in the most disadvantaged areas of the state.

Some states are prioritizing vaccine appointments or eligibility for certain groups or areas. In response to early data showing gaps in vaccinations in certain wards of the city, Washington DC changed its vaccine appointment system to prioritize people living in these low-income, underserved areas. Residents in these wards are given the opportunity to register for vaccine appointments 24 hours before they become available to people living in other areas of the city. California provided codes that would provide access to vaccine appointments to community organizations that were intended to be distributed to people living in largely Black and Hispanic communities, although media reports pointed to problems with the initial rollout of this approach. Rhode Island has taken a different approach of prioritizing eligibility for broader groups of residents in certain geographic areas that have an increased risk for COVID-19 hospitalizations and deaths, including Central Falls and certain other areas of the state. Montana and Utah include people of color in their initial vaccine priority groups. With Montana vaccinating American Indians and people of color who may be at elevated risk for COVID-19 complications in Phase 1b, and Utah including people living in Tribal reservation communities and racial/ethnic groups at increased risk in Phase 1c.

Nineteen states have established call centers or provided text options to facilitate access to vaccine appointments for people who may not be able to navigate online sign-up systems. For example, Mississippi and Alabama have set up vaccine appointment scheduling hotlines for residents who cannot or do not want to use the web-based booking programs. In Maryland, the Departments of Health and Aging collaborated to create a telephone-based support line and appointment system designed to assist those without internet access. Connecticut is working with the United Way to provide a call center to schedule appointments that is available 12 hours a day and 7 days a week. However, many states have also encountered initial challenges with this approach, due to overwhelming demand. For example, New Jersey opened up a phone line to schedule vaccine appointments, but it was quickly stretched beyond its initial capacity. Some states are using text-based approaches to provide notifications of when appointments become available. Oklahoma is piloting a text-based notification system that sends second dose appointment updates to individuals who have registered for the vaccine through their scheduling portal.

Some states are deliberately locating vaccine clinics in underserved or disproportionately affected areas. For example, Tennessee is partnering with pharmacies and community health centers to add more than 100 vaccination sites, with a particular focus on rural and underserved areas. Colorado has outlined several strategies to increase the accessibility of vaccines, including partnering with counties to host community clinics, establishing community partnerships to reach communities of color, and coordinating with transportation providers to assist people without vehicles in getting to appointments. The state has also established a goal of having vaccines available through a community-based clinic in “50% of the top 50 census tracts with a high-density of low-income and minority communities.” Alaska is using an Area Deprivation Index to identify areas to provide targeted efforts to ensure equitable access to the vaccine through partnerships with Federally Qualified Health Centers and other community and locally-led organizations. While placing vaccine clinics in underserved or disproportionately affected areas can make vaccines more accessible to people living in areas, location alone will not necessarily ensure access if people face barriers completing sign up processes, and appointments are taken by people living in other areas. As such, prioritizing or reserving appointments for people living in those areas is also important.

Outreach and Communications Strategies

In addition to ensuring individuals can access the vaccine, making sure people receive clear information that explains how and when they can obtain the vaccine and addresses any concerns or questions they have about the vaccine also is important. Moreover, it is key for this information to be provided in culturally and linguistically appropriate ways through trusted messengers.

Some states are collaborating with and supporting community-based organizations and health centers to conduct outreach, communication, and education. For example, Massachusetts launched a targeted outreach initiative through which the Department of Health will invest resources directly into the 20 cities and towns most impacted by COVID-19 to increase awareness of vaccine safety and efficacy by working with local leaders and community- and faith-based groups. The state has also invested $1 million in the Massachusetts league of community health centers to provide grants to health centers to assist in engaging patients and community members in vaccination discussions and increase vaccination rates in the states’ hardest hit communities. The state of Washington has Community Outreach Services Contracts with several community-rooted organizations and groups to assist with COVID-19 vaccine outreach and makes investments in community/ethnic media outlets and community based organizations for community-driven messaging efforts. Colorado announced it is working to schedule more than 175 vaccine equity clinics across the state in partnership with community based organizations, local public health agencies, and Tribes, with community organizations playing a key role in providing outreach to their community members and registering people for appointments.

Many states are launching their own vaccination communications campaigns, often with a focus on reaching people of color and other groups who may face heightened barriers to vaccination. As part of its GoVAX outreach campaign, Maryland launched a mobile public health education unit—or sound truck—to provide information about COVID-19 prevention and vaccination availability in Spanish and English in selected neighborhoods that have been hardest hit by the virus. Volunteers will also distribute informational flyers and face masks at designated stops. In Ohio, health officials are hosting virtual town halls that will be replayed weekly on television to tackle COVID-19 vaccine myths. The town halls are focused on addressing questions and concerns of Black, Hispanic, Asian, Pacific Islander, and rural residents. In addition to these outreach efforts, all states provide information through public-facing websites to address questions and concerns about the vaccine. For example, many prominently feature frequently asked questions (FAQ) sections that address common questions.

Most state websites include information clarifying that the vaccine is available for free, although the information is not always highlighted prominently. Some states highlight this information up front. For example, North Carolina clarifies that the vaccine is available for free to all who want it on its landing page for vaccine information (Figure 1). Similarly, Minnesota includes this information in the FAQs listed on its “vaccine basics” page. Clarifying that people can receive the vaccine at no cost regardless of insurance status is important for facilitating equity, as recent survey data show that Black and Hispanic adults have heightened concerns about potentially having to pay out-of-pocket costs. Possibly, even more important is whether vaccine providers clarify that the vaccine is available at no cost and ensure people are able to sign up for appointments without providing insurance information.

Fewer state websites clarify that individuals are eligible for that vaccination regardless of immigration status and/or that obtaining the vaccine will not negatively affect immigration status. Clarifying this information can help address fears and confusion that could present barriers to vaccination among immigrants. For example, Rhode Island clarifies that undocumented immigrants are eligible for vaccination and that information will not be shared with immigration authorities (Figure 2). In Massachusetts, they emphasize that the vaccine is free for all Massachusetts residents, and that health care providers may request reimbursement from the federal government to cover the administrative costs of providing vaccines to undocumented immigrants.

All websites provide options to access information in different languages, but they vary in how they provide this access. Some states solely utilize google translate or similar translation software; others provide translated materials through downloadable resources, in some cases linking to translated materials provided by CDC. However, recent reporting finds that many vaccine registration and information websites at the federal, state, and local levels violate disability rights laws, hindering the ability of blind people to sign up.

Data Collection and Reporting

Collecting and analyzing COVID-19 vaccination data by race/ ethnicity is integral to gaining insight into who is and is not receiving vaccines and can be used to direct resources and efforts to address disparities as they are identified.

As of March 1, 2021, 41 states are publicly reporting COVID-19 vaccination data by race and/or ethnicity. While most states are reporting data, the quality, completeness, and timeliness of the data vary widely across states, which affects its usefulness. For example, as of March 1, 2021, in Minnesota and Washington D.C., race/ethnicity information was missing for over 40% of vaccinations, while North Carolina reported less than 1% as missing race/ethnicity information. States also vary in the extent to which they disaggregate data to allow an understanding of the experiences of specific groups. For example, Florida groups people who report their race as Asian, Native Hawaiian or Pacific Islander, or other into a single “Other race category.” In contrast, other states, like Maine, disaggregate data separately for racial and ethnic groups. Very few states report vaccination data by race/ethnicity and other demographic factors like age or gender. However, South Carolina and Washington provide data in these more detailed ways, allowing for a more nuanced understanding of who is being vaccinated that can inform efforts to address gaps.

Several states have taken actions designed to increase the completeness of race/ethnicity data. For example, North Carolina and Texas are requiring vaccine providers to collect race/ ethnicity data. Texas is updating its immunization registry system so that race and ethnicity must be entered to complete the data entry process. Michigan added a hand-entry field into their registry system to collect race and ethnicity data since the system had not previously collected this information. In addition, Virginia added language to its website to encourage individuals to report demographic data and clarifying how the data will be used (Figure 3).

Conclusion

In sum, early data pointing to racial disparities in COVID-19 vaccinations underscore the importance of intentional efforts focused on ensuring equity as the vaccine rollout continues. As highlighted in this brief, a number of states included a focus on equity in their vaccine distribution plans and are taking responsive action to try to address emerging disparities through vaccine allocation and distribution approaches, outreach and communications strategies, and data collection and reporting. Continued monitoring of data to understand who is and is not receiving the vaccine will be important for gauging the effectiveness of these approaches; and will help guide ongoing efforts to prevent and reduce disparities as distribution continues.

As noted, beyond the state-level strategies highlighted in this review, efforts to advance equitable access to the vaccines are also underway at the local level, among health systems and providers, and in the private sector. Moreover, at the federal level, the Biden administration has outlined equity as a key goal of its national COVID-19 response strategy, including as a part of vaccine distribution efforts. To that end, it has established a COVID-19 Health Equity task force; indicated plans to work with states to incorporate equity into their vaccine distribution processes; is taking steps to expand vaccine availability in underserved areas through federally-supported vaccination centers and allocations of vaccine doses directly to community health centers and retail pharmacies; is launching and vaccination communication plan; and is focused on expanding data collection and reporting. The American Rescue Plan Act includes additional funding that will further enhance these approaches.