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

Introduction

The COVID-19 pandemic has had a disproportionate impact on people of color, and previous KFF analysis of federal, state and local data has found that people of color, particularly Black people, are experiencing a disproportionate burden of COVID-19 cases and deaths. This burden is reflected in survey data, as large shares of Black adults (72%) say they are worried that they or someone in their family will get sick from the coronavirus. As the vaccination efforts roll out, a recent KFF analysis shows that across states reporting vaccination data by race and ethnicity, patterns emerge with Black and Hispanic people receiving smaller shares of vaccinations compared to their share of COVID-19 cases and share among the total population. These disparities likely reflect a variety of factors, including availability of information about how and when to get the vaccines as well as the ability to navigate sign-up processes and access vaccine clinics. Individuals’ willingness to get the vaccine and their concerns and questions about the vaccine may also be a factor. As such, understanding attitudes towards COVID-19 vaccination within these communities is one step towards addressing these disparities. Despite Black adults being among the groups most impacted by the pandemic, the KFF COVID-19 Vaccine Monitor finds that many want to wait and see how the vaccine will work for others before getting vaccinated against COVID-19 themselves when it becomes available to them for free, and one in seven say they will definitely not get vaccinated.

This new analysis examines Black adults’ responses by gender and finds that, while Black men and women are similar in many of their views, there is a gender gap in some COVID-19 vaccine attitudes and intentions.

Vaccine Hesitancy And Enthusiasm Among Black Women And Men

About one-third of Black women and four in ten Black men say they have already gotten at least one dose of the COVID-19 vaccine or want to get vaccinated “as soon as they can,” while about four in ten Black women and men (41% and 45%, respectively) say they want to “wait and see” how the vaccine is working for others before getting vaccinated themselves. However, a much larger share of Black women (19%) compared to 7% of Black men say they “definitely will not” get the COVID-19 vaccine when it is available to them for free, suggesting greater reluctance to obtain the COVID-19 vaccination among Black women.

Attitudes And Experiences Related To COVID-19 Vaccine Enthusiasm Among Black Women and Men

Several factors may influence people’s intentions and enthusiasm for getting a COVID-19 vaccine, including their level of worry about getting sick, historic experiences with health care institutions, and their views on the current vaccine distribution effort.

Reflecting historical mistreatment of people of color and ongoing racism and discrimination in the health care system, about half of Black women and men (53% and 45%, respectively), say that they trust the health care system to do what is right for them and their community “only some” or “almost none” of the time. This is consistent with a KFF/The Undefeated Survey conducted in summer 2020 that found that Black adults were less likely to trust doctors and hospitals, and that one in five Black adults, rising to one quarter of Black women and almost four in ten Black mothers, said they had personally experienced race-based discrimination while receiving health care in the past year.

When asked how they feel about the current status of COVID-19 vaccination in the U.S., a majority of Black women and men say they feel “optimistic” (65% and 66%, respectively), though six in ten Black women also report feeling “frustrated” (60%) compared to about half of Black men (48%). Further, about six in ten Black women (57%) and almost half of Black men (47%) say they are not confident that the distribution of COVID-19 vaccines in the U.S. is taking the needs of Black people into account.

Concerns About Getting A COVID-19 Vaccine Among Black Women And Men

The Monitor also reveals a gender difference among Black adults in the level of concern about certain aspects of the COVID-19 vaccine. Asked about a variety of things they might be concerned about, nine in ten Black women say they are concerned that “the long-term effects of the COVID-19 vaccines are unknown”, including six in ten who are “very” concerned. Large majorities of Black women not yet vaccinated are also concerned that they might experience serious side effects from the vaccine (87%), that the vaccines are not as safe (80%) or not as effective (75%) as they are said to be, or that they might get COVID-19 from the vaccine (68%). While large shares of Black men share these concerns, Black women are significantly more likely than Black men to say they are concerned they might experience serious side effects (87% vs. 61%) or that they might get COVID-19 from the vaccine (68% vs. 38%), indicating that there may be a greater need for messaging and information to address these concerns among Black women in particular.

Information Gaps

The concerns that Black women and men have may be alleviated by more information and discussions, as majorities say that they do not have enough information about many of the aspects of the COVID-19. While some of these gaps in information mirror their concerns regarding side effects and effectiveness, there is also a need for more information about the logistics (when and where) to get the vaccine.

Majorities of Black women and men who have not been vaccinated say they do not have enough information about the potential side effects of the COVID-19 vaccine (69% and 65%), where they will be able to get a COVID-19 vaccine (65% and 58%), the effectiveness of the vaccine (63% and 59%), when people like them will be able to get vaccinated (62% and 70%) and how their state is deciding priority groups (57% and 50%).

Messages: Convincing And Deterrents

When it comes to specific messages that may make people more likely to get vaccinated, Black women and men react similarly as the public overall to many messages such as the ability to return to normal life (58% Black women, 63% Black men), protection from illness (56% vs. 68%) and the vaccine’s effectiveness (55% vs. 62%).

Despite the positive reported reaction to pro-vaccination messages and information, a number of negative vaccine messages and information may make Black women and men less likely to receive the vaccine. Reflecting their heightened level of concern about vaccine side effects, about half of Black women and men who have not yet been vaccinated say that hearing that “a small number of people have experienced a serious allergic reaction” or that “some people were experiencing short-time side effects like pain or fever” from the vaccine would make them less likely to get vaccinated. Three in ten Black women also say that they would be deterred after hearing that masks and social distancing will still be required after getting vaccinated (28%), or that two vaccine doses several weeks apart are required (30%).

Messengers

As previously reported, 84% of Black adults who have not yet been vaccinated say they would be likely to turn to a doctor, nurse, or other health care provider for information when deciding whether to get a vaccination. At least six in ten say they would be likely to turn to other sources such as the U.S. Centers for Disease Control and Prevention (CDC) (71%), their state or local health department (71%), a pharmacist (65%), or family or friends (61%). One-third of Black adults say they would turn to a religious leader for information (33%). Similar shares of Black women and men say they would be likely to turn to each of these sources of information regarding the COVID-19 vaccine.

This KFF COVID-19 Vaccine Monitor was designed and analyzed by public opinion researchers at the Kaiser Family Foundation (KFF). The survey was conducted January 11-18, 2021, among a nationally representative random digit dial telephone sample of 1,563 adults ages 18 and older (including interviews from 306 Hispanic adults and 310 non-Hispanic Black adults), living in the United States, including Alaska and Hawaii (note: persons without a telephone could not be included in the random selection process). Phone numbers used for this study were randomly generated from cell phone and landline sampling frames, with an overlapping frame design, and disproportionate stratification aimed at reaching Hispanic and non-Hispanic Black respondents. Stratification was based on incidence of the race/ethnicity subgroups within each frame. Specifically, the cell phone frame was stratified as: (1) High Hispanic: Cell phone numbers associated with rate centers from counties where at least 35% of the population is Hispanic; (2) High Black: Cell phone numbers associated with remaining rate centers from counties where at least 35% of the population is non-Hispanic Black; (3) Else: numbers from all remaining rate centers. The landline frame was stratified as: (1) High Black: landline exchanges associated with Census block groups where at least 35% of the population is Black; (2) Else: all remaining landline exchanges. The sample also included 246 respondents reached by calling back respondents that had previously completed an interview on the KFF Health Tracking Poll at least nine months ago. Another 197 interviews were completed with respondents who had previously completed an interview on the SSRS Omnibus poll (and other RDD polls) and identified as Hispanic (n = 75; including 24 in Spanish) or non-Hispanic Black (n=122). Computer-assisted telephone interviews conducted by landline (287) and cell phone (1,276, including 931 who had no landline telephone) were carried out in English and Spanish by SSRS of Glen Mills, PA. To efficiently obtain a sample of lower-income and non-White respondents, the sample also included an oversample of prepaid (pay-as-you-go) telephone numbers (25% of the cell phone sample consisted of prepaid numbers) Both the random digit dial landline and cell phone samples were provided by Marketing Systems Group (MSG). For the landline sample, respondents were selected by asking for the youngest adult male or female currently at home based on a random rotation. If no one of that gender was available, interviewers asked to speak with the youngest adult of the opposite gender. For the cell phone sample, interviews were conducted with the adult who answered the phone. KFF paid for all costs associated with the survey.

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

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

Key Points

• One of the most daunting and urgent challenges facing the world as it seeks to address the COVID-19 pandemic is ensuring broad access to vaccines, without which it will be impossible to achieve needed levels of global population immunity.
• To date, the majority of vaccine doses (56%) have been purchased by high-income countries, who only represent 16% of the global population, locking in much of the market. In addition, while many high-income countries have started to vaccinate their populations, as of February 8, fewer than 100 doses have been administered in low income countries.
• COVAX, an international partnership led by the Coalition for Epidemic Preparedness Innovations (CEPI), Gavi, the Vaccine Alliance, and the World Health Organization (WHO), was created to respond to this challenge. Its goal is to distribute 2 billion doses of a safe and effective COVID-19 vaccine to the most vulnerable by the end of 2021.
• While virtually all countries are participating in COVAX, until recently, the U.S. was one of only a handful to sit out formal participation, when the Trump administration decided not to join, although Congress did provide $4 billion in emergency COVID-19 relief to Gavi in support of COVID-19 vaccine access, which Gavi says it will use to support the AMC. On January 21, 2021, soon after taking office, President Biden announced that the U.S. would join COVAX and play a more active role globally on COVID-19.
• Although COVAX has purchased 1.1 billion doses to date, with most of these doses to be distributed to lower-income countries, it ended 2020 with a funding gap of $755 million and faces a gap of $6.4 billion in 2021. There are also numerous other challenges including competing with bilateral and regional agreements to secure vaccine doses and navigating diverse regulatory landscapes.
• There are also key questions about the nature of U.S. participation including how much funding the U.S. will provide for COVAX going forward, either as a self-financing country to access vaccines in the COVAX portfolio and/or as a donor to the COVAX advance market commitment intended help supply vaccines for low- and middle-income countries, and if the U.S. will donate surplus doses to COVAX in the future.

Introduction

One of the most daunting and urgent challenges facing the world as it seeks to address COVID-19 is ensuring broad access to vaccines, including in low- and middle- income countries (LMICs). Not only has this been seen as a moral imperative, it is critical for achieving the levels of global population immunity needed to curb the ongoing pandemic. In addition, a recent analysis found that high income countries will bear significant, additional economic costs if broad, global vaccine access is not achieved. Yet most vaccine doses have already been purchased by high-income countries; whereas they represent just 16% of the global population, high income countries have purchased 56% of vaccine doses. In addition, while many high-income countries have started to vaccinate their populations, as of February 8, fewer than 100 doses had been administered in low income countries. Furthermore, due to development and manufacturing constraints, it is estimated that there will not be enough vaccine doses to cover the world’s population until at least 2023, or, by other estimates, 2024. COVAX, an international partnership led by CEPI, Gavi, and the WHO, is a global partnership created to respond to this challenge. Virtually all countries are participating in COVAX

While the United States has historically played a major role in responding to global health emergencies, the Trump administration decided not to join COVAX, making the U.S. one of only a handful of countries not to do so. Soon after taking office, on January 21, 2021, President Biden announced that the United States would join COVAX and play an active role globally on COVID-19.

This brief provides an overview of COVAX and identifies key questions and issues to consider for U.S. engagement.

History & Mission

In April 2020, at an event convened by the World Health Organization (WHO), France, the European Commission, and the Bill & Melinda Gates Foundation, the Access to COVID-19 Tools (ACT) Accelerator was launched to help the global community combat the COVID-19 pandemic. The ACT Accelerator brings together governments, scientific and regulatory experts, philanthropies, and global health organizations to focus on four main pillars: 1) diagnostics, 2) treatment, 3) vaccines, and 4) health systems strengthening. Each of the pillars is led and coordinated by different multilateral institutions. COVAX is the vaccine pillar of the Act Accelerator. COVAX’s goal is to distribute 2 billion doses of a safe and effective COVID-19 vaccine to the most vulnerable by the end of 2021.

Organizational Structure

Governance

COVAX’s three lead organizations—CEPI, Gavi, and the WHO—coordinate its various operations. Vaccine development and manufacturing functions are led by CEPI, procurement and delivery functions by Gavi, and allocation policy by the WHO.

• CEPI – CEPI manages the COVAX R&D vaccine portfolio including the selection of potential candidates as well as providing direct financial support for vaccine development. The portfolio includes multiple vaccine candidates in order to mitigate the risks of one or more candidates failing to be proven effective and safe. CEPI also secures agreements with manufacturers to accelerate scale-up and production. As of January 2021, CEPI had reserved manufacturing capacity with 13 manufacturers.
• Gavi – Gavi leads the COVAX Facility, which is the procurement mechanism of COVAX. Gavi works with manufacturers, participating countries, and private donors to secure vaccine dose orders. In addition, Gavi assists low- and middle-income countries with delivery preparedness through technical assistance and financing cold chain equipment.¹ 
• WHO – The WHO leads the development of an allocation policy framework to establish guidelines for equitable and effective distribution. The WHO also provides all countries with guidance on delivery preparedness, and, similar to Gavi, assists low- and middle-income countries with delivery preparedness through technical assistance and financing cold chain equipment.

Country Participation

While participation in COVAX is entirely voluntary, almost all countries are participating in some way, including 190 governments and economies as of January 2021. Countries may join as either “self-financing” countries (high-income countries) or “funded countries” (low- and middle-income countries) (See Table 1).

• Self-Financing (High Income) Countries: Self-financing countries are responsible for paying for their participation in COVAX, including providing upfront payments and procurement costs, to have access to the COVAX portfolio. To date, 90 countries and 8 economies have committed to join COVAX as self-financing, and an additional 6 countries have signaled intent to participate.
• Funded (Low- and Middle-Income) Countries: Low- and middle- income countries are eligible to participate in the Gavi COVAX Advance Market Commitment (AMC), a financial mechanism to enable them to access vaccines that they would otherwise be unable to afford. 92 countries are eligible to participate in the Gavi COVAX AMC as funded countries. Funding for the AMC is through provided by separate contributions from public and private donors.

With 190 governments involved, more than 90% of the global population is affiliated with COVAX.

Activities

Vaccine Research & Development and Manufacturing

COVAX supports the research and development as well as manufacturing of vaccines through the establishment of a vaccine portfolio managed and led by CEPI. CEPI, after expert review, determines whether or not to include a vaccine candidate in its portfolio and oversees the financing of vaccine candidate development. In addition, CEPI identifies potential manufacturing partners and provides technical and financial support in preparation for the eventual production of an approved vaccine (see Financing section). There are currently 11 vaccine candidates, with 9 in clinical trial phases, in CEPI’s portfolio. COVAX has the right of first refusal of approved vaccines from candidates included in the CEPI portfolio (currently up to 1 billion doses). However, COVAX is not limited to procuring vaccines from the CEPI R&D portfolio and can also secure doses from candidates that have not received CEPI funding.

Vaccine Procurement and Delivery

As mentioned above, the COVAX Facility, led by Gavi, is a centralized purchasing mechanism. It is responsible for negotiating pricing with manufacturers through pooled purchasing that is made possible because of advance purchase agreements with participating countries. Any country may participate in the COVAX Facility, with terms of participation differing based on income level (see Country Participation section).

To date, COVAX has purchased 1.1 billion doses through signed agreements, with an additional 900 million optioned. COVAX also anticipates securing additional doses through the CEPI portfolio. The COVAX procurement portfolio includes a mix of vaccine candidates not included in the CEPI portfolio (3 developers), candidates included in the CEPI portfolio (2 developers), as well as right of first refusal to CEPI-funded candidates that have not yet received regulatory approval.⁵  However, the majority of the doses secured by COVAX are from manufacturers that have yet to receive regulatory approval for their vaccines, including those from Janssen, Sanofi/GSK, and Novavax.

COVAX also plans to create a COVAX Exchange. The COVAX Exchange will act as a marketplace for countries, including high income countries, to trade allocations of vaccine doses they may not want or need. Countries may also donate unwanted doses to funded, or AMC-eligible, countries. For example, Norway announced plans to donate its extra vaccine doses through the COVAX Facility, and other countries are considering doing the same including the U.S., which has announced that it will develop a framework for donating its surplus vaccine, including through COVAX.

In addition to vaccine procurement, COVAX is coordinating efforts to help prepare low- and middle- income countries for vaccine delivery, including procuring equipment necessary for the delivery of a COVID-19 vaccine such as syringes and cold chain storage,⁹  as well as providing guidance and assessment tools to support all countries in their vaccine delivery efforts.

Related to vaccine delivery, COVAX plans to create a no-fault compensation fund to protect LMICs from liability issues resulting from vaccine-related adverse events. LMICs wishing to participate will be required to indemnify manufacturers against liability claims in order to utilize this fund to compensate affected individuals. The fund will be funded by a levy of $0.10 per dose. COVAX is also currently working to identify a third-party to cover the costs of damage claims on behalf of funded countries in cases where the claimant pursues damages under local law.

Vaccine Allocation

COVAX plans to follow an allocation framework proposed by the WHO in order to ensure equitable distribution among all participating countries. The framework recommends that all countries, regardless of income, receive an initial supply sufficient to cover 3%¹⁰  of their populations, targeting health care and frontline workers, and then receive enough additional doses to vaccinate a total of 20%¹¹  of their populations to cover higher-risk individuals (Phase 1). After this, countries may receive doses to vaccinate an additional 30-50% of their populations, depending on their agreements with COVAX (Phase 2). COVAX may give prioritization to certain countries based on factors such as threat (a country’s risk of severe impact from COVID-19) and vulnerability (a country’s ability to address threat based on its health system capacity).¹²  COVAX will also maintain a buffer supply of approximately 5% of available doses to respond to acute outbreaks or humanitarian needs.

COVAX plans to begin distributing vaccine doses to all AMC countries for the vaccination of health and social workers in February 2021. In the second half of 2021, additional doses will be delivered to cover the remaining portion of the Phase 1 population, for a total of 1.8 billion doses in 2021. Phase 2 delivery is not expected until 2022. For higher-income countries, COVAX expects to deliver 485 million vaccine dose orders beginning in the second half of 2021. COVAX recently released its early 2021 distribution plan, stating its intent to deliver 336 million doses of the AstraZeneca vaccine and 1.2 million doses of the Pfizer vaccine in the first half of 2021.

Financing

To date, COVAX has received approximately $6.35 billion in funding to support its efforts. This funding is comprised by a mix of direct contributions from donor governments, multilateral organizations, and private organizations ($3.95 billion) as well as prepayments from self-financing countries ($2.4 billion¹⁴ ) (See Vaccine Procurement and Delivery section above). Despite the significant resources that have already been made available, it is estimated that an additional $6.4 billion will be needed for 2021¹⁵  to support research and development, manufacturing, procurement, and delivery of a COVID-19 vaccine (see Table 4). Funding amounts and sources by area (R&D and manufacturing, procurement and delivery, and allocation) are detailed below.

Vaccine Research & Development and Manufacturing Financing

Funding from donor governments and private organizations (e.g. philanthropies) is provided directly to CEPI to support the research and development of vaccine candidates included in CEPI’s portfolio. In addition, this funding supports increasing manufacturing capacity in preparation for the eventual approval of a vaccine. To date, CEPI has received $1.41 billion in financial contributions largely in support of the research and development component. However, CEPI estimates it needs $2.5 billion to progress up to three vaccines through phase III trials, licensing, and to support national regulatory authorities. Funding for manufacturing capacity is provided through CEPI as well as from Gavi through the COVAX Facility using payments by self-financing countries.

Vaccine Procurement and Delivery Financing

Vaccine procurement is funded by self-financing countries and through donor contributions, with an option to purchase additional doses through cost-sharing, that support funded countries. To date, $2.4 billion¹⁶  has been secured in upfront payments from self-financing countries and $2.4 billion has been secured in donor contributions for funded countries through the Gavi COVAX AMC (See Vaccine Procurement and Delivery section above).

Vaccine delivery support will be provided by Gavi to low- and middle-income countries through technical assistance and the purchasing of cold chain equipment. An initial investment of $150 million has already been made by Gavi to support these delivery preparations, however, an additional $983 million will be needed for 2021. Further, UNICEF is planning to stockpile 1 billion syringes by 2021 for vaccine deployment, an effort that will be reimbursed by Gavi.

Vaccine Allocation Financing

To date, the WHO has received $160 million for all its ACT-Accelerator responsibilities, which includes the vaccine allocation work for COVAX, as well as the therapeutics, diagnostics, and health systems strengthening pillars. It is estimated that $2 million will be needed for WHO to establish allocation policy guidance for equitable distribution.

U.S. Engagement in COVAX

The Trump administration chose not to join COVAX, making the U.S. one of the only countries in the world not to formally participate in the initiative. While Congress provided $4 billion in emergency COVID-19 relief to Gavi in support of COVID-19 vaccine access, which GAVI says it will use to support the AMC, the absence of U.S. leadership in COVAX, and the ACT Accelerator, marked a break from how the U.S. has responded to most other recent global health emergencies. The Biden administration has said it is committed to multilateralism and President Biden announced shortly after taking office that the U.S. would support the Act Accelerator and join COVAX, and would develop a framework for donating surplus vaccines once there is sufficient supply in the U.S. to countries in need, including through COVAX (the Trump administration had included similar language in a December 2020 Executive Order, although the Order was largely focused on ensuring American access to vaccines). The Biden administration has not yet released additional details about its participation in COVAX.

Discussion & Challenges

While COVAX represents an innovative approach to the current global emergency and has made significant progress, it faces a number of challenges ahead. There are also several outstanding questions regarding U.S. engagement in the initiative.

• Can COVAX fill the funding gap? One of the most significant challenges facing COVAX is funding. Excluding payments from self-financing participants, COVAX has an overall funding target (2020-2021) of $11.1 billion but faces a $7.2 billion funding gap. Given the economic crisis that has gripped much of the world due to COVID-19, it is not yet clear how this gap can be filled.
• Can COVAX be a successful antidote to global vaccine inequity? Many countries, especially higher-income countries, are working to secure doses for their populations primarily through bilateral or regional purchase agreements, but at the same time are supporting access through COVAX. The competition between COVAX and these other agreements for a limited supply of vaccines may generate higher prices and result in more restricted or delayed access for low- and middle-income countries. While countries may choose to trade or donate surplus doses secured through bilateral or regional purchase agreements to lower-income countries through COVAX, there is no requirement to do so. So, countries will have to consider how best to balance domestic COVID-19 concerns with support for COVAX.
• How can COVAX quickly navigate the complex regulatory approval process in multiple countries? COVAX will also need to address the challenge of obtaining regulatory approval in multiple countries. Countries may approve a vaccine for use through a variety of regulatory authorities, such as a national regulator, regional regulator, or WHO prequalification. COVAX will need to navigate and obtain approval from these numerous regulatory mechanisms, which is not guaranteed, before a vaccine can be delivered to a country.
• Will the U.S. join COVAX as a self-financing member? While the U.S. has signaled its intent to participate in COVAX, the details of participation are unclear. If the U.S. joins COVAX as a self-financing member, its prepayments would support the AMC (and thus broader access) and also give the U.S. access to additional vaccines or doses if needed. At the same time, this would also require payments above the billions the U.S. has already made to support vaccine R&D and purchase vaccines through its own bilateral deals.
• Will the U.S. provide additional funding to COVAX? In its last emergency COVID-19 relief bill, the Congress included $4 billion to Gavi for COVID-19 vaccine procurement and distribution, which it says it will use to support the COVAX AMC. It is unclear if the Biden administration will request additional resources, and how such a request might be received by Congress.
• What framework will guide U.S. donations for any excess vaccine supply? While the U.S. has stated its intent to develop a framework to donate additional COVID-19 vaccine doses to low- and middle-income countries, including through COVAX, this donation will only occur after sufficient supplies have been secured for the U.S., which could be many months away as supply is limited and the U.S. may yet have enough doses for its own population for the time being. This could also get more complicated if booster vaccines, or modifications to or new vaccines, are required to address variants of the virus going forward.

1. While all low- and middle-income countries of COVAX are eligible to receive technical assistance and cold chain equipment, priority will be given to Gavi-eligible countries. ↩︎
2. Of the committed countries, 29 European countries have joined through the European Commission. ↩︎
3. Team Europe, comprised of 29 countries, is excluded from the counts of self-financing participants’ agreement structures. ↩︎
4. AMC countries may receive additional doses to vaccinate more than 20% of their populations but must provide funds through a tiered cost-sharing obligation for these additional amounts. India, because of its large population, has a unique agreement with COVAX to receive enough doses to cover only 7-9% of its population. ↩︎
5. Not all vaccine candidates receiving CEPI funding have an agreement with COVAX to supply COVID-19 vaccine doses. Only 6 of the 11 candidates contain supply of COVID-19 vaccine doses as part of their funding agreements: AstraZeneca, Clover Biopharmaceuticals, CureVac, Novavax, SK Bioscience, and University of Queensland/CSL. However, CEPI recently announced that the University of Queensland/CSL vaccine candidate would not be continued beyond the Phase I trial. ↩︎
6. For a vaccine candidate to be distributed through COVAX, the candidate must be on the WHO Emergency Use or Prequalification list or receive approval from a limited set of country-specific regulatory authorities. These regulatory authorities include the Therapeutic Goods Administration (Australia), European Medicines Agency (EU), Health Canada (Canada), Swissmedic (Switzerland), Medicines and Healthcare products Regulatory Agency (UK), or U.S. Food and Drug Administration (U.S.). ↩︎
7. COVAX has an agreement with Serum Institute of India to provide an additional 900 million doses of either the AstraZeneca or Novavax vaccine. ↩︎
8. COVAX has right of first refusal access to candidates funded by CEPI. These candidates are estimated to provide 1 billion doses. ↩︎
9. Cold chain storage support will be available to the 56 Gavi-eligible participants and India. The remaining 35 AMC participants may be eligible based on need and available funding. ↩︎
10. The 3% mark was determined by the WHO as the approximate proportion of health care workers within countries’ populations. ↩︎
11. The additional 17%, summing to the 20% mark, is an approximation by the WHO for countries to be able to vaccinate their high-risk populations, such as older adults and individuals with underlying health conditions. ↩︎
12. In the framework, a country’s threat level will be assessed based on the spread of COVID-19 in the country and presence of other influenza viruses. A country’s vulnerability level will be assessed based on its health systems capacity according to the universal health coverage index and occupancy of hospital beds. ↩︎
13. According to the SAGE Prioritization Roadmap, this group may include individuals with comorbidities and economically disadvantaged groups. The Roadmap also acknowledges the need for variation in priority groups among countries. ↩︎
14. This total excludes payments from the 29 countries included in Team Europe. ↩︎
15. Additionally, at the end of 2020, COVAX faced a $755 million funding gap, according to available data. ↩︎
16. This total excludes payments from the 29 countries included in Team Europe. ↩︎

Newly available data shows that the rise in the number of COVID-19 cases in the fall of 2020 was accompanied by a decline in non-COVID-19 hospital admissions during that time period. Our analysis includes medical records data of hospital admissions through December 5, 2020 from the Epic Health Research Network and updates an earlier paper that analyzed hospital admissions data through August 8, 2020. These new data provide additional information to help assess the economic impact of the COVID-19 pandemic on hospitals and insurers and also adds to our understanding of the extent to which people are continuing to delay or forgo care nearly one year into the pandemic. We analyze trends in total hospital admissions and then separately analyze non-COVID-19 admissions both overall and by patient region, age, and sex. We calculate actual admissions as a share of total predicted admissions in 2020 based on trends from past years. Key findings include:

• Total hospital admissions dropped to 69.2% of predicted admissions during the week ending April 4, 2020—the lowest point in the year—before rising again and staying at or above 90% since June 2020. As of the week ending December 5, 2020, total admissions were at 94.2% of what was predicted.
• The decrease in hospital admissions from March 8 to December 5, 2020 represent 8.5% of the total expected admissions for all of 2020.
• In November 2020, as COVID-19 cases surged, non-COVID-19 hospitalizations started to decline again and were about 80% of predicted hospitalizations by the end of the month. This suggests that people may once again be delaying or forgoing care due to the pandemic, in some cases likely due to hospital capacity constraints.

• Based on our data through the beginning of December, the more recent decline in non-COVID-19 admissions has been steepest in the Midwest and West. In both of those regions, non-COVID-19 admissions were at roughly 76% of predicted levels at the end of November, as COVID-19 cases were surging in many parts of those regions.

This new analysis is based on electronic medical record (EMR) data from Epic Health Research Network (EHRN) and includes all inpatient hospital admission volume from Dec 31, 2017 to December 5, 2020, involving patients who either were discharged or died as of January 13, 2021. Data are aggregated weekly and pooled from 34 health care organizations in the United States, representing 97 hospitals that span 26 states and cover 20 million patients. These states represent 73.0% of COVID-19 cases as of January 21, 2021 and also represent 76.7% of the U.S. population.¹  Predicted volume was calculated using historical data from Dec 31, 2017 to Jan 25, 2020.²  COVID-19 admissions were identified as admissions with either a documented COVID-19 diagnosis (U07.01) or other respiratory diagnosis involving a patient who either had tested positive or presumptive positive for COVID-19 or received a COVID-19 diagnosis within 14 days of the admission.

Background and Prior Studies on 2020 Health Care Trends

Several recent studies show that, beginning in March 2020, social distancing measures, concerns over hospital capacity, and fears of contracting COVID-19 led to sharp declines in health care spending.³  Across all health care services, not including pharmaceutical drugs, expenditures were down 32% in April 2020 on an annualized basis, compared to April 2019. Spending on health care services has since increased and as of the third quarter of 2020, year-to-date health services spending was down by 2.4% (relative to year-to-date spending as of third quarter in 2019). Changes in year-to-date spending varied by type of service, with physician office revenue down 4.0% and hospital revenue down 1.7% by the third quarter of 2020 (relative to year-to-date spending as of third quarter in 2019).

A recent EHRN analysis of EMR data found similar patterns to those presented here for overall emergency department (ED) visits, with a sharp decline (down roughly 50% of predicted ED visit volume) followed by slight recovery that has still left overall ED visits at about 65-70% of predicted volume as of the beginning of December 2020.⁴  Further, breaking down ED visit patterns by specific conditions, it was found that trends in visits associated with more severe (i.e., historically more likely to be admitted) conditions, such as stroke and acute myocardial infarction, experienced a smaller decline in Spring 2020 and recovered more quickly to predicted levels as compared to visits related to less severe conditions, such as dermatitis and conjunctivitis.⁵  Analysis of EMR data for breast, cervical, and colon cancer screenings showed an even sharper decline beginning in early March followed by an increase in screenings; even so, screening rates have remained far below 2019 levels.⁶  By mid-June, weekly volumes for these cancer type screenings remained roughly 30-35% lower than their pre-COVID-19 levels.

Findings

Trends in Overall Hospital Admissions

Our analysis of EMR data shows a precipitous drop in hospital admissions starting the week ending March 14, 2020, falling to a low of 69.2% of predicted admissions during the week ending April 4, 2020 (Figure 1)—soon after the March 13, 2020 national emergency proclamation. Admissions gradually began to increase soon after that date and, by July 4, 2020, admissions were back to approximately 95% of their predicted level and have hovered at around 93-95% in October and November.

The decrease in admissions between March 8 and December 5, 2020 account for 8.5% of the total number of admissions predicted during the 2020 calendar year. If the number of admissions remained at about 94% of predicted admissions (as they were on December 5) through the end of 2020, total admissions would be 8.9% below the predicted volume for the entire year.

IMPLICATIONS FOR HOSPITAL FINANCES

This drop in admissions was not something that hospitals could have anticipated at the beginning of the year and the steep decline in admissions early in the pandemic may have been difficult for some hospitals to weather. Hospitals’ financial strength differs widely. One recent study found that the median hospital had enough cash on hand to pay its operating expenses for 53 days in 2018, but the 25th percentile hospital only had enough cash on hand for 8 days.⁷  Smaller hospitals, public hospitals and rural hospitals are among those most likely to face financial challenges in the wake of revenue loss related to COVID-19. Some of these hospitals may be at risk of closing or merging if they do not have the financial resources to make up for declines in revenue caused by the declines in admissions shown in our data.

Hospitals and other health care providers have qualified for various types of federal assistance during the coronavirus pandemic. However, much of this money was not initially targeted to safety net hospitals operating on narrow margins.⁸  Most notably, hospitals and other health care providers received grants from the $178 billion provider relief fund that is being distributed by the Department of Health and Human Services (HHS). Hospitals qualified for grants that were the equivalent to a minimum of 2% of revenue and on average received grants that amounted to about 5.6% of revenue.⁹  Hospitals that qualified for additional grants either qualified by seeing a high number of COVID-19 inpatients by June 10 or were children’s hospitals, rural hospitals and/or safety net hospitals. About $26 billion remains available for future grant allocations as of February 3, 2021.¹⁰ 

In the coronavirus stimulus bill that was signed into law on December 27, 2020, Congress specified that 85% of the remaining money must be used to reimburse providers for lost revenue or expenses caused by the coronavirus pandemic.¹¹  It is not clear, however, how the drop in admissions translates into lost revenue for hospitals, which would depend on the type of admissions that were missed and which insurers paid for those admissions. Private insurers typically reimburse at higher rates than Medicare or Medicaid, and reimbursement widely varies by type of admission.¹² 

Hospitals and other providers that participate in traditional Medicare were also eligible for loans through the Medicare Accelerated and Advance Payment Programs, which are designed to help hospitals facing cash flow disruptions during an emergency. About 80% of the $100 billion in loans went to hospitals.¹³  CMS began distributing the loans in March 2020. Repayment for the loans was originally set to begin in August, but Congress later delayed when repayments would begin and extended the period for repayment.¹⁴  Providers will now begin repaying the loans one year after their initial loan payment was received, meaning repayment should begin in March 2021.

In addition, Medicare has increased payments to hospitals by 20% for all COVID-19 inpatients during the current public health emergency. The Biden Administration has indicated the public health emergency will likely remain in place throughout 2021. The Congressional Budget Office originally estimated that this change will increase Medicare spending by about $3 billion.¹⁵  Hospitals may also be eligible for loans being distributed by the Treasury department, the Federal Reserve, and Small Business Administration.

IMPLICATIONS FOR INSURER FINANCES

Health insurers, in contrast, may be benefiting financially from this decline in hospital admissions and certain other medical services since the start of the pandemic. KFF analysis found that at the end of the third quarter of 2020 average gross margins for health insurers had increased compared to 2019 and 2018 across the individual market, group market, Medicare Advantage and Medicaid Managed Care markets. KFF’s analysis also examined trends in medical loss ratios, or the percent of premium income that insurers pay out in the form of medical claims. Generally, lower medical loss ratios mean that insurers have more income remaining after paying medical costs to use for administrative costs or keep as profits. Compared to the same period in 2019, average loss ratios through the third quarter of 2020 were lower across the individual market, group market, Medicare Advantage and Medicaid Managed Care markets.

Trends in Non-COVID-19 Admissions

We used EMR data from EHRN to look at overall trends in non-COVID-19 admissions and also specifically at non-COVID-19 admissions by patient sex, age and region. By looking specifically at non-COVID-19 admissions, we can more easily assess declines in the use of health care due to voluntary and mandatory delays in non-emergency care. Looking at overall trends, we found that non-COVID-19 admissions reached a low of 63.4% of predicted admissions for the week ending April 11, 2020 (Figure 2). By June 2020, non-COVID-19 admissions had increased and reached a high of 92.0% of predicted levels the week ending July 4, 2020—but dipped back down soon after COVID-19 admissions began to increase again in the fall and fell to approximately 80% of predicted levels by the week ending December 5, 2020.

Our analysis does not include specific diagnoses or procedures to assess which types of admissions had the steepest declines. Declines in certain types of admissions—such as car crashes—may be explained by changes in habits due to the coronavirus pandemic. However, as discussed earlier in this paper, declines in cancer screenings suggest that the overall decline in admissions is also a sign of patients delaying or foregoing preventive care and therefore not starting necessary treatments. Some cancer treatments were also delayed earlier in the pandemic,¹⁶  although those treatments may now have resumed in many cases. In other cases, hospitals have delayed or cancelled non-emergency procedures due to capacity constraints.¹⁷ 

Non-COVID-19 Admissions By Region

We examined how non-COVID-19 admission trends varied across geographic regions, using the regions defined by the U.S. Census Bureau. To give a sense of the geographic distribution of our dataset, admissions from the Northeast, Midwest, South, and West regions account for approximately 24%, 25%, 28%, and 23% of overall admissions, respectively. While all regions experienced a large drop in COVID-19 admissions early in the pandemic followed by a rebound, the smaller decline in non-COVID-19 admissions in November and early December 2020 has not been uniform across the country. Non-COVID-19 admissions for hospitals as a percent of predicted volume dropped from 85.5% to 76.0% in the Midwest and 84.3% to 75.7% in the West between the weeks ending November 7 and December 5, 2020 (Figure 3). During this same month, COVID-19 cases were surging in many parts of these regions. Hospitals in the South went from 87.8% of predicted non-COVID-19 volume to 82.3% during that same period. Meanwhile, hospitals in the Northeast had experienced the steepest decline in non-COVID-19 admissions early in the pandemic, but non-COVID-19 admissions remained at a higher level than other regions in the fall of 2020 and were at 91.2% of predicted volume the week ending December 5, 2020.

Non-COVID-19 Admissions by Age

We stratified the EHRN admissions data by age to assess trends in non-COVID-19 admissions for patients age 65 and older compared to younger patients. We found that admissions for patients age 65 and older was just 53.4-63.0% of predicted levels in April 2020, compared to 68.6-75.1% of predicted levels for younger patients (Figure 4). This may suggest that older patients, at a higher risk of serious illness or death due to COVID-19, were more reluctant than younger patients to enter a hospital if not absolutely necessary. Non-COVID-19 admissions rebounded more slowly for older patients compared to those who are younger, but by September both age groups reached about 88% of predicted admissions. In the week ending December 5, 2020, non-COVID-19 admissions dipped again to 81.5% of predicted admissions for patients under 65 and 79.2% for patients age 65 and older.

Non-COVID-19 Admissions by Sex

Non-COVID-19 admissions for both male and female patients dropped to approximately 65% of predicted admissions in April 2020 and then increased to roughly 85-90% of predicted admissions by the summer (Figure 5). In November, non-COVID-19 admissions for both males and females dropped slightly to about 80% of predicted admissions. On an absolute level, admissions for female patients remained about approximately 20% higher than for male patients (data not shown). Much of this differential is likely due to women’s admissions for childbirth.

Implications

This updated analysis from the Epic Health Research Network provides additional insights into patterns of hospital admissions during the COVID-19 pandemic—and the impact that trends in COVID-19 cases has on non-COVID-19 admissions. By looking at the patterns in non-COVID-19 admissions, we can see how changes in behavior had a differential impact by region, age, and sex. The levels of non-COVID-19 admissions seen in the fall of 2020 suggest that people may be delaying care in ways that could be harmful to their long-term health. The impact of that forgone care will be an important subject of future analysis.

1. Epic data was compared to COVID-19 data from KFF, “State Data and Policy Actions to Address Coronavirus (available at: https://modern.kff.org/coronavirus-covid-19/issue-brief/state-data-and-policy-actions-to-address-coronavirus/) and U.S. population data from the U.S. Census Bureau, “State Population Totals and Components of Change: 2010-2019” (available at: https://www.census.gov/data/tables/time-series/demo/popest/2010s-state-total.html).   ↩︎
2. The predictive model was based on data through Jan 25, 2020 because that was the first week with a reported COVID-19 case in the United States. We used a generalized additive model and fit it to weekly admission volume, combining long term trend, yearly seasonal, and holiday effects. Forecasts were then obtained for Jan 26, 2020 through Dec 26, 2020. ↩︎
3. Cynthia Cox and Krutika Amin, “How have healthcare utilization and spending changed so far during the coronavirus pandemic?” Peterson-KFF Health System Tracker, Dec. 1, 2020; Department of Health and Human Services Office of the Assistant Secretary for Planning and Evaluation “The Impact of the COVID-19 Pandemic on Medicare Beneficiary Use of Health Care Services and Payments to Providers: Early Data for the First 6 Months of 2020,” September 29, 2020; Christopher M. Whaley; Megan F. Pera,; Jonathan Cantor, et al. Changes in Health Services Use Among Commercially Insured US Populations During the COVID-19 Pandemic. JAMA Netw Open. 2020;3(11):e2024984.   ↩︎
4. Andrea Noel, Christopher Alban, Jeff Trinkl, Sam Butler, David Berry, Eric Lindgren, Lily Rubin-Miller and Tyler Heist, “Fewer Visits, Sicker Patients: The Changing Character of Emergency Department Visits During the COVID-19 Pandemic,” Epic Health Research Network, February 3, 2021.   ↩︎
5. Andrea Noel, Christopher Alban, Jeff Trinkl, Sam Butler, David Berry, Eric Lindgren, Lily Rubin-Miller and Tyler Heist, “Fewer Visits, Sicker Patients: The Changing Character of Emergency Department Visits During the COVID-19 Pandemic,” Epic Health Research Network, February 3, 2021.   ↩︎
6. Christopher Mast and Alejandro Munoz del Rio, “Delayed Cancer Screenings—A Second Look,” Epic Health Research Network, July 17, 2020.   ↩︎
7. Dhruv Khullar, Amelia M. Bond and William L. Schpero. “COVID-19 and the Financial Health of US Hospitals.” JAMA. 2020;323(21):2127–2128.   ↩︎
8. Karyn Schwartz and Anthony Damico, “Distribution of CARES Act Funding Among Hospitals,” KFF, May 13, 2020.   ↩︎
9. This was calculated using 2019 National Health Expenditure data to estimate total revenue. We assumed that hospitals received 50% of the $10.2 billion allocated to rural providers and assumed that hospitals did not get any of the $20 billion in Phase 3 funding.   ↩︎
10. Department of Health and Human Services, “CARES Act Provider Relief Fund: General Information” https://www.hhs.gov/coronavirus/cares-act-provider-relief-fund/general-information/index.html (accessed January 23, 2021).   ↩︎
11. Melanie Evans, “Latest Covid-19 Aid Package Scales Back Funds to Hospitals, Clinics,” Wall Street Journal, Jan. 1, 2021.   ↩︎
12. Eric Lopez, Gary Claxton, Karyn Schwartz, Matthew Rae, Nancy Ochieng, and Tricia Neuman, “Comparing Private Payer and Medicare Payment Rates for Select Inpatient Hospital Services,” KFF, July 7, 2020; Eric Lopez, Tricia Neuman, Gretchen Jacobson and Larry Levitt, “How Much More Than Medicare Do Private Insurers Pay? A Review of the Literature,” KFF, April 15, 2020; MACPAC, “Medicaid Hospital Payment: A Comparison across States and to Medicare,” MACPAC, April 2017.   ↩︎
13. Juliette Cubanski, Karyn Schwartz, Jeannie Fuglesten Biniek and Tricia Neuman, “Medicare Accelerated and Advance Payments for COVID-19 Revenue Loss: Time to Repay?” KFF, Aug. 7, 2020.   ↩︎
14. Section 2501 of H.R. 8337.   ↩︎
15. CBO, “Preliminary Estimate of the Effects of H.R. 748, the CARES Act, Public Law 116-136, Revised, With Corrections to the Revenue Effect of the Employee Retention Credit and to the Modification of a Limitation on Losses for Taxpayers Other Than Corporations,” CBO, April 27, 2020.   ↩︎
16. American Cancer Society – Cancer Action Network, “COVID-19 Pandemic Impact on Cancer Patients and Survivors Survey Findings Summary,” American Cancer Society – Cancer Action Network, Available at: https://www.fightcancer.org/sites/default/files/National%20Documents/Survivor%20Views.COVID19%20Polling%20Memo.Final_.pdf (accessed January 24, 2021).   ↩︎
17. Laura Dyrda, “Where hospitals are delaying elective surgeries due to COVID-19 spikes,” Becker’s ASC Review, November 17, 2020. Available at https://www.beckersasc.com/asc-news/where-hospitals-are-delaying-elective-surgeries-due-to-covid-19-spikes.html (accessed January 24, 2021). ↩︎