Key Issues to Watch for Justice-Involved Populations: COVID-19, Vaccines, & Medicaid

Author: Madeline Guth
Published: Feb 24, 2021

As COVID-19 vaccine distribution continues, the impact of the coronavirus on people moving into and out of the criminal justice system and the staff who work with justice-involved individuals is a key issue. This issue brief explores the impact of COVID-19 on justice-involved populations, examines how states have prioritized these populations for vaccination, and highlights the significance of Medicaid coverage for this population as well as proposals to expand access to Medicaid coverage. Looking ahead, key issues to watch include continued data on COVID-19 cases, deaths, and vaccinations among incarcerated populations as well as ongoing state and federal efforts to expand Medicaid access for this population. These efforts include the bipartisan Medicaid Reentry Act to allow Medicaid coverage for inmates 30 days prior to release, introduced in the Senate and also included in the House of Representatives COVID-19 relief budget reconciliation bill. This bill also includes funding for COVID-19 testing, contact tracing, and mitigation activities in congregate settings, including correctional facilities.

What does the data show about COVID-19 cases and deaths in prisons?

Although the Centers for Disease Control and Prevention (CDC) has published evidence that broad testing strategies in correctional facilities can help control transmission and provides considerations for such strategies, coronavirus testing policies vary across prison systems. Further, reporting of coronavirus cases and deaths data varies across states and prison systems and is often incomplete. In a February 9, 2021 letter to Congressional leadership, a group of Democrats indicated plans to reintroduce the COVID-19 in Corrections Data Transparency Act, a bill that would require correctional facilities to collect and publicly report detailed data on COVID-19 (including tests, cases, and deaths) and to disaggregate this data by demographics including sex, race, and disability. The group also urged leadership to include additional provisions related to correctional facilities in the upcoming COVID-19 relief package, including a requirement for routine diagnostic testing in correctional facilities.

Coronavirus infection rates among incarcerated populations have been higher than overall infection rates in nearly all states (Figure 1). Data shows 388,168 reported cases of coronavirus among people incarcerated in state and federal prisons as of February 22, 20211 , meaning that about 28% of this population has tested positive for the virus as compared to about 9% of the total US population. These case rates vary across states, ranging from 6% of prisoners in Alabama to 68% in Michigan. This variation in case rates may reflect variation in the number of prisoners being tested in addition to the prevalence of the virus. In all but three states, the coronavirus case rate among prisoners is higher than the case rate for the total population. The total coronavirus case rate among prisoners also reflects high case rates among the population detained by Immigration and Customs Enforcement (ICE) (69%) and among the population detained by the Federal Bureau of Prisons (29%). Additionally, since the start of the pandemic, an estimated 93,190 prison staff members have tested positive for coronavirus (22% of this population); however, data for staff is more limited as not all states report staff infections and even where this data is reported, prisons are less likely to systematically test staff and thus these counts may only include staff members who voluntarily report a positive diagnosis.

More than 2,300 deaths from coronavirus have been reported among prisoners, with death rates among prisoners higher than overall death rates in most states (Figure 2). A few states have not reported coronavirus deaths among prisoners2 , and the data that is available is subject to variation and limitations noted previously. This coronavirus death total includes deaths among the population detained by the Federal Bureau of Prisons (236 deaths) and by ICE (9 deaths). Coronavirus death rates vary across states, ranging from 4.1 deaths per 10,000 prisoners in Wyoming to 43.7 per 10,000 prisoners in Nevada. These rates among prisoners are higher than overall coronavirus death rates in 26 states, lower than overall rates in 15 states, and about the same (within one percentage point) in 9 states. Given the high case rates among prisoners, it is unsurprising that death rates are also high; however, coronavirus deaths in prisons are likely partially mitigated by the fact that on average, just over 10% of prisoners are over age 55 (as compared to just over 30% of the general population) and it is well-documented that older adults are at higher risk of dying if diagnosed with COVID-19. Since the start of the pandemic, 152 deaths from coronavirus have been reported among prison staff.

How are inmates in correctional facilities reflected in state vaccine prioritization plans?

Although not all states have fully defined the populations prioritized for receiving the COVID-19 vaccine in their state vaccination plans, of those that have, just over half include inmates in their Phase 1a, 1b or 1c groups and almost all include corrections officers. Vaccine recommendations from the CDC’s Advisory Committee on Immunization Practices (ACIP) classify corrections officers as frontline essential workers who should be eligible for the vaccine following Phase 1a. While ACIP does not explicitly recommend inmates as an early priority group, it does note that states may choose to vaccinate those residing in congregate living facilities, such as correctional/detention facilities, at the same time as frontline staff). Accordingly, state vaccine plans vary in their prioritization of inmates in correctional facilities, and states also vary widely in the number of incarcerated individuals who have been vaccinated thus far.3  As of February 22, 2021, inmates in correctional facilities are eligible for the COVID-19 vaccine in just 15 states. An additional three states are allowing vaccination for inmates only in some counties and an additional 15 states are allowing vaccination of staff but not inmates. Some (including members of Congress and current inmates) have argued that incarcerated individuals should be higher priority for the vaccine, while others have critiqued state policymakers for prioritizing incarcerated individuals ahead of others in their states.

Why is vaccine access particularly important for inmates?

Justice-involved populations may have a greater need for vaccines due to underlying health conditions and increased risk of transmission in correctional facilities. Coronavirus and other infectious diseases spread easily among people in jails and prisons given close quarters and shared spaces within correctional facilities, as is demonstrated by high coronavirus infection rates (Figure 1). Policies related to COVID-19 in prisons such as quarantining, isolation, and masking vary across states. In recognition of the increased risk of transmission in these types of facilities, the House of Representatives COVID-19 relief budget reconciliation bill includes funding for COVID-19 testing, contact tracing, and mitigation activities in congregate settings, including correctional facilities. Although on average younger than the general population, many incarcerated people are at risk for experiencing complications from coronavirus due to higher rates of chronic disease among this population as compared to the general population. Further, people of color are disproportionately likely to be incarcerated in jails and prisons, and data shows racial disparities in COVID-19 outcomes in part due to higher rates of underlying health conditions. Despite increased risks for the justice-involved population, reporting from some states suggests that inmates are reluctant to take the COVID-19 vaccine, citing concerns about side effects as well as distrust of the prison health care system.

What current and future options do justice-involved individuals have for accessing health care?

Correctional facilities are required to provide health services to incarcerated individuals, and Medicaid can help cover the costs of inpatient hospital care for this population. The provision of health care to incarcerated individuals varies significantly across states and types of correctional facilities, and may include on-site infirmaries and/or contracts with outside health care providers. In fiscal year 2015, state departments of correction on average spent $5,720 per inmate to provide health care services. Current rules allow individuals to be enrolled in Medicaid while incarcerated, but the Medicaid Inmate Exclusion Policy limits Medicaid reimbursement for incarcerated individuals to inpatient care provided at facilities that meet certain requirements, including hospitals. States can facilitate access to Medicaid coverage for incarcerated individuals by suspending rather than terminating Medicaid coverage for enrollees who become incarcerated, which over 40 states reported doing as of January 2019. Suspending eligibility expedites access to federal Medicaid funds if an individual receives inpatient care while incarcerated. Although data on prisoner hospitalizations due to coronavirus is largely unavailable, Medicaid would be an important payer for any such hospitalizations.

The Affordable Care Act (ACA) and its expansion of Medicaid provided new coverage options for individuals upon release from correctional facilities. Although incarcerated individuals are not eligible to buy private health insurance through the Health Insurance Marketplace established by the ACA, they can access a Special Enrollment Period to sign up for private health coverage within 60 days of release even if there is not currently a Marketplace Open Enrollment Period. Further, particularly in states that have adopted the ACA’s Medicaid expansion, many justice-involved individuals could be eligible for Medicaid coverage. Justice-involved individuals are disproportionately low-income, with a median income prior to incarceration 41% lower than the median income of non-incarcerated counterparts. Though incarcerated people in all gender, race, and ethnicity groups have substantially lower incomes as compared to their non-incarcerated counterparts, median incomes prior to incarceration are particularly low for women of color. In the 39 states that have adopted Medicaid expansion under the Affordable Care Act, nearly all adults with incomes up to 138% of the federal poverty level (FPL) ($17,774 for an individual in 2021) are eligible for Medicaid; however, eligibility for adults remains very limited in the remaining 12 states. In states which suspend Medicaid coverage for incarcerated individuals, individuals can have their coverage active immediately upon release, which facilitates access to health care services in the community. This policy is of particular importance during the coronavirus pandemic, as some prisons have implemented early or temporary release policies to reduce prison density and viral transmission. Researchers have urged states to establish and/or strengthen systems to help enroll individuals in Medicaid upon release to protect their health and that of the general population during the pandemic.

Looking ahead, policy proposals at the state and federal level could further expand Medicaid access and increase continuity of care for justice-involved populations during and beyond the pandemic. A few states are attempting to expand the scope of services provided to incarcerated individuals that can qualify for reimbursement through Section 1115 waiver requests. For example, Utah and Kentucky have pending requests that would provide limited benefits to certain inmates with substance use disorders prior to release. At the federal level, the Medicaid Reentry Act is a legislative proposal which would allow states to cover services for Medicaid beneficiaries who are incarcerated during the 30 days preceding their release, which could facilitate coverage and access to care post-release. This proposal is included in the House of Representatives COVID-19 relief budget reconciliation bill (to be funded for five years) and a bipartisan group of Senators has introduced similar legislation. The Congressional Budget Office (CBO) has estimated that the proposal in the reconciliation bill would increase federal costs by $3.7 billion over the five-year period and result in about 55% of all inmates being enrolled in Medicaid at the end of this period.

  1. This includes data from all 50 US states, Puerto Rico, the Federal Bureau of Prisons, and Immigration and Customs Enforcement (ICE). For more info, see https://covidprisonproject.com/ ↩︎
  2. However, a different dataset (from The Marshall Project) reports at least one coronavirus death among prisoners in every state except Vermont. ↩︎
  3. State counts of the number of incarcerated individuals who have been vaccinated may include inmates who receive the vaccine based on other eligibility criteria, even if they live in states where inmates are not currently priority populations themselves. ↩︎
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COVID-19 Cases and Deaths Among Nursing Home Residents Have Declined Markedly Following the Introduction of Vaccines

Published: Feb 24, 2021

The number of residents contracting and dying of COVID-19 in nursing homes has declined markedly following the introduction of vaccination efforts in long-term care facilities, a KFF analysis finds.

Resident deaths from COVID-19 in nursing homes have decreased by two-thirds (66%) since vaccination efforts began in late December. New cases of the novel coronavirus among residents have fallen even more sharply, by 83 percent.

At the same time, deaths from COVID-19 in the general population (excluding nursing home residents) have spiked by 61 percent in the weeks since December 20. New cases have declined in recent weeks, but by only 45 percent, far less than the decline seen among nursing home residents.

The new analysis compares trends in new COVID-19 cases and deaths among nursing facility residents with trends in new COVID-19 cases and deaths among non-nursing facility residents through February 7, 2021.

It’s still unclear how much the decline in cases and deaths can be attributed directly to the vaccine, the analysis finds, but the timing suggests that vaccination efforts are having an impact and improving the safety of long-term care settings. As of February 22, 2021, at least 4.5 million residents and staff in long-term care facilities had received one or more dose of vaccine, including over 2 million residents and staff who had received both doses.

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Chris Lee
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Is the End of the Long-Term Care Crisis Within Sight? New COVID-19 Cases and Deaths in Long-Term Care Facilities Are Dropping

Authors: Priya Chidambaram, Rachel Garfield, Tricia Neuman, and Larry Levitt
Published: Feb 24, 2021

The final months of 2020 were the deadliest months of the pandemic for many long-term care facilities (LTCFs) across the country, with over 26,000 COVID-19 deaths in LTCFs reported between Thanksgiving weekend and December 31, 2020. The end of 2020 also saw the approval of the first coronavirus vaccines and the launch of vaccine administrations in LTCFs through the Pharmacy Partnership for Long-Term Care on December 21st, 2020 (Pfizer-BioNTech) and December 28th, 2020 (Moderna). As of February 22, 2021, about 4.5 million residents and staff have received one or more dose through the Partnership; over 2 million residents and staff have received both doses. In addition, some states and some LTCFs have vaccinated residents or staff outside the Partnership. Vaccinations have increased outside of LTCFs as well, though at a significantly lower rate.

This analysis compares trends in new COVID-19 cases and deaths among nursing facility residents with trends in all other new COVID-19 cases and deaths excluding nursing facility residents through February 7, 2021. Our prior analysis of trend data going from April 2020 through December 2020 found similar patterns in cases and deaths in long-term care facilities and in the general population. This updated analysis with more recent data shows a marked divergence in new cases and deaths per week between nursing facility residents and the rest of the US population since December 2020. This drop in new cases and deaths in nursing facility residents coincides with the start of vaccine administration in LTCFs, suggesting a link between the two, although the trends could also be influenced by other factors. See Methods for more details on data sources and analysis.

Weekly new deaths among nursing home residents have decreased by 66% since long-term care vaccination efforts started at the end of December, compared to a 61% increase in all other new deaths not among nursing home residents during the same period (Figure 1 and Table 1). In the period leading up to initiation of vaccination efforts in LTCFs, new deaths among nursing homes residents and non-nursing home residents had generally been increasing since late Fall 2020, peaking in the week ending December 20, 2020. Starting December 21, 2020, the week LTCF vaccination efforts began, weekly nursing home resident deaths began a steady decrease, which has continued through the most recent week of data available, dropping from 6,019 for the week ending December 20, 2020 to 2,054 for the week ending February 7th, 2021. The rate of decrease appears to have accelerated in recent weeks, as more LTCF residents got fully vaccinated. In contrast, non-nursing facility resident deaths increased overall (from 12,325 to 19,848 weekly deaths between the weeks ending December 20th 2020 and February 7th, 2021), with a slight drops the weeks ending December 27th and January 24th.

Figure 1: Weekly COVID-19 Nursing Home Resident and Non-Nursing Home Resident Deaths in the US, June 2020 – February 2021

Similarly, weekly new cases among nursing home residents have been steadily declining since December 20, 2020 and decreased faster than cases among non-nursing home residents (-83% and -45%, respectively) (Table 1). As has been widely reported, overall cases in the US have dropped precipitously in recent weeks. While cases have dropped both within and outside nursing facilities, new nursing facility resident cases peaked earlier (week ending December 20, 2020) as compared to in the general non-nursing facility resident population (week ending January 10, 2021) and declined at a faster rate in nursing facilities than outside nursing facilities.

While timing of vaccine initiation in LTCFs and declines in cases and deaths coincide and suggest a link between the two, it is still unclear how much of the decline in cases and deaths can be attributed directly to the vaccine. In particular, cases and deaths started declining upon rollout of the Partnership, but first vaccine clinics did not happen immediately in all locations. According to the CDC, there has been strong evidence that the vaccines prevent severe illness and death, and the sharp divergence in deaths inside and outside of LTCFs is consistent with that evidence. In addition, given the emerging research around the vaccines’ ability to prevent transmission of the virus, there is reason to believe that the vaccine may be playing a part in reducing virus transmission within nursing homes, contributing to the more rapid decline in new cases in nursing facility residents than in the overall population.

Table 1: Weekly COVID-19 Nursing Home Resident and Non-Nursing Home Resident Cases and Deaths in the US,June 2020-February 2021
Week EndingWeekly New CasesWeekly New Deaths
Nursing Home ResidentNon-Nursing Home Resident*Nursing Home ResidentNon-Nursing Home Resident*
6/7/202016,396129,0222,7502,748
6/14/202012,998133,8472,0783,082
6/21/202012,128172,3461,7252,400
6/28/202013,440254,6811,4682,291
7/5/202013,940331,1461,4721,946
7/12/202016,837387,4051,6123,266
7/19/202018,442441,3621,8023,403
7/26/202018,918440,6632,0504,312
8/2/202017,180408,9732,0735,850
8/9/202016,737346,7902,0815,252
8/16/202015,970341,3171,8795,565
8/23/202013,585280,8101,7305,073
8/30/202012,476273,7741,5434,829
9/6/202011,458265,8771,3644,462
9/13/202010,226227,7091,2193,754
9/20/202010,513267,3051,1764,233
9/27/202010,546295,0211,1394,080
10/4/202010,815287,7271,1863,618
10/11/202011,927330,3721,2473,628
10/18/202014,781367,8991,4683,297
10/25/202016,350464,2611,7363,881
11/1/202018,760613,8832,0123,690
11/8/202023,673775,1642,4644,584
11/15/202030,1641,014,8062,9824,940
11/22/202032,6651,165,5453,7216,624
11/29/202027,6411,094,8634,5825,424
12/6/202032,0311,345,6005,04310,229
12/13/202033,4281,448,9485,76211,170
12/20/202033,6011,468,0846,01912,325
Nursing Home Vaccinations Begin
12/27/202028,8151,240,8125,5869,679
1/3/202127,1441,459,0245,47412,853
1/10/202125,8871,683,0675,32616,984
1/17/202121,3491,489,3364,95818,206
1/24/202117,3831,163,9884,34116,926
1/31/202111,0841,012,7153,16418,738
2/7/20215,672812,3622,05419,848
Percent Change From 12/20/2020 to 2/7/2021-83%-45%-66%61%
NOTES: Nursing home cases/deaths include resident cases and deaths only. *Non-nursing home resident cases and deaths calculated as total US cases and deaths minus nursing home resident cases and deaths. These figures include nursing home staff cases and deaths.SOURCES: Nursing home cases and deaths are from CMS COVID-19 Nursing Home Data, as of the week ending on 2/7/2021. US weekly cases and deaths data is based on analysis of COVID Tracking Project data.

Methods

This analysis uses federal data on coronavirus cases and deaths in nursing facilities, which includes weekly data as of mid-May 2020 through February 7th, 2021. This analysis defines nursing facility cases and deaths as cases and deaths among nursing facility residents. Cases and deaths among nursing home staff are included in “non-nursing home resident” group. Data on non-nursing home cases and deaths are calculated based on the number of nationwide cases and deaths from the COVID Tracking Project minus nursing home resident cases and deaths; we make this adjustment to account for possible endogeneity (that is, cases or deaths in nursing homes contributing to the patterns in COVID-19 cases and deaths nationwide), particularly for deaths where long-term care deaths account for approximately 37% of overall COVID-19 deaths. The federal data includes only data on federally certified nursing facilities. This analysis therefore does not include data on other long-term care settings, such as assisted living facilities, residential care facilities, group homes, or intermediate care facilities.

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COVID-19 is the Number One Cause of Death in the U.S. in Early 2021

Authors: Cynthia Cox and Krutika Amin
Published: Feb 22, 2021

A updated issue brief examines the most recent data on deaths from COVID-19 and other causes, and finds that COVID-19 is currently the number one cause of death in the United States.

As of February 20, 2021, an average of more than 2,400 people per day died of COVID-19 in the U.S. during February 2021 – a number nearly 20% higher than the next leading cause. Heart disease, which is typically the number one cause of death in the U.S. each year, leads to the death of about 2,000 Americans per day, and cancer claims about 1,600 American lives per day.

The issue brief is available in full on the Peterson-KFF Health System Tracker, an online information hub dedicated to monitoring and assessing the performance of the U.S. health system.

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Growing Gaps in COVID-19 Vaccinations among Hispanic People

Author: Samantha Artiga
Published: Feb 22, 2021

As noted in our latest analysis of state vaccination data by race/ethnicity, a big gap is emerging in COVID-19 vaccination rates for Hispanic people. As of mid-February, White people were over three times more likely than Hispanic people to have received at least the first dose of a vaccination (10% vs. 3%) based on data from just over half the states. These data are early, with vaccinations still only available to limited groups in some states, which may affect demographic trends. They also are subject to a range of gaps and limitations. However, the consistency in patterns across states point to potential challenges for vaccinating Hispanic people, whose health and finances have been extremely hard hit by the pandemic. Low rates of vaccination among Hispanic people would leave them at increased risk for the virus, could further widen existing health disparities, and would leave gaps that hinder our ability to achieve overall population immunity.

There has been substantial focus on heightened concerns among Hispanic and Black adults about the vaccines’ safety and side effects that leave many wanting to “wait and see” how others fare before they receive it. As of late January 2021, just over a third of Hispanic adults (37%) said they wanted to “wait and see” how the vaccine works for other people, compared to 43% of Black adults and just over a quarter (26%) of White adults, while 42% had already gotten the vaccine or wanted to get it as soon as possible and the remaining roughly one in five said they would only get it if required or definitely will not get it.

However, these differences in “willingness” to get the vaccine do not appear large enough to explain disparities that are emerging in vaccination rates, suggesting that other factors, such as access barriers, may be playing a significant role. Hispanic people face a combination of factors that may make accessing the vaccine particularly challenging. They have a high uninsured rate, which has likely further increased due to the pandemic. As such, they may be more likely to be concerned about potential costs associated with obtaining the vaccine and less likely to have an existing relationship with a health care provider. Hispanic adults also are more likely than White adults to say it is difficult to find a health care location that is easy for them to get to. Moreover, some Hispanic people may face linguistic barriers to care. Those with an immigrant family member face potential added complications, including confusion about eligibility to obtain the vaccine and concerns about whether accessing the vaccine could negatively affect their or a family member’s immigration status or put them at risk for enforcement action.

The federal government is making COVID-19 vaccines available in ways that address many of these potential barriers. They currently are available for free to all individuals regardless of insurance status. The federal government is launching new efforts to make vaccines available through more locations, including community health centers, which are a key source of care for the Hispanic population and a place where many Hispanic adults currently receive their flu vaccine. Moreover, the Department of Homeland Security has clarified that vaccines are available to all individuals regardless of immigration status and that enforcement activities will not be conducted at or near vaccine distribution sites or clinics. Further, U.S. Citizen and Immigration Services has specified that it will not consider testing, treatment, or preventive care, including vaccines, related to COVID-19 as part of a public charge inadmissibility determination.

However, for these broad policies to be effective, it will be important for the information to be clearly communicated to people in the community through trusted messengers and in-language, when needed. Proactively communicating that the vaccination is available for free even for people without insurance, providing details on when and how to access the vaccine, and clarifying that receiving the vaccine will not negatively impact immigration status will likely be particularly important. Notably, about six in ten Hispanic adults say they do not have enough information about where to get the vaccine, compared to about half of White adults who say the same. Moreover, survey data show Hispanic adults are much more likely than White adults to report an increased likelihood of getting vaccinated after hearing that there is no cost to get vaccinated (54% vs. 32%) or that a friend or family member (53% vs. 26%) or a health care provider they trust (51% vs. 34%) got the vaccine. Like other groups, the majority (81%) of Hispanic adults point to health care providers as a trusted resource for information to help them decide whether to get the vaccine. The Centers for Disease Control and Prevention, state or local health departments, and family or friends are also top trusted resources for Hispanic adults.

Beyond providing information through trusted resources, it will be important to ensure that, at the provider level, vaccine sign-up processes do not leave some people facing barriers. For example, although insurance is not required to obtain the vaccine, many providers are requesting insurance information to cover costs of administering the vaccine, and anecdotal reports suggest some providers have insurance information as a required field to book a vaccine appointment. Providers may also be requesting personal identification or proof of state residency to obtain the vaccine, particularly while vaccines are limited to certain priority groups. Ensuring that vaccine providers offer clear options for people to make a vaccine appointment if they do not have insurance and providing alternative options for people to provide documentation if they do not have a government-issued identification card will also be important for facilitating access.

Addressing these potential barriers to vaccination can be done. However, doing so will require intentional and deliberate action. Working closely with community leaders to better understand access barriers, develop strategies to address them, and provide outreach and education through trusted messengers is one place to start.

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Insurance coverage and financing landscape for HIV treatment and prevention in the USA

Authors: Jennifer Kates, Lindsey Dawson, and 5 co-authors
Published: Feb 19, 2021

In this article for The Lancet, KFF’s Jennifer Kates and Lindsey Dawson, and five co-authors provide an overview of the coverage and financing landscape for HIV treatment and prevention in the U.S., discuss how the Affordable Care Act has changed the domestic health care system, examine the major programs that provide coverage and services, and identify remaining challenges.

The article was published online on February 19, 2021. To access it at no charge, register for an online account at The Lancet.

In addition to KFF’s Jennifer Kates and Lindsey Dawson, the article’s other co-authors are: Tim Horn and Amy Killelea of National Alliance of State and Territorial AIDS Directors, Nicole McCann of the Department of Medicine, Medical Practice Evaluation Center, Massachusetts General Hospital, Jeffrey Crowley of the O’Neill Institute for National and Global Health Law, Georgetown University, and Rochelle Walensky of Division of Infectious Diseases, Massachusetts General Hospital.

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KFF COVID-19 Vaccine Monitor: Attitudes Towards COVID-19 Vaccination Among Black Women and Men

Published: Feb 19, 2021

The latest from the KFF COVID-19 Vaccine Monitor finds that Black men (45%) and women (41%) are more likely than other groups to want to “wait and see” how the COVID-19 vaccine works for others before getting it themselves, making them a key target for public health officials seeking to boost vaccination rates equitably.

This analysis explores similarities and differences in the attitudes of Black men and women toward COVID-19 vaccination. Highlights include:

  • Providing accurate information about side effects may be key to communicating with this group. Among those not yet vaccinated, large shares of Black women (87%) and men (61%) say they are worried they might experience serious side effects from a COVID-19 vaccine. Many Black women (69%) and men (65%) who have not yet gotten the vaccine also say they do not have enough information about vaccine side effects.
  • About one in five (19%) Black women say they “definitely will not” get vaccinated for COVID-19, larger than the share of Black men (7%) who say the same. This greater reluctance may be related to Black women’s higher levels of concerns about side effects. In addition, among those not yet vaccinated, many more Black women (68%) than men (38%) say they worry about contracting COVID-19 from a vaccine, suggesting that learning that doesn’t happen could influence their decision.
  • About half of Black women (53%) and men (45%) 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 suggests addressing historic mistreatment and inequities in the vaccine distribution process could help outreach efforts aimed at vaccine hesitancy among both Black women and men.

Available through the Monitor’s online dashboard, the new analysis also probes the messages that make Black men and women more or less likely to want to get vaccinated, as well as their confidence in the fairness of vaccine distribution efforts.

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

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Craig Palosky
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Poll Finding

Attitudes Towards COVID-19 Vaccination Among Black Women And Men

Published: Feb 19, 2021
Section:
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Findings

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.

Key Takeaways:

  • Compared to other groups, a larger share of Black women (41%) and Black men (45%) say they want to “wait and see” how the vaccine is working for others before getting vaccinated themselves. Providing accurate information about side effects may be key to communicating with these groups, since large shares of Black women and men say they do not have enough information about the vaccine’s side effects and are worried they might experience serious side effects themselves.
  • As is true for the public overall, messages that emphasize the vaccine’s effectiveness, protection from illness, and the ability to return to normal life are the most effective with both Black women and Black men, and health care providers are the source they are most likely to turn to when making decisions.
  • About one in five (19%) Black women say they “definitely will not” get vaccinated for COVID-19, larger than the share of Black men (7%) who say the same. This greater reluctance among Black women may be related to the fact that Black women are more likely than Black men to say they are concerned about experiencing serious side effects (87% vs. 61%) or getting COVID-19 from the vaccine (68% vs. 38%). It may also be related to concerns about how the vaccine is being distributed, as about six in ten Black women do not believe the vaccine distribution is taking the needs of Black people into account and most have low levels of trust in the health care system to do what is right for their community.
  • Because women often play the role of health care decision-makers for their families, it may be particularly important to reach Black women with messages that emphasize the safety of the vaccine and address concerns about side effects. These messages could also convey accurate information about how the vaccine works to combat the misperception that it is possible to get COVID-19 from the vaccine. In addition, building trust by addressing historic mistreatment and inequities in the vaccine distribution process may play a part in helping alleviate vaccine hesitancy among Black women and men.

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.

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.

In Their Own Words: What is the biggest concern you had/have, if any, about getting a COVID-19 vaccine?

The KFF COVID-19 Vaccine Monitor conducted interviews with a nationally representative sample of 1,009 adults, using open-ended questions to better understand public concerns around receiving a COVID-19 vaccine as well as to hear from the public in their own words about the messages and messengers that could increase the likelihood of people getting a COVID-19 vaccine.

“I have had 5 family members die from COVID-19. I don’t want to be next. The vaccine is very important to me because of all my underlying conditions that make me more susceptible to the disease and virus.” -Black man, age 50-64, Ohio

“I’m afraid that the vaccine might cause a divide between people who can get it and those who are unable due to whatever reason.” -Black man, age 18-29, New York

“This country is not to be trusted when rolling out anything in such a short time. The fallout will be massive.” -Black woman, age 30-49, Maryland

“Will it agree with my body for me not to have serious complications or even physical deformation?” -Black woman, age 30-49, California

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%).

In Their Own Words: If there is one message or piece of information you could hear that would make you more likely to get vaccinated for COVID-19, what would it be?

“I would like to hear that the people that took the vaccine are fine and do not have any reaction to the vaccine.” -Black woman, age 18-29, Ohio

“Less chance of an allergic reaction and effectiveness for people of color.” -Black woman, age 50-64, Kentucky

“I am going to get the vaccine, I just will not be anywhere near the front of the line!” -Black man, age 50-64, Michigan

“More data about side-effects in pregnant women and those who are looking to become pregnant.” -Black woman, age 30-49, South Carolina

“That is has been tested multiple times on a variety of people before it was approved by the FDA.” -Black woman, age 50-64, Arkansas

“[More information on] the failure rate and the testing process.” -Black man, age 18-29, New York

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%).

Table 1: Responses To Pro-Vaccine Messages And Information Among Total And By Gender Among Black Adults
Percent who say that hearing each of the following would make them more likely to get vaccinated:Total adultsTotal Black adultsBlack womenBlack men
The vaccines have been shown to be highly effective in preventing illness from COVID-1957%58%55%62%
The vaccine will help protect you from getting sick from COVID-1956615668
The quickest way for life to return to normal is for most people to get vaccinated54615863
Millions of people have already safely been vaccinated for COVID-1946504654
We need people to get vaccinated to get the U.S. economy back on track45514954
A doctor or health care provider you trust has gotten the vaccine38434343
There is no cost to get the vaccine36333334
A close friend or family member got vaccinated for COVID-1932353734
NOTE: Asked among those who say they have not been vaccinated against COVID-19.

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%).

Table 2: Responses To Negative Vaccine Messages And Information Among Total And By Gender Among Black Adults
Percent who say that hearing each of the following would make them less likely to get vaccinated:Total adultsTotal Black adultsBlack womenBlack men
A small number of people have experienced a serious allergic reaction to the COVID-19 vaccine39%49%50%48%
Some people were experiencing short-term side effects like pain or fever from the COVID-19 vaccine33464647
You will need to continue to wear a mask and practice social distancing even after getting vaccinated20262824
You had to receive two doses of the vaccine several weeks apart18263022
NOTE: Asked among those who say they have not been vaccinated against COVID-19.

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.

Table 3: Likely Sources of COVID-19 Vaccine Information Among Total And By Gender Among Black Adults
Percent who say that, when deciding whether to get a COVID-19 vaccine, they are very or somewhat likely to turn to each of the following for information:Total adultsTotal Black adults Black women Black men
A doctor, nurse, or other health care provider79%84%87%80%
The Centers for Disease Control and Prevention (CDC)60717170
Family or friends58616457
Their state or local public health department57717071
A pharmacist54656664
A religious leader such as minister, pastor, priest, or rabbi17333630
NOTE: Asked among those who say they have not been vaccinated against COVID-19.

Methodology

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.

GroupN (unweighted)M.O.S.E.
Total1,563± 3 percentage points
Total Black adults310± 7 percentage points
Total Black adults who have not gotten a COVID-19 vaccine297± 7 percentage points
Black adults by Gender
Black women164± 10 percentage points
Black men146± 10 percentage points
Black adults by Gender, Not Vaccinated
Black women who have not gotten a COVID-19 vaccine156± 10 percentage points
Black men who have not gotten a COVID-19 vaccine141± 10 percentage points
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New Analysis: Updated State Data Continues To Show Wide Disparities in COVID-19 Vaccination Rates by Race/Ethnicity

Published: Feb 18, 2021

KFF has an updated analysis of state-reported data as of February 16, 2021 on COVID-19 vaccinations, cases, and deaths by race/ethnicity.

New to the analysis are comparisons of vaccination rates in each racial/ethnic group based on state-reported data of total people who have received at least one dose of the vaccine. Among just over half of states reporting data, the vaccination rate among White people is over three times higher than the rate for Hispanic people (10% vs 3%) and twice as high as the rate for Black people (10% vs. 5%). The vaccination rate for Asian people is closer to the rate for White people in most reporting states, although they are less likely to have been vaccinated in most reporting states.

Across the 34 states reporting data on vaccinations by race/ethnicity, there is a largely consistent pattern of Black and Hispanic people receiving smaller shares of vaccinations compared to their shares of cases and deaths and compared to their shares of the total population.

For example, in Texas, 20 percent of vaccinations have gone to Hispanic people, while Hispanic people account for 42 percent of COVID-19 cases, 47 percent of deaths from the virus, and 40 percent of the total population in the state. Similarly, in Mississippi, Black people have received 22 percent of vaccinations but make up 38 percent of COVID-19 cases, 40 percent of deaths, and 38 percent of the total population in the state.

The share of vaccinations among Asian people was similar to their share of the total population in most states and when there was a disparity in most cases the differences were small. White people received a higher share of vaccinations compared to their share of cases and deaths and their share of the total population in most states reporting data.

Vaccination patterns may change as more data is available and more parts of the country gain greater access to vaccines. Eighteen states and Washington DC are not yet reporting vaccinations by race/ethnicity and some states have high shares of vaccination data with unknown race/ethnicity and/or reporting “other or multiple races.

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Chris Lee
KFF

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COVAX and the United States

Published: Feb 18, 2021
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Issue Brief

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.

Table 1: Self-financing v. Funded Countries in the COVAX Facility
Self-financing countriesFunded countries
Number of participating countries902  countries and 8 economies have signed commitment agreements and an additional 6 have signaled intent to participate.92 countries are eligible to participate in the AMC.
Eligibility requirementsNoneGNI per capita less than $4,000 or World Bank IDA-eligible
Deadline for countries to commitThe original deadline to commit was September 18, 2020, with upfront payments due October 9, 2020.Applications to confirm participation opened on November 13, 2020 and were due December 7, 2020. 88 countries have submitted vaccine requests.
Funding structureTwo payment options:
  • Committed purchase option – Cost of this plan includes an upfront cost of $1.60 per dose and purchasing agreement of $8.95 per dose. (30 countries have agreed to this option.) Countries with this agreement may only opt out of purchasing a vaccine candidate if they have indicated in their commitment agreement to not purchase vaccines with prices exceeding $21.10 per dose.
  • Optional purchase option – Cost of this plan includes an upfront cost of $3.10 per dose, purchasing agreement of $6.20 per dose, and risk-sharking cost of $0.40 per dose. (39 countries have agreed to this option.3 ) Countries under this agreement can decide to opt out of purchasing certain candidates either before entering the COVAX Facility through its participation agreement or once the COVAX Facility confirms orders with a manufacturer.

Additionally, all self-financing countries will be required to pay a speed premium (used to accelerate manufacturing) and a COVAX Facility operation fee.

The Gavi COVAX AMC is funded primarily through contributions from public and private donors which in turn support the provision of vaccine doses to funded countries. Funded countries wishing to receive more than their allotted amount of doses may elect to provide additional funds through a tiered cost-sharing obligation. Support from multilateral development banks may be utilized to cover cost-sharing obligations.
Initial doses countries in financing group may receiveSelf-financing countries can request enough doses to vaccinate 10-50% of their populations, depending on their level of investment.Funded countries will receive enough doses to vaccinate up to 20% of their populations.4 
Projected doses to be received from COVAX in 2021485 million1.8 billion

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.

Table 2: COVAX Procurement Portfolio
Developer/manufacturerDosesConfirmed or reservedCEPI-fundedClinical trial and licensure phase6 
Pfizer40 millionConfirmedNoApproved for emergency use by the WHO.
AstraZeneca270 millionConfirmedYesApproved for emergency use by the WHO.
Janssen500 millionConfirmedNoRegulatory review
Novavax100 millionConfirmedYesPhase III
Sanofi/GSK200 millionConfirmedNoPhase I/II
AstraZeneca/Novavax7 900 millionOptionedYesVarious stages of development and licensure
CEPI R&D Portfolio8 1 billionConfirmedYesVarious stages of development and licensure

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.

Table 3: COVID-19 Vaccine Allocation Plan for AMC Countries
PhasePopulationEstimated percentage of population to be coveredDelivery timeline
Phase 1 – Tier 1Frontline workers in health and social care settings3%February 2021
Phase 1 – Tier 2High-risk individuals13 20%Second half of 2021
Phase 2Weighted allocation based on country’s risk assessment.30-50%2022

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.

Table 4: COVAX Funding Targets and Gaps, 2020-2021
COVAX ActivityDeliverable2020 needs2021 needsTotals
TargetGapTargetGapTargetGap
Research & developmentAccelerate clinical trials to bring vaccine to licensure$1.595 billion$262 million$855 million$855 million$2.45 billion$1.117 billion
Facilitate global Solidarity phase III trial for up to 10 candidates
Support regulatory networks
Manufacturing and procurementInvest in manufacturing and procure doses for AMC-eligible countries$2 billion$0$5 billion$4.6 billion$7 billion$4.6 billion
Allocation and deliveryEnsure equitable allocation through policy guidance$642 million$492 million$983 million$983 million$1.625 billion$1.475 billion
Ensure country readiness for delivery
Provide country-level technical assistance
TOTAL$4.237 billion$755 million$6.838 billion$6.438 billion$11.075 billion$7.192 billion
NOTES: These estimates exclude costs financed by self-financing countries.

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.

Endnotes

  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. ↩︎
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