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

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

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

What are COVID-19 Vaccine Passports?

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

Where are COVID-19 Vaccine Passports Being Used Now?

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

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

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

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

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

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

What are Key Implementation Issues to Consider?

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

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

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

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

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

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

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

Conclusion

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

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

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

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

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

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

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

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

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

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

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

Source

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

Gender and age differences are revealed in a new analysis that finds nearly seven in ten (69%) young women ages 18 to 29 say the COVID-19 pandemic has negatively impacted their mental health, compared to smaller shares of women who are older and men across all age groups.

By mid-2020 about half (53%) of adults reported that worry and pandemic-related stress had negatively impacted their mental health. Now with millions of U.S. residents getting vaccinated against COVID-19, the latest analysis from the KFF COVID-19 Vaccine Monitor finds 47% of adults continue to report negative mental health impacts, and about a third of this group (or 15% of adults overall) report unmet needs for mental health care. The new report highlights recent data on the mental health impacts of the COVID-19 pandemic across gender, age, race, and income. Key findings include:

• Women, including mothers with children under 18, younger adults, and those in middle income groups are most likely to report their mental health has been negatively impacted as a result of the pandemic, compared to those 65 and older and men, including fathers with children under 18, who are least likely to report any mental health impact from the pandemic.
• The groups most likely to be worried that they or a family member may get sick from COVID-19 are women, Black and Hispanic adults, and younger adults. Among those expressing this worry, nearly six in ten say it has negatively impacted their mental health, showing a direct link between worry and negative mental health impact.
• Among mothers who say their mental health had been negatively impacted by the pandemic, nearly half (46%) report they did not get the mental health services or medications they needed, representing about one in four (27%) mothers overall.
• Among adults who did not get the mental health care they may have needed in the past year, some of the biggest reasons include not being able to find a provider (24%), inability to afford the cost (23%), or being too busy or unable to take off work in order to seek treatment (18%).

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.

Private insurance companies are expecting to pay out $2.1 billion in rebates to consumers this fall, the second highest amount ever issued under the Affordable Care Act, according to a new KFF analysis.

The rebates, which are calculated based on the share of premium revenues that insurance companies paid out for health care expenses and quality improvement, are roughly $400 million lower than last year’s record high of $2.5 billion, but more than 50 percent higher than the $1.4 billion insurers sent back to policy holders in 2019.

Rebate amounts will vary by market. Individual market insurers account for the majority of the payments, with expected rebates of at least $1.5 billion, finds the analysis of data reported by insurers to the Centers for Medicare and Medicaid Services. Rebates in the small and large group insurance markets are expected to be $308 million and $310 million, respectively. The amounts are preliminary estimates, with final rebate data coming later this year.

The rebates are the result of insurance companies not meeting the ACA’s medical loss ratio threshold, which requires insurers to spend at least 80 percent of premium revenues (85% for large group plans) on health care claims or quality improvement activities. Most people in large group plans are in self-insured plans, which the MLR threshold rule does not apply to.

Not all policy holders are due rebates, but among those who are, this year’s rebates work out to roughly $299 per plan member in the individual market, $127 per member in the small group market and $95 per member in the large group market, according to KFF’s analysis. By law, insurance companies must begin issuing the latest rebates to eligible consumers later this fall.

One reason some companies failed to meet the threshold in 2020 is that the pandemic drove health spending and utilization down, as providers cancelled elective procedures and consumers opted to forego routine care out of fear of being infected. As a result, insurers generated higher levels of profits than they had anticipated when they set their 2020 premiums well before the pandemic emerged. Overall rebates would have been even higher had some insurers not taken steps to increase their claims costs relative to their premium income, including offering premium holidays and waiving certain out-of-pocket costs for enrollees, such as costs for telemedicine and for treatment for COVID-19. Claims costs also began to rise toward the end of the year during the winter surge in COVID-19 cases.

Rebates are calculated using a three-year average so the large rebates are not just a side effect of the pandemic. In the individual market, this year’s rebates are driven in large part by significant insurer profits in 2018 and 2019 (as rebates issued in 2021 are based on insurer financial performance in 2018, 2019, and 2020).

For more data and analyses about the pandemic, insurers’ financial performance and the ACA, visit kff.org.

In spite of a new price transparency rule that requires hospitals to publish the prices of common health services, comparing prices across hospitals remains challenging due to limited compliance with the law and a lack of standardization in the available data, a new KFF analysis finds.

The federal rule, which went into effect on January 1, 2021, aims to lift the veil on how much health plans pay hospitals for health services. To be compliant, hospitals must post payer-specific negotiated rates for medical services and products in two formats on their websites: in a machine-readable file that insurers, employers, health care providers, and other stakeholders can use to compare prices across providers, and in a consumer-friendly tool that allows patients to shop for lower-priced care.

Using data collected from large hospitals in all 50 states and the District of Columbia, the analysis finds limited compliance with the new federal rule. Only 35 of the 102 hospitals included in the analysis provide some payer-negotiated rates accessible to the public in a machine-readable file; only 3 provide payer-negotiated rates via consumer tools.

Even when hospitals are compliant, the lack of data standardization makes it difficult to compare prices across facilities. Many of the hospitals included in the analysis define and describe prices differently. For example, some hospitals include professional fees (e.g., for physician services) in the posted prices, other hospitals do not, and still others do not specify either way. Many hospital machine-readable files are inconsistently formatted and leave out key information, including the full range of payers and plans in a given region.

While the new price transparency data does not yet support price comparison across hospitals, it could in some cases facilitate analysis of price variation within a hospital. Using payer-negotiated rates from ten U.S. hospitals, the brief finds significant variation in the price of common services. For example, the price of a lower back MRI at a hospital in New Mexico ranged from $221 to $2,142 depending on the payer. The authors note that the available hospital data does not always clearly indicate the market in which a payer is operating; thus, an analysis of variation in prices by insurer market segment is not possible for most hospitals examined.

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

A new issue brief examines compliance with a new federal price transparency rule and variation in payer-negotiated rates at U.S. hospitals. The analysis looks at the websites of the two largest hospitals in each state and the District of Columbia, and finds that a lack of consistency in the data and limited compliance among the hospitals sampled makes it difficult to compare prices across facilities.

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

Summary

With the distribution of the COVID-19 vaccine underway, ensuring equitable and rapid distribution to the U.S. population will be important for mitigating the disproportionate impacts of the pandemic for people of color, preventing widening racial health disparities going forward, and achieving broad population immunity. Reflecting underlying inequities, the COVID-19 pandemic has disproportionately affected American Indian and Alaskan Native (AIAN) people who account for over 5 million people in the U.S. At the same time, vaccination rates among AIAN people have been higher than average to date. This brief presents available data on COVID-19 vaccinations among AIAN people from federal and state sources and discusses factors contributing to success in these vaccination efforts. It finds:

Underlying inequities that existed prior to the pandemic contribute to AIAN people facing increased barriers to accessing health care and being disproportionately affected by the COVID-19 pandemic. Chronic underfunding of the Indian Health Service (IHS) relative to health needs and high uninsured rates contribute to barriers to health care among AIAN people. Existing social, economic, and health inequities have also led to higher rates of illness and death among AIAN people due to COVID-19.

Data available to date show that AIAN people are being vaccinated at a higher rate compared to other racial/ethnic groups. Federal data show that 32% of AIAN people had received at least one dose of a COVID-19 vaccine, compared to 19% of White people, 16% of Asian people, 12% of Black people and 9% Hispanic people of as of April 5, 2021.State data similarly find higher vaccination rates among AIAN people compared to other groups.

The high vaccination rate among AIAN people largely reflects Tribal leadership in implementing vaccine prioritization and distribution strategies that meet the preferences and needs of their communities. The high rates may also, in part, reflect the greater supply of vaccine doses delivered to the IHS relative to the number of people served compared to state vaccination programs. Tribes have supported and built on existing trusted community resources and providers to distribute vaccines. The success Tribes have achieved in vaccinating their communities provide lessons learned that may help inform broader vaccination efforts going forward.

Background: Health and Health Care for AIAN People

Under treaties and laws, the federal government has a unique responsibility to provide health care services to AIAN people. The IHS is the primary vehicle through which the federal government fulfills this responsibility for members of federally recognized tribes, who make up approximately 2.6 million of the over 5 million individuals who self-identify as AIAN nationwide. The IHS provides services directly, through Tribally operated health programs, and through services purchased from private providers. The IHS also funds Urban Indian Organizations to make health care services accessible to people who reside in urban areas, who include most of the AIAN population.

Due to longstanding limitations and underfunding of the IHS, AIAN people face disproportionate barriers to accessing health care. IHS services generally are limited to members of or descendants of members of federally recognized Tribes, and not all individuals who self-identify as AIAN belong to one of these Tribes. IHS historically has been underfunded to meet the health care needs of AIAN people, and access to services through IHS often varies across locations. Given the limitations of IHS, Medicaid and other sources of health insurance remain important for expanding access to care for AIAN people. However, as of 2019, 22% of AIAN nonelderly people were uninsured, the highest of all racial and ethnic groups (Figure 1).

The COVID-19 pandemic has disproportionately affected AIAN people. AIAN people face increased risk of exposure to the virus to due underlying social and economic factors and have higher high rates of health conditions that put them at increased risk for serious illness if they contract coronavirus. Reflecting these increased risks, AIAN people are nearly twice as likely to be infected with the virus, nearly four times likely to be hospitalized, and nearly two and half times as likely to die due to COVID-19 as their White counterparts, based on age-adjusted data (Figure 2).

COVID-19 Vaccination among AIAN People

The federal government is allocating COVID-19 vaccines directly to the IHS, and Tribal health programs and Urban Indian Organizations choose whether to receive vaccines directly from the IHS or through their respective state distribution mechanisms. As of March 15, 2021, 351 of the 609 IHS facilities, Tribal health programs, and Urban Indian Organization facilities had elected to receive vaccines directly through IHS; facilities can change their election. When Tribal health programs and Urban Indian Organizations elect to receive vaccines through the state, the CDC provides the state a “sovereign nation supplement” of vaccine doses. CDC data shows that as of April 5, 2021, nearly 1.5 million vaccine doses had been delivered to IHS, over 1 million doses had been administered via IHS, and more than 630,000 people had received at least one dose through IHS, making up over 30% of the population served by IHS.

Data available to date suggest that AIAN people are being vaccinated at a higher rate compared to other racial/ethnic groups. Data gaps limit the ability to have a complete picture of who is being vaccinated and how vaccination rates vary across groups. However, data available to date show that AIAN people are being vaccinated at a higher rate relative to other racial/ethnic groups. For example, federal data from CDC, which were available for about half of people who have received at least one dose as of April 5, 2021, suggest that over 720,000 AIAN people had received at least one COVID-19 vaccine dose, making up over 30 percent of the 2.2 million people who self-identify solely as AIAN (Figure 3). In contrast, these data show 19% of White people, 16% of Asian people, 12% of Black people, and 9% of Hispanic people had received at least one vaccine dose.

State-level data on vaccinations among AIAN people is limited. Only 36 states were reporting vaccinations among AIAN people as of March 29, 2021. Moreover, the state-reported data does not reflect vaccines administered through allocations received through IHS, and, as such, may understate vaccination rates and further limit the ability to calculate reliable estimates. However, data from several states show that AIAN people are being vaccinated at higher rates compared to other groups. For example, in Alaska, 22% of vaccinations have gone to AIAN people while they account for 15% of the population. The pattern is similar at the county-level. As of April 5, 2021, counties with high shares of AIAN people had a higher average vaccination rate (20%) when compared to the average across counties and counties with low shares of AIAN people (19% and 18%, respectively).¹ 

Factors Contributing to High AIAN Vaccination Rates

The high vaccination rate among AIAN people stands in stark contrast to the gaps in vaccinations for Black and Hispanic people observed to date. The underlying inequities and barriers to health care facing AIAN people similarly could have led to barriers to vaccination. However, experiences suggest that the autonomy provided to Tribes to design and implement vaccine distribution efforts among their communities has contributed to success in vaccinating the population. The high rates may also, in part, reflect the greater supply of vaccine doses delivered to the IHS relative to the population served compared to state vaccination programs. As of April 5, 2021, over 1.5 million doses had been delivered to IHS, which represents roughly nearly 75,000 per 100,000 people served by the IHS. Only 2 states and Washington DC had higher rates of doses delivered than the IHS, although the IHS rate of doses administered is lower compared to these states. Additionally, the availability of more complete race/ethnicity data for AIAN people receiving the vaccine, since many are receiving it through IHS, Tribal health, and Urban Indian Organization facilities, may also be contributing to the high rates. Federal and some state data have high shares of vaccinations with unknown or “other” race/ethnicity, which may affect vaccination rates across racial/ethnic groups.

IHS, Tribal health programs, and Urban Indian Organizations have autonomy and flexibility to implement priority and distribution strategies that meet the needs and preferences of their communities. The IHS developed a COVID-19 Vaccine Task Force (VTF) to advance plans for prioritization strategies, vaccine administration, distribution, data management, safety and monitoring, and communications. Consistent with the federal recommendations from the Advisory Committee on Immunization Policies (ACIP), IHS first prioritized health care workers and residents of long-term care facilities. Initial doses allocated to IHS were estimated to be sufficient for 100% of its health care workforce and residents of long-term care facilities. Like states, Tribes and Urban Indian Organizations have authority to make their own prioritization decisions. Many chose to prioritize elders and some, like the Standing Rock Sioux Tribe, prioritized speakers of native languages, to protect against further losses of culture and traditions that the pandemic has threatened. Several Tribes, including Chickasaw Nation, Cherokee Nation, and Lummi Nation, have already had so much success in vaccinating their priority groups that they have expanded distribution to include non-Native members of the public.

Tribes are building on and supporting existing trusted community resources and providers to distribute vaccines. Tribes are utilizing the networks and resources in the community and drawing upon years of experience to reach tribal members with various access barriers. For example, the Navajo Nation has vaccinated between 4,000 and 5,000 homebound citizens by collaborating with public health workers to reach those residents in rural communities. In Alaska, tribal health organizations relied on longstanding strategies developed to reach geographically isolated communities, including partnering with local pilots to transport pharmacists and vials of vaccines to such areas. In addition, many Tribes have established vaccine sign-up systems that match the resources and preferences of their populations. For example, media reports suggested that many Tribes have set up call centers to answer inquiries, book appointments, and reach out to people.

Tribes have launched tailored outreach and communication plans that share culturally relevant messages through trusted individuals in the community. A national survey of AIAN people conducted in late 2020 found that the majority were willing receive a COVID-19 vaccine and that the most commonly held motivation for getting a vaccine was a sense of responsibility to protect the Native community and preserve cultural ways. Regardless of willingness to get a vaccine, the most frequently reported concern about the vaccine was how fast the vaccine moved through clinical trials. Some Tribes have utilized fluent language speakers to address concerns about the vaccine among the community. For example, the Cherokee Nation prioritized Cherokee language speakers to create optimism and show that the vaccine was safe. Similarly, the Navajo Nation employed fluent doctors and health care professionals to serve as trusted sources of information on the vaccine.

Looking Ahead

Given the disparate impacts of COVID-19 on AIAN people and the barriers and challenges they face to accessing health care, ensuring access to the COVID-19 vaccine is particularly important. Data available to date show a high COVID-19 vaccination rate among AIAN people, largely reflecting the role of Tribes in designing and implementing vaccine distribution strategies that meet the needs and preferences of the communities they serve. The success Tribes have achieved in vaccinating their communities provide lessons learned that may help inform broader vaccination efforts going forward. The American Rescue Plan Act of 2021 provides IHS with an additional $600 million for vaccine efforts, $1.5 billion to trace COVID-19 infections, $240 million to establish and sustain a COVID-19 public health workforce, and $600 million for COVID-19 related facility improvements, which may further enhance Tribal vaccination efforts and their response to COVID-19.

1. KFF analysis of Centers for Disease Control and Prevention’s (CDC) COVID-19 Integrated County View data. Counties in which the share of AIAN people is above the national average of 0.7% were classified as counties with high shares of AIAN people. Of the 2,350 reporting counties, 617 fall into the high share of AIAN people category (26% of the counties). ↩︎

More than half (54%) of rural adults say they have already gotten at least one dose of a COVID-19 vaccine or will do so as soon as possible, as rural residents report less issues with both supply and access than those living in urban and suburban areas, according to a new KFF COVID-19 Vaccine Monitor report focused on rural America.

A somewhat larger share of rural residents (39%) than those living in urban (31%) or suburban (31%) areas say they have already received at least one dose of a COVID-19 vaccine.

However, there is a larger share of rural residents (21%) than urban (10%) or suburban (13%) ones saying they will “definitely not” get a COVID-19 vaccine, a gap largely explained by the concentration of Republicans and White Evangelical Christians who live there.

Among rural residents who say they will “definitely not” get vaccinated, nearly three quarters (73%) identify as Republican or Republican-leaning, and 4 in 10 (41%) identify as White Evangelical Christians.

“There’s nothing inherently unique about living in a rural area that makes people balk at getting vaccinated,” KFF President and CEO Drew Altman said. “It’s just that rural areas have a larger share of people in the most vaccine-resistant groups: Republicans and White Evangelical Christians.”

The new report examines in depth the vaccine-related views and experiences of a nationally representative sample of rural residents. Earlier Vaccine Monitor reports showed concerns about vaccine uptake among this group, which represents about a fifth of the nation’s population and has often reported difficulty accessing health care.

Among rural residents who have not received a COVID-19 vaccine, few (11%) say they have tried to get an appointment – half the share of those living in urban (21%) and suburban (22%) areas.

The large share of rural residents who say they will “definitely not” get vaccinated, and the relatively small shares who have tried to get an appointment or who hope to get vaccinated “as soon as possible” suggest the potential for vaccination rates in rural America to eventually lag behind those in urban and suburban areas.

Rural residents are more likely to say that their area has enough COVID-19 vaccine to serve their communities (58%) than residents of urban or suburban communities are (46% each). In addition, two thirds (68%) of rural residents say there are enough locations to get vaccinated, compared to just over half of urban (52%) and suburban (55%) residents.

Importantly, fewer Black rural residents (53%) than White (69%) or Hispanic (67%) rural residents say there are adequate vaccination locations in their communities. In addition, half of Black (47%) and Hispanic (52%) residents, compared to 6 in 10 White adults (59%), say there is an adequate supply of vaccine.

“Contrary to conventional wisdom, most rural residents have embraced the COVID-19 vaccine, with over half saying they’ve gotten it already or want to get it as soon as they can,” KFF Executive Vice President Mollyann Brodie said. “Most people in rural areas believe their communities have enough vaccine and places to get vaccinated, though fewer Black residents do, suggesting a gap in access.”

The report also captures the impact of a variety of potential incentives, messages, and pieces of information on vaccination uptake.

Similar to the general public, various incentives and messages are most effective in moving rural residents in the “wait and see” and “only if required” groups. For example, at least half of those in the “wait and see” group say hearing that the vaccines are nearly 100% effective at preventing hospitalization and death from COVID-19 (64%) or that scientists have been working on the technology used in the new COVID-19 vaccines for 20 years (52%) will make them more likely to get vaccinated.

Across the board, none of the messages or pieces of information were effective at moving those who say they will definitely not get vaccinated.

Other highlights include:

• Half of adults in rural areas (49%) who have received at least one dose of a COVID-19 vaccine say it took them less than 15 minutes to get to the vaccination site, similar to the share of urban and suburban residents who say so.
• Rural residents (40%) are less likely to say they are worried about themselves or their family members getting sick from coronavirus than urban (54%) and suburban residents (49%) are, and are more likely to believe the news has “generally exaggerated” the seriousness of the coronavirus pandemic (44%) than urban (27%) and suburban (33%) residents are.
• More (58%) rural residents view getting vaccinated as a personal choice rather than part of everyone’s responsibility to protect the health of others (42%). The reverse is true among urban residents, while suburban residents are more evenly divided.

Designed and analyzed by public opinion researchers at KFF, the KFF Vaccine Monitor: Rural America was conducted from March 15-29 among a nationally representative random digit dial telephone sample of 1,001 adults living in rural America, the margin of sampling error is plus or minus 4 percentage points. For results based on subgroups, the margin of sampling error may be higher. All comparisons to urban and suburban residents are from the KFF March Vaccine Monitor. The KFF COVID-19 Vaccine Monitor is an ongoing research project tracking the public’s attitudes and experiences with COVID-19 vaccinations. Using a combination of surveys and qualitative research, this project tracks the dynamic nature of public opinion as vaccine development and distribution unfold, including vaccine confidence and hesitancy, trusted messengers and messages, as well as the public’s experiences with vaccination.