Early State Vaccination Data Raise Warning Flags for Racial Equity

Authors: Nambi Ndugga, Olivia Pham, Latoya Hill, Samantha Artiga, and Salem Mengistu

Published: Jan 21, 2021

The latest data on COVID-19 vaccinations by race/ethnicity is available here.

Federal data show that, as of January 19, 2021, over 12 million COVID-19 vaccines had been administered across the country. As vaccine distribution continues, ensuring racial equity will be important for mitigating the disproportionate impacts of COVID-19 on people of color, preventing widening health disparities, and achieving broad population immunity. Some states have centered equity as a key principle in their vaccine distribution plans. Across states, data to understand access to and uptake of the vaccine by race/ethnicity and other demographic factors will be central to efforts to ensure equity. These data are necessary to move past “color blind” policies that reinforce systematic racism and inform decisionmakers on how to develop culturally responsive interventions and direct resources to ensure equitable distribution and uptake of the vaccine. KFF is compiling and will regularly update state-reported data on vaccination by race/ethnicity through its COVID-19 state data and policy tracker.

As of January 19, 2021, 17 states were publicly reporting COVID-19 vaccination data by race/ethnicity. All but one of these states report the distribution of vaccinations by race/ethnicity, while North Dakota reports vaccination rates by racial/ethnic group. States vary in whether they report total doses administered, total first doses administered, and/or total people vaccinated by race/ethnicity.

To date, vaccination patterns by race and ethnicity appear to be at odds with who the virus has affected the most. Based on vaccinations with known race/ethnicity, the share of vaccinations among Black people is smaller than their share of cases in all 16 reporting states and smaller than their share of deaths in 15 states. For example, in Mississippi, Black people account for 15% of vaccinations, compared to 38% of cases and 42% of deaths, and, in Delaware, 8% of vaccinations have been received by Black people, while they make up nearly a quarter of cases (24%) and deaths (23%). Similarly, Hispanic people account for a smaller share of vaccinations compared to their share of cases and deaths in most states reporting data. For example, in Nebraska, 4% of vaccinations are among Hispanic people, while they make up 23% of cases and 13% of deaths. There are fewer and smaller gaps between the share of vaccinations and cases among Asian people, and data on their share of deaths remain limited. Gaps remain in data available for American Indian and Alaska Native as well as Native Hawaiian and Other Pacific Islander people. Reflecting these trends, the share of vaccinations among White people is larger than their share of cases in 13 of the 16 reporting states and larger than their share of deaths in 9 states. For example, in Maryland, White people account for nearly two-thirds of vaccinations (65%), but 39% of cases and 50% of deaths. Similarly, in North Carolina, 82% of vaccinations have been among White people, while they make up 62% of cases and 65% of deaths.

Data also show that the shares of vaccinations among Black and Hispanic people are lower compared to their shares of the total population in most reporting states. In contrast, the share of vaccinations among White people is higher than their share of the total population in most states. While this will be an important metric to track over time, it is still early in the process to interpret these data since the vaccines are not yet broadly available to the public.

Together the data raise some early warning flags about potential racial disparities in access to and uptake of the vaccine, but it is difficult to draw strong conclusions given that the vaccines are not yet broadly available and due to data limitations. As noted, the vaccines still are not yet broadly available to the public as the early priority groups for vaccination have primarily been health care workers and long-term care residents and staff. Different patterns may emerge as the vaccines roll out more broadly. In addition, there remain gaps and inconsistencies in the data. In some states, race/ethnicity is unknown for a significant share of vaccinations, and the share unknown may not be distributed equally across racial/ethnic groups. For example, in three states (Pennsylvania, Virginia, and Tennessee), race/ethnicity is unknown for over half of vaccinations. In addition, as noted above, states vary in what vaccination data they are reporting, with some reporting doses administered and others reporting people vaccinated. States also vary in their racial/ethnic classifications, limiting the comparability of data across states. For example, some include Hispanic people in their racial categories, while others limit racial groups to non-Hispanic people. Additionally, some states report Asian and Pacific Islander people in a combined group, while others disaggregate data for Asian and Native Hawaiian and other Pacific Islander people.

Comprehensive standardized data across states will be vital to monitor and ensure equitable access to and take up of the vaccine. Given the dearth of COVID-19 data by race/ethnicity at the outset of the pandemic, it is encouraging that some states are reporting vaccinations by race/ethnicity during this early stage of the vaccine rollout. However, most states are not yet reporting these data, and the data that are reported are incomplete and inconsistent, limiting their usefulness. In a recent KFF briefing, President Biden’s COVID-19 Equity Task Force Chair, Dr. Marcella Nunez-Smith, emphasized the importance of accurate, high-quality data for addressing disparities noting, “we cannot address what we cannot see.” The Centers for Disease Control and Prevention (CDC) has outlined COVID-19 vaccine data reporting and sharing requirements that include the collection of race/ethnicity data. However, since “unknown” or “unable to report due to policy or law” are response options, data completeness will hinge on collection efforts, which may vary across states and providers given potential burdens and challenges associated with collecting it.

KFF will keep a close eye on vaccination data going forward and continue to report additional state and national data as they become available.

The COVID-19 Vaccine Priority Line Continues to Change as States Make Further Updates

Authors: Jennifer Tolbert, Jennifer Kates, and Josh Michaud

Published: Jan 21, 2021

See updated state data table.

The COVID-19 vaccine rollout has stumbled in much of the country, with uneven experience across states and many doses going unused. Meanwhile, with the death toll rising and concern increasing about new variants of the virus, there is new urgency to get more people vaccinated.

Drew Altman wrote recently in The Washington Post, a “much simpler plan” based on age could improve distribution. President Biden has said he would encourage states to vaccinate those ages 65 and older. And, on January 12, 2021, as one of the last COVID-19 actions of the Trump administration, the Department of Health and Human Services issued new guidance to states recommending they open vaccine availability to all people ages 65 and older and to those under 65 with high-risk medical conditions. This latest recommendation differed from CDC Advisory Committee on Immunization Practices (ACIP) recommendations issued in December 2020, that called for targeting limited vaccine doses to health care workers and long-term care facility residents in phase 1a and people over age 75 and frontline essential workers in phase 1b. Most states had initially followed the ACIP guidelines.

We assessed how states are changing vaccination plans by comparing prioritization groups on January 19 to those that were in place on January 11. Many states have, in fact, moved to redefine their priority populations or open vaccine availability to people 65 and older; a smaller number moved those under age 65 with high risk medical conditions up in line:

As of January 19^th, 28 states include people ages 65 and older in their phase 1a or 1b priority groups, up from 16 on January 11^th. The 12 states that moved those 65+ up in line were Idaho, Maine, Mississippi, Nebraska, New Hampshire, New Jersey, New York, North Carolina, Oregon, Pennsylvania, Virginia and Washington.
A total of 19 states include younger adults with high-risk medical conditions in phase 1a or 1b, including 6 states (Maine, Mississippi, Nebraska, New Jersey, Pennsylvania, and Virginia) that have revised their plans since January 11^th.
States continue to operate on different timelines, depending on how large their priority groups are, their capacity to vaccinate, and vaccine supply. Of the 28 states that include those 65+ in phase 1a or 1b, only 15 states are currently registering them for the vaccine (and in several of these states, there are long waits to get a vaccine appointment). In the 19 states that include high-risk younger adults, only 10 have opened eligibility to this group.
In some cases, who is eligible or who can make an appointment to get vaccinated varies within states by county and even by health system within counties.
While states did not make other broad changes to their phase 1a and 1b priority groups, by moving others into the same group or, in some cases, ahead of existing groups through further sub-prioritization, the timeline to receive a vaccine for many—particularly frontline workers—will likely be extended.

Even as some states broaden and simplify the priority groups eligible for COVID-19 vaccination based on new federal guidance, they face the challenge of communicating these changes to an anxious public. And, while expanding who is eligible to receive the vaccine may help to accelerate the pace in some cases, the limited supply of vaccine means many who are now eligible will continue to wait in line for an extended period of time.

Table

Table 1: State COVID-19 Vaccine Prioritization and Phase of Vaccine Distribution, as of January 19, 2021

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Key Characteristics of Health Care Workers and Implications for COVID-19 Vaccination

Authors: Samantha Artiga, Matthew Rae, Gary Claxton, and Rachel Garfield

Published: Jan 21, 2021

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Data Note

Introduction

Across states, health and long-term care workers and residents have been the first groups offered COVID-19 vaccines, consistent with federal recommendations. Previous KFF analysis estimated that, nationwide, 19.7 million adults work in health and long-term care settings, of which roughly 15.5 million are estimated to have direct patient contact and be included in the initial priority group for vaccination. Media reports suggest that the initial vaccination efforts have been slower than expected and that some health care workers who have been offered the vaccine have chosen not to get vaccinated, particularly among staff in long-term care facilities. More information is needed to understand why some health care workers are declining the vaccine, although there are anecdotal reports of concerns about safety and/or side effects. KFF survey data show that roughly three in ten health care workers (29%) express hesitancy about getting the COVID-19 vaccine and that, among all adults, levels of vaccine hesitancy and reasons for hesitancy vary across demographic groups.

This analysis provides an overview of demographic characteristics and health insurance coverage of health care workers with direct patient contact, including those working in hospital and long-term care settings, who may be most at risk of patient contact with someone with coronavirus due to the concentration of cases in these facilities. Increased understanding of who these health care workers are can help inform vaccination efforts and prevent disparities in vaccination among this group.

Findings

Table 1 presents data on race/ethnicity, citizenship status, sex, age, education, poverty status and health insurance coverage for the 15.5 million health and long-term care workers who are estimated to have direct patient contact. It also includes separate data for those working in hospitals and long-term care facilities, who account for 37% and 25% of health care workers with direct patient contact, respectively.

Overall, the data show that, although most of these health care workers are White (59%) and citizens (95%), 41% are people of color and 5% are noncitizens. The majority are women (77%), and nearly one in four (23%) are age 55 or older. Most have completed at least some college (80%), and, reflecting that they are all employed, few are low-income (17%) and nearly all have health insurance coverage (93%). Hospital workers largely mirror these overall patterns, although they have higher levels of education, income, and health coverage. Workers in long-term care settings include higher shares of people of color (52%), non-citizens (8%), women (84%), and workers age 55 or above (27%) and have lower levels of educational attainment, lower incomes, and higher uninsured rates compared to the overall population of health care workers with direct patient contact. More detailed findings include:

Race/ethnicity. Roughly six in ten health care workers with direct patient contact are White (59%), while the remaining 41% are people of color, including 17% who are Black, 14% who are Hispanic, and 8% who are Asian (Figure 1). Among those working in long-term care settings, over half (52%) are people of color, including over one in four (28%) who are Black.¹

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Citizenship Status. The large majority of health care workers with direct patient contact are citizens (95%), while 5% are noncitizens (Figure 1). However, the share who are noncitizens is higher, at 8%, among those working in long-term care settings.

Sex. Over three-quarters (77%) of health care workers with direct patient contact are women, and this share rises to 84% among those working in long-term care settings.

Age. Nearly a quarter (23%) of health care workers with direct patient contact are age 55 or older, while four in ten (41%) are age 35-54 and over one-third (35%) are below age 35. Those working in long-term care settings include a slightly higher share of workers age 55 or above (27%), while those working in hospital settings have a slightly lower share of workers age 55 and older (21%).

Education. Eight in ten of health care workers with direct patient contact have completed at least some college, including 45% who have a bachelor’s degree of higher (Figure 1). Education levels are higher among hospital workers, with nearly nine in ten (88%) completing at least some college, including over half (54%) who have a bachelor’s degree or higher. In contrast, among those working in long-term care, six in ten have completed some college, with only 20% having a bachelor’s degree or higher and 10% having less than a high school education.

Poverty Status. Overall, 17% of health care workers with direct patient contact are low-income (household income less than 200% of the federal poverty level (FPL)), with only 5% with household income below the poverty level (Figure 1). Over half (54%) have income at 400% FPL or higher. Those working in hospitals generally have higher incomes, with nearly two-thirds (64%) having household income at 400% FPL or higher. Household income is lower among those working in long-term care, where one-third (33%) are low-income, including 11% who have household income below poverty.

Health Insurance Coverage. Less than one in ten (7%) health care workers with direct patient contact are uninsured (Figure 1). Nearly eight in ten (79%) have private health insurance coverage, 10% are covered by Medicaid, and 4% have Medicare coverage. Coverage rates are higher among those working in hospitals, with only 3% uninsured and 90% having private coverage. In contrast, coverage rates among those working in long-term care are lower, with 14% uninsured. Moreover, they have higher rates of Medicaid coverage (21%) and lower rates of private insurance (60%).

Table 1: Demographic Characteristics of Adult Health Care Workers with Direct Patient Contact, 2019
	Total	Working in Hospitals	Working in Long-Term Care
Total (millions)	15.5	5.8	3.8
Race/Ethnicity
White	58.6%	61.0%	48.0%
Black	16.6%	14.9%	27.9%
Hispanic	13.8%	11.9%	15.1%
Asian	8.0%	9.4%	5.9%
American Indian or Alaska Native	0.5%	0.4%	0.6%
Native Hawaiian or Other Pacific Islander	0.2%	0.2%	0.2%
Multiple Races	2.2%	2.2%	2.4%
Citizenship Status
Citizen	94.8%	95.7%	91.7%
Noncitizen	5.2%	4.3%	8.3%
Sex
Male	22.6%	23.6%	15.7%
Female	77.4%	76.4%	84.3%
Age
19-25	11.1%	9.8%	12.5%
26-34	23.9%	26.3%	18.8%
35-54	41.8%	42.5%	40.8%
55-64	16.9%	17.1%	19.2%
65+	5.9%	4.1%	7.7%
Education
Less than high school	3.9%	2.1%	9.8%
High school graduate	16.0%	9.8%	29.7%
Some college	35.6%	33.7%	40.0%
Bachelor’s or higher	44.6%	54.4%	20.5%
Federal Poverty Level (FPL)
<100% FPL	5.4%	2.8%	11.5%
100-199% FPL	12.0%	7.5%	21.5%
200%-399% FPL	28.7%	25.6%	34.9%
400%+ FPL	54.0%	64.0%	32.2%
Health Coverage
Uninsured	7.2%	3.1%	13.6%
Private	78.5%	89.6%	59.6%
Medicaid/Other Public	10.2%	5.2%	20.9%
Medicare	4.0%	2.0%	5.8%
Notes: Totals may not sum to 100% due to rounding. Persons of Hispanic origin may be of any race but are categorized as Hispanic; other groups are non-Hispanic. Medicaid/Other Public includes those covered by Medicaid, Medical Assistance, Children’s Health Insurance Plan (CHIP) or any kind of government-assistance plan for those with low incomes or a disability; people who have both Medicaid and another type of coverage, such as dual eligibles who are also covered by Medicare; and people covered under the military or Veterans Administration. Private includes those covered through a current or former employer or union, either as policyholder or as dependent and those covered by a policy purchased directly from an insurance company, either as policyholder or as dependentSource: KFF Analysis based on 2019 American Community Survey

Discussion

Increased understanding of who health care workers with direct patient contact are can help inform vaccination efforts and prevent disparities in vaccination among this group. In sum, these findings show that the roughly 15.5 million health care workers with direct patient contact are a racially diverse workforce. They are predominantly female, with most between ages 35-54. Most have completed at least some college and, reflecting their employment, few are low-income, and the large majority have health insurance. However, those working in long-term care settings are more likely to be Black and have lower levels of education, income, and insurance coverage, which may have implications for access to the COVID-19 vaccine and willingness to get vaccinated.

KFF survey data show, as of December 2020, roughly one in three adult health care workers (29%) said they probably or definitely would not get vaccinated, similar to the share among adults overall (27%). Data also show that levels of vaccine hesitancy vary across demographic groups. For example, adults age 30-49 and Black adults have relatively high levels of hesitancy, while adults ages 65 and older report greater willingness to get the vaccine. Hesitancy varies among health care workers in similar ways. For example, an earlier KFF/The Undefeated survey found that, among adults who are health care workers or who live in a household with a healthcare worker, Black adults were much less likely to say they would definitely get vaccinated compared to White adults (24% vs. 46%). Moreover, different groups have different reasons for vaccine hesitancy. For example, among adults overall who say they probably or definitely won’t get vaccinated, Black adults are more likely than White adults to cite concerns about side effects and the newness of the vaccine, and about half of Black adults in this group cite worries they may get COVID-19 from the vaccine or that they don’t trust vaccines in general as major reasons.

People living in immigrant families and people who are uninsured may also have specific concerns which could make them less likely to seek vaccination. For example, people living in immigrant families may have concerns about potential negative effects on their or a family member’s immigration status. People who are uninsured are less likely to have an established relationship with a health care provider and generally have greater concerns about potential costs of health care.

Addressing concerns and potential access barriers to vaccination among health care workers will be particularly important since, as one of the first groups offered the vaccination and a top trusted messenger for information on the COVID-19 vaccine, their experiences and take-up may help inform the general public’s attitudes and willingness to get the vaccine. Together these data suggest that providing information to respond to concerns about potential side effects and safety of the vaccine is key, particularly among Black health care workers. Clearly communicating that personal information collected for vaccination cannot be used for immigration-related purposes may help reduce fears among noncitizen workers. Moreover, ensuring people know that they will not face any costs associated with the vaccine may reduce concerns among people who are uninsured. Beyond providing education and information, making the vaccine easily accessible is key. While many health care workers are able to access the vaccine directly through their employment site, ensuring it is available in ways that accommodate workers’ varied schedules, caregiving responsibilities, and transportation options can help reduce potential access barriers among those who need to obtain it through pharmacies or community sites.

Methods

The estimates of health care workers are based on KFF analysis of the 2019 American Community Survey (ACS), 1-year file. The ACS includes a 1% sample of the US population. The health care industry is defined as industry codes 5070 and 7970 through 8290 and does not include the childcare or vocational training industries. We include retail pharmacies (industry code 5070) as a healthcare industry. We identified people working specifically within hospital settings using industry code 8191 and 8192, which includes psychiatric and substance abuse hospitals, and people working specifically within long-term care settings using industry codes 8270 (skilled nursing facilities), 8290 (residential care facilities), and 8170 (home health care services). For more information see here. This analysis only includes those individuals who work in health care settings, so does not include health professionals working in other care settings, such as school nurses, and does not include individuals who provide other services to clients, such as social services. We exclude individuals in these industries who are not currently in the labor force. For information on how the healthcare workforce has changed during the course of the pandemic see here.

We identified health care workers who likely have direct patient contact by reviewing the occupation codes of workers in healthcare industries. We included workers providing direct clinical care, such as doctors, nurses, and aides; workers providing direct patient support, such as environmental and food staff; and first line supervisors and managers of these occupations. We excluded administrative and managerial staff who are likely able to work remotely and/or not expected to have direct patient contact through their job duties. It is possible that estimate includes some workers who normally have direct patient contact but who can work remotely, for example, through the use of telehealth.

Endnotes

This share differs slightly from that published in previous KFF analysis due to the inclusion of people earning less than $1,000 per year and slightly different definitions of direct contact workers. ↩︎

Long-Term Care Facilities Battled Rising COVID-19 Cases In Weeks Leading Up to Roll Out of Vaccines to Residents and Staff

Authors: Priya Chidambaram, Daniel McDermott, Chelsea Rice, and Hanna Dingel

Published: Jan 20, 2021

In recent months, the US has experienced record-breaking numbers of coronavirus cases and deaths. A new KFF analysis finds long-term care facility (LTCF) cases and deaths were highest in the final two months of 2020 in many states, mirroring the spike in total COVID-19 case numbers and deaths this winter. A separate KFF analysis of 30 studies published since the start of the pandemic finds increased community-level cases are associated with increased cases in long-term care facilities (LTCFs). The findings underscore the urgency to vaccinate residents and staff at LTCFs, who are included in phase 1a vaccination rollout that began in mid-December.

Approximately three-quarters of reporting states with trend-able data (28 of 38) experienced their highest average weekly number of new coronavirus cases in long-term care facilities in November or December 2020. Over half of reporting states (21 of 39 states) experienced their highest average weekly new COVID-19 deaths in long-term care facilities in the last two months of 2020, mostly in December. These trends align with the timing of when many states experienced their highest state-wide new cases and deaths. Early data from 2021 indicates that states are on track to surpass the record-high new cases and deaths from late 2020, indicating the true peak in long-term care cases and deaths has yet to come in some states.

Rising case numbers in LTCFs are particularly concerning, as these facilities bear a disproportionate burden of COVID-19 deaths. In recognition of their high-risk status, the Centers for Disease Control and Prevention (CDC) has recommended states include LTCF residents and staff in the highest priority group for vaccine distribution, a recommendation all states have followed. However, initial reports indicate slower-than-anticipated rollout, with some reports of high levels of vaccine hesitancy among LTCF staff members. Staff vaccine hesitancy was also a recurring theme in a recent KFF briefing, where experts discussed the LTCF vaccination effort and agreed that there were challenges to overcome. These delays will likely mean additional deaths due to COVID-19 in LTCFs.

Source

Patterns in COVID-19 Cases and Deaths in Long-Term Care Facilities in 2020

The Language of Health Care Reform

Author: Larry Levitt

Published: Jan 19, 2021

Published in the Jan. 19 edition of JAMA, this article from KFF Executive Vice President for Health Policy Larry Levitt lays out the major health policy challenges that will confront President-elect Biden and potential approaches to major reform.While a big reform debate may not be likely this year, one is likely coming as the nation will need to confront much higher costs than in other high-income countries, worse outcomes in many cases, tens of millions of people still uninsured, and many more with burdensome out-of-pocket costs.The broader reform plan likely will draw on President-elect Biden’s campaign plan to create a public health insurance option, administered by Medicare, that anyone could join with premiums capped as a percentage of income. In the short term, though, the new administration may pursue administration actions, including many that would undo what President-elect Biden has called “sabotage” of the Affordable Care Act.

This Week in Coronavirus: January 8 to January 14

Published: Jan 15, 2021

During the 51st week since the first coronavirus case appeared in the United States, the U.S. surpassed 23.3 million total cases and 388,700 deaths due to the pandemic. Here’s our recap of the past week in the coronavirus pandemic from our tracking, policy analysis, polling, and journalism.

With the country’s coronavirus pandemic continuing unabated as cases and deaths increase and a more contagious variant of the virus spreads, there is greater focus on vaccine distribution troubles. KFF President and CEO Drew Altman’s op-ed in The Washington Post calls for a simplified process to fit our “fragmented, multi-layered health system.”

A new analysis examines the different approaches states are taking to manage the limited initial supply of COVID-19 vaccines and balance the desire to vaccinate those at greatest risk first with the need to ensure a fast and effective statewide vaccination effort.

One of the high-priority groups for vaccination are residents and staff of long-term care facilities (LTCFs). The latest data, published this week in a new analysis of the patterns of infections and deaths in LTCFs since the start of the pandemic, outlines that most states saw their highest numbers of LTCF cases and deaths due to COVID-19 in the last two months of 2020. KHN reports that only a quarter of the COVID-19 vaccine doses allocated to Walgreens and CVS through the federal program to vaccinate residents and staff of these facilities has been distributed so far.

Watch a recording of the discussion KFF Medicare and Medicaid policy analysts had this week with long-term care stakeholders, who shared their perspectives on the pandemic response and the ensuing vaccine rollout. In a KFF literature review of more than 30 studies done to analyze these trends so far, cases and deaths were associated with LTCFs that included a relatively large share of Black or Hispanic residents, for-profit status, a large number of beds, and/or an urban location.

The pandemic has disproportionately impacted people of color. In addition to Black and American Indian and Alaska Native people, Hispanic people are overrepresented in coronavirus cases, more likely to suffer worse outcomes, and hit harder by the economic impact of the pandemic than their peers. The latest analysis from the KFF COVID-19 Vaccine Monitor examined Hispanic vaccine hesitancy this week and found that 71% of Hispanic adults said they will “definitely get” the COVID-19 vaccine, with some generational variation. For the non-citizen immigrant population — which represents approximately 13 million members of the U.S. workforce and significant shares of workers categorized as “essential” — our analysis outlines the potential barriers to vaccine rollout.

Drew Altman highlighted another sector of the population that presents a challenge for vaccination efforts: rural America. More than a third of rural Americans say they either will not or probably won’t get the COVID-19 vaccine – a level of overall hesitancy similar to that of Black Americans.

Here are the latest coronavirus stats from KFF’s tracking resources:

Global Cases and Deaths: Total cases worldwide reached 88 million this week – with an increase of nearly 5 million new confirmed cases in the past seven days. There were approximately 95,200 new confirmed deaths worldwide, bringing the total for confirmed deaths to nearly 2 million.

U.S. Cases and Deaths: Total confirmed cases in the U.S. reached 23.4 million this week. There was an increase of nearly 1.7 million confirmed cases between Jan. 7 and Jan. 14. Approximately 23,400 confirmed deaths in the past week brought the total in the United States to 388,700.

State Social Distancing Actions (includes Washington D.C.) that went into effect this week:

Extensions: AK, DC, MI, MN, MT, NM, NV, UT

Rollbacks: IL, OK, WA

The latest KFF COVID-19 resources:

The COVID-19 “Vaccination Line”: An Update on State Prioritization Plans (News Release, Issue Brief)
We Need a Better Way Of Distributing the COVID-19 Vaccine. Here’s How To Do It. (Washington Post Op-Ed)
The Challenge of Vaccine Hesitancy In Rural America (Full Column, Axios Column)
Factors Associated With COVID-19 Cases and Deaths in Long-Term Care Facilities: Findings from a Literature Review (News Release, Issue Brief)
Patterns in COVID-19 Cases and Deaths in Long-Term Care Facilities in 2020 (Issue Brief)
January 14 Web Event: A Shot in the Arm For Long-Term Care Facilities? Early Lessons from the COVID-19 Vaccine Rollout to High Priority Populations (Archived Recording)
Vaccine Hesitancy Among Hispanic Adults (News Release, Poll Finding)
Immigrant Access to COVID-19 Vaccines: Key Issues to Consider (Issue Brief)
Updated: COVID-19 Coronavirus Tracker – Updated as of January 15 (Interactive)
Updated: State Data and Policy Actions to Address Coronavirus (Interactive)

The latest KHN COVID-19 stories:

Hospitals’ Rocky Rollout of Covid Vaccine Sparks Questions of Fairness (KHN)
Feeling Left Out: Private Practice Doctors, Patients Wonder When It’s Their Turn for Vaccine (KHN, CNN)
In Search of a Baby, I Got Covid Instead (CHL, New York Times)
Is Your Covid Vaccine Venue Prepared to Handle Rare, Life-Threatening Reactions? (KHN, NBC News)
Are You Old Enough to Get Vaccinated? In Tennessee, They’re Using the Honor System (KHN, NPR)
Health Workers Unions See Surge in Interest Amid Covid (KHN, NPR)
One Ambulance Ride Leads to Another When Packed Hospitals Cannot Handle Non-Covid Patients (KHN)
California Budget Reflects ‘Pandemic-Induced Reality,’ Governor Says (KHN)
Lost on the Frontline: New this week (KHN, The Guardian)
CVS and Walgreens Under Fire for Slow Pace of Vaccination in Nursing Homes (KHN, CNN)
Delicate Covid Vaccines Slow Rollout — Leading to Shots Given Out of Turn or, Worse, Wasted (KHN, CNN)
Vaccination Disarray Leaves Seniors Confused About When They Can Get a Shot (KHN)
California Counties ‘Flying the Plane as We Build It’ in a Plodding Vaccine Rollout (KHN)
5 Reasons to Wear a Mask Even After You’re Vaccinated (KHN)
When Covid Deaths Aren’t Counted, Families Pay the Price (KHN, The Guardian)
Geography Is Destiny: Dentists’ Access to Covid Shots Depends on Where They Live (KHN)
Journalists Examine How Covid Polarizes Communities (KHN)

Medicaid: What to Watch in 2021

Authors: Robin Rudowitz, MaryBeth Musumeci, and Rachel Garfield

Published: Jan 15, 2021

As the Biden Administration takes office, the ongoing effects of the coronavirus pandemic and related economic downturn are the key issues that will substantially shape Medicaid coverage and financing policy in the year ahead. Other issues to watch in 2021 include efforts to maintain and expand Medicaid coverage, potential changes in Medicaid demonstration waiver policy, issues around state budgets and Medicaid financing, initiatives to strengthen long-term services and supports and efforts to address social determinants of health.

Medicaid Coverage and Enrollment

Enrollment Prior to the Pandemic. Before the pandemic, Medicaid enrollment growth peaked after implementation of the Affordable Care Act (ACA). The ACA Medicaid expansion has been adopted by 39 states and covers more than 15 million adults. However, Medicaid enrollment declined from 2017 through 2019, which has contributed to increases in the overall number and rate of uninsured. Enrollment declines could reflect a more robust economy during those years, but experiences in some states suggest declines may have also been due to individuals experiencing challenges completing enrollment or renewal processes. In addition, the Trump Administration promoted a number of policies that restrict enrollment including issuance of the public charge rule that imposed new barriers to obtaining permanent immigration status or immigrating to the U.S. (leading to declines in participation in Medicaid and other programs broadly across immigrant families). The Trump Administration also supported proposals to repeal and replace the ACA as well as litigation to overturn the law that is pending at the Supreme Court.

Enrollment and COVID-19. As a counter-cyclical program, Medicaid enrollment grows during economic downturns when more people experience income and job loss and qualify for coverage. Since the start of the coronavirus pandemic, enrollment in Medicaid and the Children’s Health Insurance Program (CHIP) grew to 76.5 million in August 2020, an increase of 5.3 million from February 2020 (7.4%). This trend likely reflects changes in the economy due to the pandemic and provisions in the Families First Coronavirus Response Act (FFCRA) that require states to ensure continuous coverage for current Medicaid enrollees to access a temporary increase in the Medicaid match rate. These FFCRA provisions are tied to the Public Health Emergency (PHE) period, which currently expires in April 2021 but may be extended longer.

Key Biden Priorities to Expand Coverage. Biden has proposed building on the ACA by increasing Marketplace premium assistance and creating a Medicare-like public option plan, which would be available to anyone and automatically cover people with low incomes in states that have not expanded Medicaid. While not as sweeping as proposals like Medicare for All, Biden’s proposals are broad changes that could be difficult to pass with a closely divided Senate even with Democrats in the majority. More narrow proposals to address those who fall into the coverage gap in states that have not adopted the expansion include legislation to reinstate the 100% federal matching rate for states that newly adopt the expansion for a period of time (the current match rate for the expansion is 90%), or extending ACA marketplace premium help to people below the poverty level. States that have already expanded Medicaid and are currently paying 10% of the cost might look for additional federal help as well. Twelve states have not adopted the Medicaid expansion, leaving many poor adults in a coverage gap, ineligible for Medicaid or Marketplace subsidies.

Other Options to Expand Coverage. There has been bi-partisan support for legislation that would allow states to extend postpartum Medicaid coverage from the current 60 days to 12 months. Another targeted bi-partisan legislative proposal is the Medicaid Reentry Act, 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. In addition, Congress could consider legislation to allow states the options to cover recent immigrants on Medicaid (eliminating the current 5 year coverage ban for groups other than pregnant women and children).

What to Watch:

How will the health and economic effects of the pandemic affect Medicaid enrollment?
How long will the PHE and the maintenance of eligibility requirements be in place, and what will be the effects on Medicaid coverage when they end?
What will happen with the ACA litigation pending at the Supreme Court?
What efforts to protect and build on the ACA and expand Medicaid will the Biden Administration and Congress pursue?

Medicaid Demonstration Waivers

Section 1115 waivers generally reflect priorities identified by the states and the federal Centers for Medicare and Medicaid Services (CMS), as well as changing priorities from one presidential administration to another. Past administrations have used waivers to expand coverage, modify delivery systems, and restructure financing and other program elements. Although each administration has some discretion over which waivers to approve and encourage, that discretion is not unlimited. Section 1115 waivers are governed by statutory requirements as well as longstanding executive branch policy that waivers be budget neutral to the federal government. The Trump administration’s Section 1115 waiver policy has emphasized work requirements and other eligibility restrictions, payment for institutional behavioral health services, and capped financing.

The Biden Administration can revise current demonstration waiver policy to focus on expanding coverage and rescind or reverse waivers or guidance that could limit coverage (including work requirements) or cap federal financing. The Supreme Court is hearing cases involving the Arkansas and New Hampshire work requirement waivers this term. The Biden Administration also can encourage waivers that expand coverage to targeted groups or help make Marketplace coverage more affordable. This could include guidance to states about using Medicaid Section 1115 waivers in combination with Section 1332 waivers to advance public option proposals or other strategies to improve affordability for consumers and expand coverage. In addition, while addressing behavioral health and substance use disorder through waivers is likely to remain a high priority, the Biden Administration may emphasize the need to provide services across a full care continuum, including institutional community based care. Waivers could also be used to address social determinants of health.

What to Watch:

How will the Biden Administration use Section 1115 waivers?
Will the Biden Administration rescind certain waivers that have already been approved?
Will the Biden Administration issue guidance for states to use combination Section 1115 and 1332 waivers?
What will the Supreme Court decide in pending litigation about work requirements?

Medicaid Financing

Medicaid’s current financing structure provides some protections for states facing higher costs during economic downturns, as federal matching funds (FMAP) automatically increase as enrollment grows. In addition, temporary increases in the federal share of Medicaid funds can provide fiscal relief to states, offsetting some state funds. The FFCRA provided an FMAP increase of 6.2 percentage points through the end of the quarter in which the PHE ends so provided states meet certain requirements to maintain coverage and provide access to COVID-19-related services. With the recent extension of the PHE, the FMAP will be in place through June 2021. However, there is uncertainty about how long the fiscal relief will be in place, and many states are seeing year over year declines in revenues. States need to pass balanced budgets and may face tough choices to cut spending (including for Medicaid) in the upcoming fiscal year. Often during economic downturns, states implement provider rate cuts or benefit restrictions; however, these policies could be difficult given pandemic’s health effects, as states strive to support health care providers and maintain Medicaid provider networks. Changes to the FMAP require legislation and cannot be made through Administrative action alone.

President-elect Biden has indicated support for further increasing the FMAP and may try to work with Congress to enact legislation. Republican leaders have generally opposed substantial increases in state and local assistance during the pandemic and economic crisis, though an increase in federal Medicaid payments could be included in a budget reconciliation bill that requires just a simple majority to pass the Senate. The Medicaid and CHIP Payment and Access Commission (MACPAC) in December 2020 announced moving toward a recommendation calling for an automatic Medicaid countercyclical financing model based on earlier recommendations from the General Accountability Office. The HEROES Act passed by the House in May and then updated and passed again in October would have increased the enhanced FMAP to 14 percentage points through September 2021, providing states with an estimated $55.5 billion in federal support according to the Congressional Budget Office. Congress could also consider alternative options to target the relief to states experiencing higher enrollment increases. However, it remains unclear if Congress will provide additional relief through the FMAP or if they will revisit the maintenance of effort requirements as part of another coronavirus relief package.

Another Medicaid financing issue could be to re-examine the financing for Puerto Rico and the rest of the territories. Federal funding for Medicaid in the territories is subject to a statutory cap and a fixed federal matching rate, unlike in the states, where federal Medicaid funding is not capped, and the federal share varies based on states’ per capita income. As a result of the capped financing, the effective FMAP is generally lower than the statutory levels. Hurricanes and other emergencies exacerbated long-standing fiscal issues in the territories. Additional funding support (through both increased amounts and increases in the FMAP) have been provided through the ACA and then in response to other emergencies. For Puerto Rico, support is expected to expire at the end of FY 2021. Congress could extend relief or make more permanent funding changes for Puerto Rico and other territories.

What to Watch:

To what extent will the pandemic continue to affect state budgets and ability to finance Medicaid? Will states propose Medicaid cuts in the upcoming state fiscal year?
How long will the PHE and the temporary increase in the FMAP remain in place?
Will Congress consider proposals to adopt additional fiscal relief or a permanent counter-cyclical adjustment or address Medicaid financing in the territories?

Long-Term Services and Supports

Medicaid is a significant source of coverage for seniors and people with disabilities, including those who need long-term services and supports (LTSS). Most eligibility pathways based on old age or disability, and nearly all home and community-based services (HCBS), are optional for states, creating state variation. The COVID-19 public health crisis has highlighted the significance of Medicaid coverage for people with disabilities through the ACA expansion as well as optional eligibility pathways based on old age or disability and optional HCBS benefit packages, as these populations have been hit particularly hard by the pandemic. Many seniors and people with disabilities rely on Medicaid LTSS to meet daily self-care and independent living needs, which has taken on even greater consequence during the pandemic. At the same time, state budget shortfalls could make it challenging for states to maintain optional LTSS.

President-elect Biden supports legislative changes to increase federal Medicaid funding for and expand access to HCBS. More broadly, Congress could consider proposals to eliminate Medicaid’s historical institutional bias by making HCBS a mandatory benefit. Federal and state policymakers also are expected to continue focusing on nursing home oversight, including compliance with federal Medicaid and Medicare infection control and other care quality measures as the pandemic continues. As states rollout their vaccine priority plans, additional attention will focus on reaching LTSS users and staff beyond nursing facilities, including people receiving and delivering HCBS.

What to Watch

What actions will states continue to take to address the pandemic’s disproportionate impact on seniors and people with disabilities, and will any of these policy changes continue after the PHE ends?
Will Congress consider legislation to expand coverage and financing for Medicaid community-based LTSS?

Social determinants of health (SDOH) are the conditions in which people are born, grow, live, work, and age that shape health. Addressing SDOH is important for improving health and reducing longstanding disparities in health and health care. SDOH include but are not limited to housing, food, education, employment, healthy behaviors, transportation, and personal safety. Within the health care system, there are multi-payer federal and state initiatives as well as Medicaid-specific initiatives focused on addressing social needs. Although federal Medicaid rules prohibit expenditures for most non-medical services, states have been developing strategies to identify and address enrollee social needs both within and outside of managed care. Medicaid managed care plans may use administrative savings or state funds to provide some of these services. CMS released additional guidance for states about opportunities to use Medicaid and CHIP to address SDOH on January 7. The pandemic has exacerbated the challenges for state Medicaid programs related to health care access and other SDOH and has shined a light on persistent health inequities due to the disparate impact of COVID-19 on people of color. Access to food and housing are areas of growing need as many people have lost jobs and income.

What to Watch:

How can Medicaid be leveraged to help address SDOH during the pandemic and beyond?
How will efforts be implemented (e.g. through managed care, waivers, etc.)?
How will efforts affect health and health disparities?

News Release

Most Hispanic Adults Lean Towards Getting a COVID-19 Vaccine, But Many Younger Adults are Hesitant

Younger Hispanic Adults are Less Likely to Express Confidence that the Vaccine Is Safe and to See Vaccination as a Shared Responsibility

Published: Jan 14, 2021

A new analysis of KFF COVID-19 Vaccine Monitor survey data finds that most Hispanic adults across the country want to get a COVID-19 vaccine at some point though younger adults are more hesitant, in part because of lower confidence that it is safe and effective.

Overall a quarter (26%) of Hispanic adults say they will get a COVID-19 vaccine “as soon as possible” and an additional 43% say they will “wait until it has been available for a while to see how it is working for others” before getting it. Fewer say they will only get a vaccine “if required to do so for work, school or other activities” (11%) or that they “will definitely not” get the vaccine (18%).

In addition, a quarter (26%) of Hispanic adults say they definitely or probably won’t get the vaccine, similar to the national average (27%), while some of the most vaccine-hesitant groups are Black adults (35%), rural residents (35%) and Republicans (42%).

The data shows a wide age divide, with Hispanic adults under age 50 twice as likely to say they “definitely will not” get the vaccine as older Hispanic adults (22% and 11%, respectively). In addition, nearly one in five (18%) Hispanic essential workers (who also tend to be younger) say they would “definitely not get” a vaccine, a potential concern for vaccination efforts since they are required to work outside their homes and are more likely to have interactions with other people.

The age gap reflects differences in attitudes about a COVID-19 vaccine.

Older Hispanic adults are more likely than younger ones to express confidence that a vaccine has been proven safe and effective (73% vs. 56%). In addition, two thirds of older Hispanic adults also say getting a COVID-19 vaccine is “part of everyone’s responsibility to protect the health of others,” while younger ones are about as likely to say so (48%) as to say it is “a personal choice” (50%).

These findings suggest that younger Hispanic adults may need to be reassured about vaccine safety and could be more receptive to messages about how vaccination would protect themselves and allow their lives to return to normal than about the impact on the broader community. Similar to the public at large, a large majority of Hispanic adults say they would trust vaccine information from their own doctor or health care providers (75%). Most also say they would trust information from the CDC (71%), the FDA (66%), their local public health department (65%), Dr. Anthony Fauci (62%) and President-elect Joe Biden (58%).

Many Hispanic adults also face additional barriers to getting vaccinated, such as lack of health insurance or a usual source of care, lack of information about the vaccine being cost-free, and logistical barriers such as limited transportation.

Contact

Craig Palosky

KFF

cpalosky@kff.org

Poll Finding

Vaccine Hesitancy Among Hispanic Adults

Authors: Audrey Kearney, Lunna Lopes, and Mollyann Brodie

Published: Jan 14, 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 focus groups, this project will track the dynamic nature of public opinion as vaccine development unfolds, including vaccine confidence and hesitancy, trusted messengers and messages, as well as the public’s experiences with vaccination as distribution begins.

Vaccine Hesitancy Among Hispanic Adults

The COVID-19 pandemic has had a disproportionate impact on people of color. A previous KFF analysis found that along with Black and American Indian and Alaska Native (AIAN) people, Hispanic people were overrepresented in coronavirus cases and more likely to suffer worse outcomes than their White counterparts. Moreover, Hispanic adults have been harder hit by the economic impact of the pandemic as the December 2020 KFF COVID-19 Vaccine Monitor poll finds half (52%) of Hispanic adults say their household has lost a job or income since the coronavirus began spreading in the U.S. in February 2020 –compared to fewer White adults (42%) who say the same. With the risk of coronavirus ever present, four in ten Hispanic adults (43%) say they are essential workers required to work outside their home during the coronavirus outbreak (78% of all employed Hispanic adults compared to six in ten employed White and Black adults). With Hispanic adults being among the groups most impacted by the pandemic, the KFF COVID-19 Vaccine Monitor finds that while most Hispanics are open to getting vaccinated, there remains a sizeable share, particularly among younger Hispanics, who express at least some vaccine hesitancy. Communication efforts focused on reaching Hispanics will need to take this and other heterogeneity into account. This analysis seeks to shed light on what we know so far about vaccine hesitancy among Hispanic adults and the messages and trusted messengers that might succeed at ensuring a robust vaccination effort for this key group.

Most Hispanic adults indicate they are likely to get the COVID-19 vaccine with seven in ten (71%) saying they will “definitely get” the vaccine (36%) or “probably get it” (35%). While a similar share of White adults (73%) say they will probably or definitely get the vaccine, Hispanic adults are less likely than their White counterparts to say they “definitely” will get it (36% vs. 46%). About one in four Hispanic adults say they will “probably not get it” (8%) or “definitely not get it” (18%).

Figure 1: Seven In Ten Hispanic Adults Say They Will Get A COVID-19 Vaccine

One in four Hispanic adults (26%) report being the most enthusiastic to get the vaccine saying they will get the COVID-19 vaccine “as soon as possible,” an additional four in ten (43%) say they will “wait and see” how it is working for others before getting the vaccine. One in ten (11%) say they will only get the vaccine if they are required to do so for work or other activities and 18% of Hispanic adults say they “will definitely not” get the vaccine, similar to the share of White and Black adults who say they definitely will not get the vaccine (15% each). While a majority of Hispanic adults indicate they are open to getting the vaccine, a smaller share of Hispanic adults compared to White adults express enthusiasm of wanting to get the vaccine as soon as possible (26% vs. 40%).

Figure 2: One In Four Hispanic Adults Say Will Get The Vaccine ASAP, Four In Ten Want To “Wait And See”

Among Hispanic adults, differences across age groups are more pronounced than those across gender, education, and income levels. Mirroring age differences among White adults, there is a generational divide among Hispanic adults when it comes to vaccine hesitancy. While eight in ten Hispanic adults ages 50 or older say they will either “definitely” (44%) or “probably” (36%) get the COVID-19 vaccine, two-thirds of Hispanics under 50 say the same. Moreover, when asked more specifically about when they would like to get vaccinated, four in ten (38%) Hispanic adults over 50 say they would want to get vaccinated “as soon as they can,” compared to one in five younger adults who say the same. Indeed, the largest share of younger Hispanic adults would prefer to “wait and see” (45%) before getting the COVID-19 vaccine. As about three in four Hispanic adults in the U.S. are under the age of 55, these younger Hispanics will be a key group for vaccination outreach efforts.

Notably, though most Hispanic essential workers — a group that is largely made up of adults under age 50 — say they will definitely or probably get the vaccine (69%), just one in four (23%) say they want to get the vaccine “as soon as they can” while one in five (18%) say they will “only get the vaccine if it is required” and a similar share of essential workers say they “definitely won’t” get the vaccine (18%). As efforts to distribute the COVID-19 vaccine continue, vaccine acceptance among these Hispanic essential workers will be particularly important given they are more likely to have interactions with many other people.

Figure 3: Among Hispanics Larger Shares Of Younger Adults And Essential Workers Express Vaccine Hesitancy

Hispanic Age Gap In Confidence In The Vaccine

The December KFF COVID-19 Vaccine Monitor finds a generational confidence gap may be contributing to why older Hispanic adults are more likely to report wanting a COVID-19 vaccine “as soon as they can,” while younger Hispanic adults may be more hesitant. Overall, six in ten Hispanic adults say that they are at least somewhat confident that when a COVID-19 vaccine is available, it will have been tested for safety and effectiveness (61%), it will be distributed in a way that is fair (61%), and that the development of the COVID-19 vaccine is taking into account the needs of Hispanic or Latino people (60%). However, Hispanic adults over the age of 50 are more likely than those under 50 to say they are confident in each of these items, with larger shares of older adults saying they are confident that a vaccine will have been tested for safety and effectiveness (73% vs. 56%), that it will be distributed in a way that is fair (70% vs. 57%), and that the development of the COVID-19 vaccine is taking into account the needs of Hispanic or Latino people (68% vs. 56%).

Figure 4: Nearly Seven In Ten Older Hispanic Adults Are Confident The Development Of A COVID-19 Vaccine Considers People Like Them

Moreover, while two-thirds of older Hispanic adults (67%) see getting vaccinated for COVID-19 as “part of everyone’s responsibility to protect the health of others,” younger Hispanic adults under 50 are divided on whether they see getting the vaccine as a collective responsibility (48%) or as a personal choice (50%). Half of Hispanic essential workers (52%) say that getting vaccinated is more a “personal choice.”

Figure 5: Two-Thirds Of Older Hispanic Adults Say Getting Vaccinated Is Part Of Everyone’s Responsibility

Hispanic Trust In Public Health Messengers May Help Address concerns Among Those Most Hesitant

Despite a sizeable share of younger Hispanic adults and Hispanic essential workers expressing some hesitancy towards the COVID-19 vaccine, majorities of Hispanic adults overall say they trust their own doctor or health care provider to provide reliable information about a COVID-19 vaccine (75%) and majorities say they trust the CDC (71%), the FDA (66%), their local public health department (65%), Dr. Fauci (62%), or President-elect Joe Biden (58%). Even among Hispanic adults who say they want to “wait and see” before they get the vaccine, at least six in ten say they trust these public health officials and organizations.

Yet notably, younger Hispanic adults are less trusting than their older counterparts of government officials, including President-elect Joe Biden and state government officials. However, about two-thirds of Hispanic adults, regardless of age, say they trust their local public health department to provide reliable information about the COVID-19 vaccine and about seven in ten or more trust their own doctors and the CDC.

Figure 6: Younger Hispanic Adults Are Less Trusting Of Political Sources Of Information For The COVID-19 Vaccine

Notably, many people, including many Hispanic adults, also face additional barriers to getting vaccinated, such as lack of health insurance or a usual source of care, lack of information about the vaccine being cost-free, and logistical barriers such as limited transportation. However, as the new Biden Administration is set to take over the country’s vaccine distribution efforts and address vaccine hesitancy, Hispanic adults overall and as well as those who express some hesitancy to get vaccinated, appear to be open to information from public health organizations and individuals.

Younger Hispanic adults, in particular, may need to be reassured about the safety and effectiveness of the vaccine. Moreover, these younger Hispanic adults who express hesitancy about the vaccine may not be swayed by messages stressing the importance of vaccination for the health of the broader community, but may instead be more receptive to information that highlights how getting vaccinated may be the right choice for them to make in order to protect themselves, their families and get their lives back to normal.

Methodology

This KFF Health Tracking Poll/ KFF COVID-19 Vaccine Monitor was designed and analyzed by public opinion researchers at the Kaiser Family Foundation (KFF). The survey was conducted November 30- December 8, 2020, among a nationally representative random digit dial telephone sample of 1,676 adults ages 18 and older (including interviews from 298 Hispanic adults and 390 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. The sample also includes interviews completed with respondents who had previously completed an interview on the KFF Tracking Poll (n =267) or an interview on the SSRS Omnibus poll (and other RDD polls) and identified as Hispanic (n = 80; including 14 in Spanish) or non-Hispanic Black (n=179). Computer-assisted telephone interviews conducted by landline (391) and cell phone (1,285, including 947 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.

Group	N (unweighted)	M.O.S.E.
Total	1,676	± 3 percentage points

Hispanic adults
Total Hispanic adults	298	± 7 percentage points
Hispanic adults, ages 18-49	186	± 8 percentage points
Hispanic adults, ages 50+	111	± 12 percentage points

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News Release

Despite Efforts to Slow the Spread of the Virus in Long-Term Care Facilities, KFF Analysis Finds Many States Experienced the Worst COVID-19 Outbreaks and Highest Number of Deaths in December

Long-Term Care Facilities Were More Likely to Have COVID-19 Cases and Deaths If They Had a Relatively Large Share of Black or Hispanic Residents, Were For-Profit Status, Had A Relatively Large Number of Beds, and Were in Urban Areas, Based on KFF Review of 30 Studies

Published: Jan 14, 2021

For some regions of the country, recent months have brought the worst COVID-19 outbreaks in long-term care facilities since the start of the pandemic, a new KFF analysis of state-reported cases and death shows, underscoring the importance of current efforts to vaccinate this high priority group.

The novel coronavirus has had a disproportionate impact on older adults in general and nursing home and other long-term care facility residents and staff in particular. Six percent of all COVID-19 cases nationally and 38 percent of deaths from the virus have been associated with long-term care settings.

The new analysis finds that many states reported their highest average weekly number of new coronavirus cases in long-term care facilities in November or December 2020, mirroring the nationwide surge in cases in fall and early winter.

Deaths in such facilities nationally also were rising late in the year, but were still below the peaks seen in April, when the novel coronavirus first swept through nursing homes in the Northeast. Overall COVID-19 cases and deaths are still rising nationally, which means they likely are in long-term care facilities as well. The authors note that it is likely that many states will hit peak new cases and deaths in long-term care facilities in the early months of 2021, surpassing 2020 levels.

A second new KFF analysis synthesizes the findings of 30 studies that examined potential factors associated with COVID-19 cases and deaths in long-term care facilities. It finds that community transmission was consistently associated with cases and deaths. It also finds that certain facility characteristics are associated with COVID-19 cases and deaths, including having a relatively large share of Black or Hispanic residents, for-profit status, having a relatively large number of beds, and being located in urban areas. Further, there is some evidence that nursing homes with higher staffing levels, including higher 5-star quality ratings for staffing from the Centers for Medicare and Medicaid Services, have a lower likelihood of cases or deaths.

In other areas the evidence is less clear, such as whether patient transfers from hospitals or other settings contribute to the spread of the virus, and the relationship between overall nursing home quality ratings and COVID-19 cases and deaths. The review also identified gaps in the literature, including lack of research evaluating whether shortages of personal protective equipment, testing and staff were associated with COVID-19 cases or deaths, or whether practices such as setting up separate COVID-19 facilities or policies restricting nursing home visitors directly affected the spread of infection in long-term care facilities.

KFF released the new analyses in advance of a public briefing that examines the status of COVID-19 vaccination efforts in long-term care facilities, including challenges so far and opportunities for improvement.

For more data and analyses about the pandemic and long-term care, visit kff.org

Contact

Chris Lee

KFF

clee@kff.org

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Table

Table 1: State COVID-19 Vaccine Prioritization and Phase of Vaccine Distribution, as of January 19, 2021

Key Characteristics of Health Care Workers and Implications for COVID-19 Vaccination