Republicans and Black Americans are More Likely to Be Hesitant but Even Among These Groups Reasons Vary

KFF has launched a new COVID-19 Vaccine Monitor to dive deeply into the public’s views about the vaccine and experiences getting it for as long as the pandemic lasts.

First results released today show that Americans’ enthusiasm for getting a COVID-19 vaccination varies substantially across groups, with Republicans and Black Americans among those most hesitant.

Overall, 71% of the public says they definitely or probably would get a vaccine, up from 63% in September. Still about a quarter (27%) of the public is vaccine hesitant, saying they probably (12%) or definitely (15%) would not get a COVID-19 vaccination even if it were available for free and deemed safe by scientists.

Hesitancy remains highest among Republicans (42%), those ages 30-49 (36%), rural residents (35%), and Black adults (35%), a group that has been disproportionately affected by the pandemic.

Some Black adults are hesitant for reasons that could change with more information. For example: 71% of those who say they won’t get vaccinated say a major reason is that they are worried about possible side effects (which are expected to be mild) and half (50%) say they worry they could get COVID-19 from the vaccine. But nearly as many hesitant Black adults (47%) say they are hesitant to get the COVID-19 vaccine because they don’t trust vaccines in general.

Among another large group of the hesitant – Republicans – top reasons for not getting vaccinated may be tougher to change, including believing the dangers of COVID-19 have been exaggerated (57% of hesitant Republicans cite this as a major reason), and that they don’t trust the government to ensure a vaccine is safe and effective (56%). Nearly as many (54%) also worry about possible side effects.

“Many who are hesitant are in wait-and-see mode, and their concerns include worries about side effects and whether the vaccine can cause COVID-19, which may dissipate as people get more information and see the vaccine introduced successfully among people they know,” KFF President and CEO Drew Altman said.

The initial Monitor survey identifies four broad categories of enthusiasm for getting a vaccination that pose different messaging challenges:

• A third of the public (34%) are in the most enthusiastic “as soon as possible” group, who want to get vaccinated as soon as they can. This group is disproportionately made up of Democrats, seniors, white adults, and people with college degrees. Some in this group may become frustrated if they are not among the priority groups receiving early vaccinations.
• The “wait and see” group is the largest, comprising 39% of the public, and generally want to see how vaccinations work for other people before getting it themselves. This group looks like the public at large, and their willingness to get vaccinated may depend on what they learn during its initial rollout, including news reports about its effectiveness, safety and side effects.
• The “only if required” group is the smallest, representing 9% of the public, and say they would only get vaccinated if required for work, school or other activities. Most (61%) of this group are essential workers who work outside their homes during the pandemic, a category considered high risk for exposure.
• The most resistant group, representing 15% of the public, says they would “definitely not” get vaccinated, even if it were deemed safe and available for free. This group is disproportionately made up of Republicans and of people with no more than a high-school level education.

“Many Americans who are hesitant are simply reserving judgment before they are ready to get vaccinated. However, nearly one in four Republicans don’t want to get vaccinated because they don’t believe COVID poses a serious threat,” KFF Executive Vice President Mollyann Brodie said. “It will be a real challenge to undo COVID denialism among this slice of President Trump’s political base.”

Those who are more hesitant to get vaccinated for COVID-19 are also more likely to harbor misconceptions about the pandemic and related public health measures, which may make them less receptive to public health messages generally, including those about the importance of vaccinations.

For example, two-thirds (68%) of the “definitely not” group and more than a third (37%) of the “only if required” group incorrectly believe that wearing a face mask does not protect the wearer from coronavirus. Similarly, more than half (54%) of the “definitely not” group and about three in ten (29%) of the “only if required” group believe that wearing a face mask is harmful to one’s health.

Personal Health Care Providers are the Public’s Most Trusted Sources for Vaccine Information

As with many health topics, the poll finds people’s personal health care providers are at the top of the list as a trusted source of vaccine information, ahead of any national, state, or local messengers.

More than eight in ten (85%) say they trust their own doctor or health care provider to provide reliable information on a COVID-19 vaccine, while about seven in ten also trust national messengers like the U.S. Centers for Disease Control and Prevention (73%), the Food and Drug Administration (70%), and Director of the National Institute of Allergy and Infectious Diseases, Dr. Anthony Fauci (68%), as well as their local public health department (70%).

Somewhat fewer, but still a majority, put at least a fair amount of trust in their state government officials (58%), President-elect Joe Biden (57%), and pharmaceutical companies (53%), while about a third (34%) say they trust President Trump.

Trust in personal doctors is high among all racial and ethnic groups and across partisan groups. When it comes to government sources of information, however, a much larger share of Democrats than Republicans say they trust such sources to provide reliable information about a COVID-19 vaccine, with independents generally falling in the middle.

The survey suggests the race to develop a vaccine is helping to improve the public’s views of pharmaceutical companies. Most (58%) of the public say that drug companies working on a COVID-19 vaccine are equally interested in the public good and making a profit. That contrasts sharply with the public’s view in July that found the majority of the public (76%) say drug makers generally care mostly about profits.

Designed and analyzed by public opinion researchers at KFF, the survey was conducted from Nov. 30-Dec. 8 among a nationally representative random digit dial telephone sample of 1,676 adults, including oversamples of adults who are Black (390) or Hispanic (298). Interviews were conducted in English and Spanish by landline (391) and cell phone (1,285). The margin of sampling error is plus or minus 3 percentage points for the full sample. For results based on subgroups, the margin of sampling error may be higher.

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 reactions 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.

Introduction

The Centers for Disease Control and Prevention (CDC) and other public health officials recommend that people who are sick with COVID-19 should stay home and that employers should consider implementing a telecommuting program when possible. Benefits such as sick leave and family leave can help employees follow these guidelines. However, the U.S. does not have national standards on paid family or sick leave. Our current system is a patchwork of policies that are determined by employers, state and local laws, or negotiated through labor contracts. Offer rates vary between employers, the reasons for needing leave, and the employment status of their workers. The lack of a national policy means some employees are forced to take unpaid leave, or come to work when they are ill. The lack of paid leave disproportionately impacts certain populations, including low-income persons, who are less likely to have access to these benefits, and could have public health consequences if people cannot afford to take time off. Lack of paid leave also has a large impact on women, who take on the bulk of health care responsibilities for their family members and may have to miss work as a result.

While there have been previous congressional efforts to create a uniform national floor for paid leave, this issue has gained new urgency with efforts to stem the spread of COVID-19. Since the outbreak began in the U.S., the President has signed into law the Families First Coronavirus Response Act as well as the C.A.R.E.S. Act. These laws include the following emergency short-term paid sick leave benefits and longer-term paid family leave policies.

• Employers with fewer than 500 employees and all public employers are required to provide up to two weeks of fully-paid sick leave (up to $5,110) for immediate use to workers unable to work due to their own quarantine or symptoms of coronavirus, and up to two-thirds of regular pay for two weeks (up to $2,000) for employees who are unable to work in order to care for someone in quarantine or whose child’s school or daycare is closed because of coronavirus.
• Separately, employers with fewer than 500 employees and all public employers are required to provide paid family leave to workers who are unable to work because their child’s school or daycare has closed due to coronavirus in the amount of two-thirds of their regular pay (up to $10,000) for up to 12 weeks, after a 10-day unpaid waiting period.
• The emergency paid family leave benefit only applies to employees covered by Title II of the Family and Medical Leave Act (FMLA); therefore, most federal employees are not eligible.
• Neither emergency paid leave provision applies to employees of private businesses with 500 or more employees.
• Health care workers, emergency responders, and certain federal employees in the Executive Branch may also be excluded from receiving these benefits.
• Workers employed by a business with fewer than 50 employees may also be excluded from receiving these benefits if their reason for missing work is due to their child’s school or daycare closure.
• Participating employers will receive advanceable quarterly tax credits to cover the costs of providing the new leave benefits.
• All provisions take effect 15 days after enactment (April 1, 2020), do not provide for retroactive benefits, and expire December 31, 2020.

Access to paid sick leave benefits varies greatly between employees, employers, and regions.

Sick leave benefits typically allow employees to miss work without losing pay when they or a family member has a short-term illness. There is no federal requirement that employers offer employees paid sick leave, but some employees, including federal government employees, have generally had access to paid sick leave through employee benefits packages.

Thirteen states plus D.C. and 22 cities and counties¹  have passed laws requiring that eligible employees get paid time off to care for themselves or sick family members. Another two states (ME and NV) require employers to provide general paid time off for workers to use as needed, including for sick leave (Figure 1). These state and local laws, however, do not apply to all workers in these locations; small employers are sometimes exempt, and part-time workers and those who have worked for their employers for a short duration may not be eligible for these benefits. Additionally, the duration, accrual rates, and circumstances under which paid sick leave may be taken vary by policy and state. Eight states’ and 11 localities’ requirements explicitly apply to public health emergencies, such as closure of a business or child’s school to protect public health.

In response to coronavirus, on March 17, 2020, New York state implemented a temporary emergency paid sick leave law for workers who are subject to coronavirus-related quarantine (or to care for their children subject to quarantine). Since then, another four states, plus D.C., and 14 localities²  have passed their own emergency paid sick leave laws, many aimed at closing the gaps in the federal FFCRA legislation.

Research suggests that paid sick leave can help stem the spread of illness by reducing presenteeism (going to work ill) in the workplace and the chance of sending sick children to school or daycare. Sick workers are more likely to stay home when they do not lose pay. Parents with paid sick leave benefits may be less likely to send sick children to school than parents without these benefits.

How many workers have paid sick leave?

According to the Bureau of Labor Statistics, three in four (75%) of workers in private industry have access to at least some paid sick leave, as do approximately nine in ten (91%) state and local government workers.

However, there are wide disparities in access to paid sick leave (Table 1). Among private industry workers, rates of paid sick leave rise with wages, with about half (49%) of workers in the lowest wage quartile ($13.25/hour on average) having this benefit, compared to 92% in the highest quartile. Less than half of part-time workers (45%) in private industry have paid sick leave, compared to 86% of full-time employees. The lower likelihood of paid sick leave for part-time workers has a disproportionate impact on women, who are more likely than men to hold part-time jobs. Workers in certain industries are more likely to have paid sick leave than in others. Union workers (88%) and workers are larger employers (88%) are more likely than non-union workers (74%) and workers at smaller employers (66%) to offer paid sick leave to their workers. Access to paid sick leave also varies by worker occupation. For example, 95% of workers in management, business, and financial occupations have paid sick leave, compared to 57% of workers in construction, extraction, farming, fishing, and forestry occupations.

Among workers in private industry who have paid leave benefits, the average duration is seven days; however, one-quarter (25%) of workers have fewer than five days. For state and local government workers, the average is 11 days, and 9% have fewer than five days.

Most workers do not have paid family and medical leave benefits.

Should the coronavirus require employees to stay home from work for longer periods, some may turn to family and medical leave benefits, which typically can be used for longer-term illnesses. This is particularly important for COVID-19, given that some infected persons could be quarantined for as long as 14 days.

There is no federal requirement for employers to provide paid family and medical leave. The Family and Medical Leave Act (FMLA) requires eligible employers to provide 12 weeks of unpaid family leave to care for seriously ill family members, and job protection when employees return to work. Employees can use family leave to care for children or other relatives, including aging parents, who are at heightened risk for coronavirus. Women are the primary caregivers for the nation’s older population, comprising roughly two-thirds of informal caregivers, and many work outside the home.

The FMLA protections apply to 60% of the workforce, as the law only applies to employers with at least 50 employees, and not all employees within covered worksites are eligible. This means that in addition to losing pay when they take medical leave, many workers’ jobs may not be protected by the FMLA.

Currently, nine states and D.C. have enacted paid family leave laws, with partial wage replacement up to a designated cap (Figure 2). Duration of leave varies by state, but most provide for 6 to 12 weeks, and all allow leave for the care of seriously ill children, spouses, partners, parents, and in some cases to all blood relatives. Some of these state policies use disability benefits systems to provide the wage replacement.

How many workers have paid family and medical leave?

Despite strong public support and the growing interest in paid family and medical leave at the local level, only 20% of private industry workers and 26% of state and local government workers have access to it, with wide variation around worker and employer characteristics (Table 2). As with access to paid sick leave, full-time workers, higher-wage earners, workers at larger employers, and management/professional occupations are more likely to have access to paid family leave than their counterparts.

Few low-wage workers have worked at home.

The CDC has also encouraged employers to consider greater use of telecommuting as part of the push for social distancing during the pandemic. However, not all employers or job positions are amenable to telecommuting. Just a quarter (25%) of workers worked at home in 2017-2018. The rate of telecommuting varies greatly between industries, with almost half of workers in financial activities and professional services (47%) having worked at home, compared to less than a tenth of workers in leisure and hospitality industries (7%). Within industries, there can be variation by position. Half (51%) of those in management positions have worked at home, compared to 7% in maintenance and repair positions. The share is also lower among workers with lower wages as well as Hispanic workers (Figure 3).

Among workers with children, mothers are usually the ones to stay home when children are sick. Most do not get paid during this time.

The limits on paid leave benefits are also of importance to parents who work outside the home, as some schools across the country have closed and many others are considering it in response to COVID-19. Women comprise nearly half of the nation’s workforce and are usually the ones to care for children when they are sick and cannot attend school or daycare. Four in ten (40%) mothers working outside the home say they must take time off work and stay home when their children are sick, compared to 10% of fathers working outside the home (Figure 4). However, more than half (56%) of the working mothers who must miss work when their children are sick forgo their wages when they take time off (Figure 5).

Having to miss work to care for a sick child has a disproportionate impact on workers who are low-income or in part-time jobs, as they are less likely than their counterparts to have paid sick leave or family leave benefits (Table 3). Furthermore, mothers in part-time jobs are more likely to report they have to miss work when their child is sick (51%) compared to about a third (36%) of their full-time counterparts. Low-income mothers who must miss work when their child is sick are also far more likely to lose pay (73%) compared to higher-income mothers (47%).

Should children become sick with COVID-19, lack of paid leave will also have a disproportionate impact on the nation’s mothers, who, more often than fathers, report being the primary person to take children for doctor’s appointments (77% mothers, 24% fathers) or obtain any recommended follow up care (77% mothers, 19% fathers) (Figure 6). Women also comprise the majority of caregivers for aging and sick parents.

Conclusion

The COVID-19 pandemic is shining a spotlight on gaps in employer leave benefits and the risk of employees losing pay if they stay home because they are sick or to care for others. Some employers have changed policies in light of this situation and are now offering more workers paid leave, which may encourage employees to stay home if they are sick and reduce risks to public health. Some employers say that they do not have the means to offer paid leave to their employees. While this pandemic adds new urgency to this issue, it is important to recognize that nearly all workers will need to take time off at some point during the course of their careers either for their own health or to care for a family member. However, those who earn the lowest wages are the least likely to have this important benefit. These individuals had a gap in benefits before the COVID-19 pandemic, and unless long term action is taken, will likely continue to lack paid leave after the urgency of the pandemic is behind us.

1. Bernalillo Co., NM, has a paid sick leave law that is not included here because it only applies to employers in unincorporated parts of the county; most employers are located in Albuquerque. ↩︎
2. San Mateo and Sonoma Counties (CA) have temporary emergency paid sick leave laws that are not included here because they only apply to certain employers in unincorporated parts of the county. ↩︎

Recent KFF analysis suggests that the overall uninsured rate may not have changed that substantially during the pandemic. On one hand, this is good news since early estimates predicted a drastic increase in the uninsured rate given the scale of employment losses. On the other hand, if the uninsured rate has indeed held steady, it would mean there are still tens of millions of people without health coverage during the pandemic. Many of these uninsured people are eligible for financial assistance under the Affordable Care Act (ACA), but they may have just hours left to sign up for coverage before the ACA Open Enrollment window closes at midnight December 15.

As the chart below shows, most of the uninsured in a typical year are eligible for financial help to buy coverage, and of those, most are eligible for a free or nearly free plan. Before the pandemic, about one in four uninsured people were eligible for Medicaid and another third were eligible for financial assistance on the Marketplaces, meaning, in total, 57% of the uninsured could get financial help to access coverage. In fact, most of those eligible for help can get free (or nearly free) insurance coverage. The 24% of uninsured people who are eligible for Medicaid (6.7 million people) generally would pay no premium to sign up, and another 16% of the uninsured (4.5 million people) are eligible for a Bronze plan with a $0 premium.

More than a month into the current Marketplace Open Enrollment period for 2021, signups in federal exchange states appear strong, but the vast majority of signups are from returning enrollees. We still are not seeing a surge of signups from new enrollees relative to past years, but many people who are uninsured may be surprised at what they find if they look at their options.

The federal Open Enrollment period runs through midnight December 15, but it extends into January in most states that operate their own health insurance exchanges. There is no deadline to sign up for Medicaid. If you have questions about signing up for coverage, please see our FAQ page.

Source

Millions of Uninsured Americans are Eligible for Free ACA Health Insurance

Introduction

On December 11, the Food and Drug Administration (FDA) issued the first emergency use authorization (EUA) for a COVID-19 vaccine – the Pfizer-BioNTech vaccine – followed by the Centers for Disease Control and Prevention (CDC)’s recommendation for use, clearing the way for delivery and administration of the vaccine throughout the country. Initially, supply will be very limited, meaning states have to make difficult decisions about who should get the first allocations.

To help guide these decisions, the CDC’s Advisory Committee on Immunization Practices (ACIP) released an interim recommendation on December 1 for the highest priority group (“Phase 1a”) to include health care workers (HCWs) and long-term care (LTC) residents; we estimate that this populations together represents about 17.6 million people.  ACIP also provided further guidance regarding sub-prioritization within these groups. While ACIP has yet to finalize recommendations on subsequent prioritization (expected soon), according to presentations and materials provided in recent ACIP meetings, the committee is likely to recommend that (non-health care) essential workers be the next priority group (“Phase 1b”), followed by persons age 65 and older and those with conditions that place them at high risk for severe illness from COVID-19 (“Phase 1c”).  These groups are much larger, which will likely make the next stages of prioritization much more difficult given that supply will still be limited (according to ACIP, there are an estimated 87 million essential workers, 53+ million seniors and more than 100 million individuals with high-risk medical conditions).

States look to and often follow ACIP guidance, but the federal recommendations are not binding and some states may choose to depart from the prioritization sequence outlined by ACIP, which could mean that initial access will depend on where people live. To see where states stand on prioritization, we collected and reviewed all statements and releases from state officials that reference the criteria they will use to prioritize vaccines during Phase 1, as defined by ACIP (these prioritization criteria build on and add detail to states’ initial vaccine distribution plans, which we already examined here). We did not assess how individual facilities (such as hospitals) will allocate vaccines once they arrive at their doors.

Findings

All states have released updated prioritization criteria for Phase 1, primarily in response to ACIP deliberations and guidance. Some had planned emergency meetings in anticipation of the FDA’s announcement and ACIP’s follow-on recommendation. Importantly, most indicate that these criteria could change depending on supply, vaccine characteristics, and other factors.

Most states are following ACIP’s Phase 1a recommendation.

• 45 states are following ACIP’s interim Phase 1a recommendation to prioritize HCWs and LTC residents. Some states will start vaccinating both of these groups together, while others will start with one of these groups first as they await more supply to start vaccinating the other. Still, even with these state criteria, decisions about how to allocate limited initial vaccines to HCWs and LTC residents will mostly be left to facilities.
• 7 states depart from ACIP’s Phase 1a recommendation in some way. For example, the District of Columbia and Utah include HCWs in Phase 1a but LTC residents in Phase 1b.  In addition to HCWs and LTC residents, Nevada, New Hampshire, and Wyoming also include law enforcement in Phase 1a (per ACIP’s proposed framework, they are in 1b). Massachusetts also includes people incarcerated in prisons and those living in homeless shelters in Phase 1a (neither is explicitly mentioned in ACIP’s Phase 1 framework).
• More than 20 states also provide further sub-prioritization rankings or criteria within HCW and/or LTC resident groupings. For example, Alabama segments HCWs into “very-high”, “high”, and “medium” risk. Idaho provides specific rankings within each group. Texas groups Phase 1a into “first” and “second” tier.

The majority of states are still developing criteria for subsequent Phase 1 prioritization, but there are already some differences from ACIP’s preliminary framework.

• 30 states indicate that they are still developing more specific criteria for these next phases.
• Of the 21 with criteria, 8 follow ACIP for Phase 1b and 5 follow ACIP for 1c.
• The main differences lie in where states place people ages 65 and older and those with high risk medical conditions, relative to essential workers. For example, Alabama, Delaware, Florida, Maryland, North Carolina, and Tennessee each prioritize those 65+ and/or those with high risk medical conditions over non-health essential workers; North Carolina and Tennessee prioritize those with high risk medical conditions over those ages 65 and older.
• In addition, some include other congregate settings (not indicated in ACIP’s framework). Alabama, Nebraska, Nevada, North Carolina and Oklahoma explicitly include those living in homeless shelters and prisons in Phases 1b or c. Delaware and Tennessee explicitly include people incarcerated in prisons in 1c.

Discussion

Our review finds that almost all states hew to ACIP regarding initial allocations of a COVID-19 vaccine (Phase 1a) and have looked specifically at ACIP for decision-making.  Beyond that, a good number of states are still developing criteria for Phases 1b-c.  Given that ACIP has yet to issue recommendations for these phases, states may be waiting for further guidance. However, based on ACIP’s preliminary framework, there are some differences between state priorities and where ACIP is likely to land, primarily related to the prioritization of seniors and/or those with high risk medical conditions relative to non-health essential workers. Moreover, these later prioritization decisions are likely to be more difficult given the large numbers of people in these groups and continued limits on vaccine supply.

As the U.S. prepares for nationwide distribution of vaccines to combat COVID-19, some are asking whether people who get the first of two doses will return to complete the series. The leading vaccine candidates from Pfizer/BioNTech and Moderna both require individuals to receive a second shot within a specific timeframe to achieve maximum effectiveness.

This analysis draws on Medicare Part D prescription drug claims data for the herpes zoster vaccine Shingrix, which also requires two doses, to shed light on this potential challenge of the leading COVID-19 vaccine candidates. Shingrix is recommended for adults ages 50 and older to prevent herpes zoster, also known as shingles, a viral infection that causes a painful rash and can lead to long-term pain and other problems. The second dose of Shingrix is to be administered between 2 and 6 months after the first dose. Overall, one-third of adults ages 60 and older in 2018 reported having ever received a shingles vaccine, but this estimate does not provide insight into which groups of older adults were more or less likely to get the second dose within the recommended timeframe after having received the first.

To address this question, we looked at Medicare beneficiaries who received an initial dose of Shingrix in the first half of 2018 to analyze what share received the second dose within the recommended timeframe and which subgroups of beneficiaries were more or less likely to receive both doses. Because people 65 and older are expected to be one of the earlier groups to receive COVID-19 vaccination, this analysis offers insight into what the experience might be among older adults in receiving the full regimen of multidose COVID-19 vaccines.

The majority of Medicare beneficiaries who received an initial dose of the Shingrix vaccine received the second dose within six months, but follow-up rates were lower among beneficiaries in communities of color, those who are younger than age 65 with long-term disabilities, and low-income beneficiaries.

Most (74%) Medicare beneficiaries who received an initial dose of Shingrix between January and June of 2018 received the second dose within 6 months (Figure 1). Conversely, 1 in 4 beneficiaries (26%) who received an initial dose of Shingrix between January and June 2018 did not receive the second dose within the recommended timeframe. An additional 6% of beneficiaries received the second dose after the 6-month timeframe but no later than the end of 2018.

• Follow-up Shingrix vaccination rates were higher among White beneficiaries (76%) than among Hispanic (58%), American Indian/Alaska Native (61%), Black (61%), and Asian/Pacific Islander beneficiaries (69%). In other words, roughly 4 in 10 Black, Hispanic, and American Indian/Alaska Native beneficiaries did not receive their second shingles shot within the recommended 6-month timeframe. The share of beneficiaries receiving the second dose by the end of 2018 was higher among each group, but all estimates for beneficiaries of color were lower than for White beneficiaries.
• Medicare beneficiaries under age 65, who qualify for Medicare because of a long-term disability, were less likely than beneficiaries ages 65 and older to receive a second dose of Shingrix within 6 months. Among beneficiaries under age 65 who received a first dose of Shingrix between January and June of 2018, 66% received a second dose within 6 months of their first dose – a lower rate than among beneficiaries ages 65 to 74 (75%), 75 to 84 (76%), and 85 and older (71%).
• Beneficiaries with incomes less than 150% of poverty were less likely than beneficiaries with higher incomes to receive the second dose of the shingles vaccine within 6 months. (We used the share of beneficiaries receiving Part D low-income subsidies (LIS) as a proxy for low income). Only 64% of beneficiaries with lower incomes received the second dose within 6 months of their first dose in 2018, compared to 77% of those with higher incomes.

Notably, unlike the COVID vaccine which will be covered at no cost for Medicare beneficiaries, the Shingrix vaccine is not free to Medicare beneficiaries without LIS, but it is covered at very low cost to beneficiaries who receive LIS. In 2018, Medicare Part D enrollees without LIS paid an average of $57 out of pocket for each shot, while those who received LIS paid $5. (Under Part D, a separate copayment is required for each dose in the series.) It is possible that out-of-pocket costs deterred some beneficiaries from getting the follow-up shingles vaccine, but other factors may also be barriers to completing the series, such as lack of communication between providers and patients or misunderstanding about the necessity of the second dose, the hassle factor of a return visit to a doctor’s office or pharmacy for the second shot, or being deterred by adverse effects after the first dose. Patients can sign up on the Shingrix website to receive a second dose reminder, but doing so requires knowledge and action by patients. Research shows that pharmacist reminder calls can also help boost compliance with the shingles vaccine series, but this may not happen systematically across all providers.

The fact that the second dose of the two leading COVID-19 vaccine candidates is administered no more than one month after the first dose – versus up to 6 months between the first and second doses of the shingles vaccine – could mitigate some of the loss to follow up observed with the shingles vaccine. Moreover, preliminary evidence showing that the two COVID-19 vaccines closest to FDA authorization are highly effective in preventing COVID-19, a potentially fatal disease, may translate to higher take-up rates for the second shot than we observed with Shingrix. In addition, states and vaccine providers are being encouraged by the Centers for Disease Control and Prevention to attempt to schedule a second dose appointment at the time of a patient’s first dose. As part of a national vaccine education campaign, having systems in place for providers to communicate with patients about returning for a second dose is likely to be important in ensuring full compliance with the new COVID-19 vaccines. But the differences we observed in the percent of beneficiaries in different racial and ethnic groups, different age cohorts, and different income levels who received the second dose of Shingrix also underscore the challenges ahead in inoculating vulnerable populations against COVID-19.

Here’s our recap of the past week in the coronavirus pandemic from our tracking, policy analysis, polling, and journalism.

The U.S. surpassed 15.6 million total cases this week as an independent Food and Drug Administration panel of outside advisers supported emergency use authorization for the Pfizer COVID-19 vaccine.

At KFF, our new analysis provides national and state-level estimates of the number of health care workers and long-term care residents who are expected to be part of the group first in line to receive the coronavirus vaccine. KHN reports that there won’t be enough to vaccinate everyone in the priority group in the first few weeks. Meanwhile advocacy groups for certain workers are already pushing to be next in line as “people who keep society functioning.”

In an event held today by KFF and the Morehouse School of Medicine’s Satcher Health Leadership Institute, panelists discussed racial health disparities that have surfaced during the pandemic and what could be done to assure equity as COVID-19 vaccines come to market. This was part of a larger discussion on racism and discrimination in health care.

The economic impact of the pandemic has contributed to job losses, but as analysts write in Policy Watch this week, declines in employer sponsored insurance are far less than overall declines in employment and may have been offset by strong enrollment in Medicaid and the Affordable Care Act Marketplaces.

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

Global Cases and Deaths: Total cases worldwide reached 69.6 million this week – with an increase of nearly 4.4 million new confirmed cases in the past seven days. There were approximately 75,600 new confirmed deaths worldwide, bringing the total for confirmed deaths near 1.6 million.

U.S. Cases and Deaths: Total confirmed cases in the U.S. passed 15.6 million this week. There was an increase of nearly 1.5 million confirmed cases between Dec. 4 and 10. Approximately 15,800 confirmed deaths in the past week brought the total in the United States to 292,100.

Race/Ethnicity Data: Hispanic individuals made up a higher share of cases compared to their share of the total population in 42 of 46 states reporting cases. In 6 states (OR, WA, MA, NC, PA, and NH), Hispanic peoples’ share of cases was more than 2.5 times their share of the population. Black individuals made up a higher share of cases/deaths compared to their share of the population in 27 of 50 states reporting cases and 30 of 49 states reporting deaths. In 4 states (ME, VT, NH, and MI) the share of COVID-19 related deaths among Black people was at least two times higher than their share of the total population. COVID-19 continues to have a sharp, disproportionate impact on American Indian/Alaska Native as well as Asian people in some states. In 7 states, the share of COVID-19 related deaths among AIAN people was at least two times higher than their share of the total population (AK, NM, MT, AZ, MS, WA and NE).

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

Extensions: AL, GA, ID, IN, IA, ME, MI, ND, OH, RI, TN, WA

New Restrictions: CA, MA, MS, NC, PA, UT, WY

Enhanced Face Covering Requirement: MS, UT, WY

The latest KFF COVID-19 resources:

• How is the Number of People with Employer-Based Health Coverage Changing During the Pandemic? (Policy Watch)
• Options to Make Medicare More Affordable For Beneficiaries Amid the COVID-19 Pandemic and Beyond (Report)
• Estimates of the Initial Priority Population for COVID-19 Vaccination by State (News Release, Issue Brief)
• Racism and Discrimination in Health Care – Experiences Today and Actions to Address Going Forward (Archived Recording)
• How Has the Pandemic Affected Health Coverage in the U.S.? (Policy Watch)
• State of the U.S. Health System: 2020 Update (Issue Brief, Dashboard)
• Updated: COVID-19 Coronavirus Tracker – Updated as of December 11 (Interactive)
• Updated: State Data and Policy Actions to Address Coronavirus (Interactive)
• WTO Delays Decision On Proposal To Waive Intellectual Property Rules For COVID-19 Drugs, Vaccines (KFF Daily Global Health Policy Report)

The latest KHN COVID-19 stories:

• Demand for COVID Vaccines Expected to Get Heated — And Fast (KHN, NBC News)
• Opinion: It’s Time to Scare People About COVID (KHN, New York Times)
• What Seniors Can Expect When COVID Vaccines Begin to Roll Out (KHN, CNN)
• Tracking COVID’s Spread Inside a Tight-Knit Latino Community
• (KHN, CNN)
• A Child’s Death in the Heartland Changes Community Views About COVID (KHN, NPR)
• With Pandemic Surging, Ohio Gov. DeWine Dials Back His Aggressive Response (KHN, US News)
• ‘An Arm and a Leg’: Obamacare Alum Andy Slavitt Takes Stock of the COVID Pandemic — So Far (KHN)
• Farmworkers, Firefighters and Flight Attendants Jockey for Vaccine Priority (KHN, NBC News)
• Going Home for the Holidays? For Many Americans, That’s a Risky Decision (KHN, USA Today)
• KHN’s ‘What the Health?’: Vaccines Coming Soon but COVID Relief Bill Still Stalled (KHN)
• Supply Is Limited and Distribution Uncertain as COVID Vaccine Rolls Out (KHN)
• A Battle-Weary Seattle Hospital Fights the Latest COVID Surge (KHN, NPR)
• I Found My Secret to Feeling Younger and Stronger. The Pandemic Stole It Away. (KHN, New York Times)

This month the Centers for Disease Control and Prevention (CDC) adopted a recommendation that health care workers and long-term care residents should be the first to receive the COVID-19 vaccine once it is authorized or approved by the FDA.

A new KFF analysis estimates there are 15.5 million people working in health care settings who have direct patient contact, 1.2 million nursing facility residents and another 800,000 assisted living facility residents nationwide. These 17.6 million adults, about 7% of U.S. adults, would qualify for priority vaccinations as the first doses of vaccines are distributed to states this month, based on the CDC recommendation.

The analysis shows the share of each state’s adult population who are health care workers with direct patient contact or nursing facility residents, ranging from 4% in Washington, DC to 10% in North Dakota. California has the largest number of adults in these groups, more than 1.7 million, followed by Texas (1.3 million) and New York (1.2 million). Due to data limitations, our state-level estimates do not include people who live in assisted living facilities or in other residential settings.

While no public information has been released about initial state allotments of COVID-19 vaccines, certain states may be faced with inadequate vaccine supply for their priority population and will then have to apply additional factors to determine priority recipients. For the full state-by-state estimates and discussion read the full brief, Estimates of the Initial Priority Population for COVID-19 Vaccination by State.

Job losses caused by the coronavirus pandemic have threatened to disrupt health coverage for millions of people as most working-age adults get coverage for themselves and their families through their work. Tracking real-time changes in coverage and the uninsured rate is difficult to do with much precision because the large national surveys that produce these estimates lag by months or years, and private surveys generally lack sufficient sample to measure coverage changes precisely. Many real-time surveys have faced challenges of high rates of survey nonresponse (not responding to the survey or particular questions) particularly among populations most likely affected by the economic downturn, including the Census Bureau’s Household Pulse Survey. However, various sources of administrative data allow us to piece together what might be happening to health coverage rates amid the pandemic.

Declines in employer sponsored insurance are far less than overall declines in employment.  First, using administrative data insurers file with state regulators (compiled by Mark Farrah Associates TM), we can see how enrollment in employer plans has changed through the end of September. Although employment rates fell by 6.2% from March to September, enrollment in the fully-insured group market decreased by just 1.5% over the same period.

If we extrapolate this finding to the entire group market, including self-insured employer plans, this would suggest that a total of roughly 2 to 3 million people may have lost employer-based coverage between March and September. To be very clear, this is only a rough estimate. We do not have reliable data for self-insured employers (which insure about 6 in 10 people with employer coverage and tend to be larger), and those employers may have made different decisions than fully-insured employers did about layoffs and whether and how to maintain coverage for employees.

Loss of employer-based coverage may have been offset by strong enrollment in Medicaid and Marketplaces. Many of those who lost job-based health coverage would have qualified for Medicaid or for a special enrollment opportunity to purchase individual market health coverage (either on- or off- exchange). Preliminary administrative data for the Medicaid program shows enrollment increased by 4.3 million people (6.1%) from February through July 2020. More recent data for 30 states show that enrollment in managed care plans increased by about 5 million, or 11.3%, from March to September 2020. Nationally, MCOs cover over two-thirds of Medicaid beneficiaries. States attribute these increases to rising unemployment (and loss of employer sponsored insurance) as well as the “maintenance of eligibility” (MOE) requirements tied to a 6.2 percentage point increase in the federal match rate (FMAP) authorized by the Families First Coronavirus Response Act (FFCRA) – which prevents states from disenrolling Medicaid beneficiaries if they accept the additional federal funding.

Using the same administrative data above (from Mark Farah Associates TM), we find that enrollment in the individual market was fairly steady from March to September 2020. In normal years, there is typically more attrition during these months as more people leave the market than come in during special enrollment periods (SEP). However, SEP enrollment was higher this year in healthcare.gov and state based exchanges.

While much is unknown, a review of administrative data suggest that the uninsured rate may not have changed much during the pandemic to date. There is still much we do not know, and these administrative data do not account for other changes like people aging on to Medicare and population growth. Nonetheless, it appears that the decline in employer-based health insurance coverage may have been offset by gains in Medicaid and largely steady enrollment in the individual market.

There are several possible explanations for the relatively modest decrease in employer-based coverage despite massive job losses. First, many of the people who have lost employment likely were never enrolled in coverage through their job in the first place; lower wage workers are less likely to be covered by their employer’s plan and, similarly, job losses have been highest and most sustained among industries that tend to have lower coverage offer rates (e.g., retail, service, hospitality). Second, many people who lost their jobs may have been able to retain their health coverage temporarily. A number of employers elected to keep furloughed or laid off workers enrolled in their firm’s plan at least in the short term. In addition, an unknown number of permanently laid off employees may have elected COBRA (which would be classified as group coverage) at their own expense, although this number is likely small due to the high costs of such coverage. Employment rates are starting to recover but a larger share of people filing unemployment claims say their job loss is permanent compared to earlier in the pandemic, suggesting there may be more coverage loss to come.

That the uninsured rate may not have substantially changed this year could be taken as both good news and bad news. A largely flat uninsured rate would be good news because health insurance coverage rates tend to fall whenever there is an economic downturn in the United States. Between many employers maintaining coverage and the Affordable Care Act along with Medicaid serving as a safety net for those who did lose coverage, the uninsured rate in the U.S. does not appear to have risen nearly as much as it could have, given the scale of employment losses.

The bad news is that, if the uninsured rate has indeed held steady, there are still tens of millions of people without health coverage during the worst pandemic to hit the country in one hundred years. Despite some recent legislation and administrative action aimed at protecting the uninsured from some of the costs associated with COVID-19 testing and treatment, those without coverage still face tremendous financial and health risks.

Four out of ten people who were uninsured before the pandemic could be getting health insurance coverage for free, either through Medicaid or a zero-premium bronze plan on the exchange. Open Enrollment for 2021 coverage on the ACA exchange markets is now in its fifth week and early figures show that, while overall enrollment is strong, new enrollment is about the same as past years. The Trump Administration has drastically reduced funds for ACA outreach and marketing activities, as well as for navigators who help people enroll in Marketplace coverage. President-elect Biden has vowed to reinstitute funding for ACA marketing, outreach, and navigator programs. The federal Open Enrollment period will have ended by the time Biden takes office, but he could open a new SEP without limitations on who qualifies to enroll.