Introduction

With the U.S. still in the midst of an escalating COVID-19 pandemic, attention to the race for a safe and effective COVID-19 vaccine has intensified. What is clear is that when vaccines do become available, ensuring equitable and rapid distribution to the U.S. population will present an unprecedented challenge. The Trump Administration, under Operation Warp Speed, has already purchased in advance hundreds of million doses of several vaccine candidates, two of which have already demonstrated significant efficacy in Phase 3 clinical trials, and has begun planning for what will be the largest scale vaccination distribution effort ever undertaken in the U.S. This task will soon be inherited by the incoming Biden Administration, which has established a COVID-19 Task Force and is already planning its response.

A limited number of COVID-19 vaccine doses may start to become available as early as December, with more doses available over time. State, territorial, and local governments, who already have primary authority over routine vaccination, will play an increasingly important role in the distribution of these vaccines as more doses become available. In preparation, the federal government has asked the 64 jurisdictional immunization programs (all 50 states and DC, 8 U.S. territories and freely associated Pacific states and five cities) that the Centers for Disease Control and Prevention (CDC) funds and works with to develop COVID-19 vaccine distribution plans based on an Interim Playbook. The Playbook includes planning assumptions for jurisdictions to follow and requested information in 15 key areas (see Box). First drafts of these plans were due by October 16.

CDC guidance and federal oversight could evolve over the next several months as vaccines become available and distribution begins. The Biden campaign and transition team have planned for a more prominent role for the federal government in the U.S. COVID-19 response, which would likely include more detailed federal guidance and a stronger federal hand in vaccine distribution, planning and implementation, even as state and local jurisdictions will remain responsible for much of this effort. A critical challenge facing vaccine distribution efforts will be funding. To date, only $200 million has been distributed to state, territorial, and local jurisdictions for vaccine preparedness, though it is estimated that at least $6-8 billion is needed. President-elect Biden has said his administration would seek to invest $25 billion in manufacturing and distribution, which would require Congressional action.

While the CDC has made executive summaries of these plans available, there is no central repository for the full plans. We therefore sought to collect plans available from all 50 states and DC, as of November 13, identifying 47 full state plans in total (linked in the “State Plans” tab). We then reviewed each plan to gauge how states described their vaccine distribution planning progress to date. Rather than assess every single component of these plans in detail we identified common themes and concerns across the state plans, in particular focusing on what states reported regarding their progress in the following key areas:

• identifying priority populations for vaccination in their state;
• identifying the network of providers in their state that will be responsible for administering vaccines;
• developing the data collection and reporting systems needed to track vaccine distribution progress; and
• laying out a communications strategy for the period before and during vaccination.

Where are States in their Planning?

Based on the information in their plans, states are in varying stages of preparation for distributing a COVID-19 vaccine. While all have established a task force or planning committee to steer these efforts, which include representatives from different sectors, some have been planning for several months while other states’ planning efforts have started more recently. Some states have already begun the process of signing up providers to administer COVID-19 vaccines and building out existing immunization registries, while others are still just developing plans to do the same. All reported, however, that these initial plans are to be considered drafts only, to be updated as more information from the federal government and about a vaccine itself was available. Specifically, almost all cited the need to know which vaccine(s) would be authorized or approved, and that they will look to further federal guidance and recommendations before some key decisions are made, such as finalizing which individuals will be targeted as priority populations. Several raised concerns about the lack of visibility regarding vaccine distributions that will be made directly from the federal government to certain providers in their states, such as large pharmacy chains. These concerns were raised before the November 12 announcement by the federal government that it will be distributing future COVID-19 vaccines directly to some independent pharmacies and multi-state pharmacy chains across the U.S., in parallel to state efforts to recruit vaccination providers. States also discussed lessons learned from previous vaccine distribution efforts such as H1N1 pandemic influenza, including the need to build flexibility into distribution plans when supply is unpredictable and tailoring messages and outreach to diverse populations, which are certain to be challenges for a COVID-19 vaccine as well. Finally, even recognizing the that states are in different states of readiness in terms of their distribution planning efforts, it is clear all state health departments are taking this responsibility seriously and are overseeing significant efforts to make progress in their preparations.

Priority Populations¹ 

Each state will have to determine exactly who will be first in line to receive the likely limited number of vaccine doses that will be made available initially. In their plans, almost every state reports they are relying heavily on guidance from the federal government to define who these priority populations are, drawing on recommendations from the National Academies of Medicine and also expecting additional guidance from the CDC’s Advisory Committee on Immunization Practices. Many states report they will shape their prioritization plans using locally-defined criteria as well. Every state plan highlights the following broad categories as being priority populations for Phase 1 efforts: health care workers, essential workers, and those at high risk (older people and those with pre-disposing health risk factors). Most plans recognize (and CDC indicated in its guidance) that there will likely not be enough vaccines at first for all individuals identified in these Phase 1 priority groups. Even so, plans show that some states are much further along in defining prioritization categories and enumerating the number of people that fall into those categories. For example:

• Less than half (19 of 47, or 40%) of state plans reviewed include a numerical estimate of the number of individuals in different priority populations; the majority of states report they are still developing their data sources and methodology to calculate the number in their priority groups.
• Some states report already developing specific estimates of the numbers of health care workers likely among the first individuals targeted for vaccination, while other states do not include these estimates, or mention that they are working on developing methods to identify the numbers to be targeted in this group.
• A majority of states (25 of 47, or 53%) have at least one mention of incorporating racial and/or ethnic minorities or health equity considerations in their targeting of priority populations. Some states expect to make racial and ethnic minorities an explicit priority population group, while others report using more general or indirect methods to do so, such as through use of the social vulnerability index (as was recommended by the NAM) and/or a Health Equity Team or Framework, as in the case of Arizona, California, Georgia, Louisiana, New Jersey, Ohio, and Vermont.

Providers

Each state will rely on a network of providers to administer the vaccines to individuals. These providers will likely include hospitals and doctors’ offices, pharmacies, health departments, federally qualified health centers, and other clinics that play a role in administering vaccines today. However, given the need to quickly vaccinate most residents, states will need to include additional partners, such as long-term care facilities, in the network and will potentially establish mass vaccination sites in public locations like schools and community centers. Prior to distribution and administration of vaccines, states will have to identify, vet, and approve hundreds to thousands of partners and site locations for vaccine delivery. According to the draft plans, states are at different points in the process of identifying these providers and expanding their network of providers needed to deliver vaccines to priority population groups. States that require providers to participate in immunization registries or those that already have most providers participating in these registries are further along in developing their provider networks, while other states report that they still need to start the process of enrolling providers.

• Less than a third (13 of 47, or 28%) of states’ plans provide an estimate of the number of vaccine providers in the state, and only six provide some estimate of the number of providers by type (though some of these are limited to only one provider type).
• About half (24 of 47, or 51%) report an estimate of the number of providers already participating in their immunization registries. A few states have also begun specific outreach to register as COVID-19 providers, although these efforts are in their beginning phases. At the same time, some states, particularly rural states, raise concerns about the lack of personnel to carry out vaccination in some areas, or how they will be able to send small enough batches of vaccines to be distributed by rural providers who may only be vaccinating a limited number of individuals.
• Only a subset (12 of 47, or 26%) of state plans specifically mention or consider providers that are needed to reach racial and ethnic minorities.
• Across plans, the most common types of providers that states report still needing to reach out to or incorporate as COVID-19 vaccine providers include: tribal providers, long-term care facilities, correctional facilities, and other types of adult care providers.

Data Collection and Reporting

All states have an immunization registry of one kind or another to track vaccinations administered by providers in their state. These registries range in terms of their comprehensiveness and reporting functionality. To incorporate the data collection and reporting needs for COVID-19 vaccination, many states are relying on (and often expanding) existing state-level immunization registries, while other states are developing new systems or using systems provided by the federal government. From the information in the draft plans, it is clear that some states are in a much better position in terms of their data collection and reporting capacity for COVID-19 vaccines, while others have more work to do to develop their systems, In addition, some common issues have been raised by states in their plans.

• Just over half (25 of 47, or 53% ) of state plans report having immunization registries/database systems in place that are described as being (at least fairly) comprehensive and reliable; in the other state plans that information is unclear. Most states report still having to develop or add functionality to their existing immunization registries to be prepared for COVID-19 vaccine administration.
• Most states report they will have no issues reporting the key data from their immunization registries to federal systems, though at least fifteen states report that data sharing agreements with federal partners are still being reviewed or remain in process.
• Several states raise concerns about the ability to report certain CDC-recommended data elements to federal systems or meet CDC time requirements for reporting. States also mention limitations in collecting race/ethnicity data on individuals vaccinated.
• Virtually all states’ plans incorporate expectations and procedures to report any vaccine adverse events through federal reporting systems such as the Vaccine Adverse Events Reporting System (VAERS).

Communications

Developing a communications plan before and during COVID-19 vaccination will be critical component of state planning. CDC requested that states outline how they will proactively design communication plans that anticipate and respond to the needs and concerns of different population groups. This includes the need to address misinformation and vaccine hesitancy, as well as crisis communications. Some states’ plans have very detailed explanations of their approach to communications across the vaccination phases, while others provide very little detail. Additionally, some state plans recognize the need to develop targeted messaging for vulnerable populations, while others do not.

• About half (23 of 47, or 49%) of plans specifically mention racial/ethnic minorities or vulnerable populations when discussing COVID-19 vaccine communication.
• Just over a third (18 of 47, or 38%) of state plans include at least a mention of addressing vaccine misinformation but most of these states do not provide specific strategies for countering misinformation.

Links to State Plans

1. While jurisdictions were asked to reach out to tribal nations within their respective areas for involvement in planning efforts, tribal nations have sovereign authority to provide for the health and welfare of their populations. This authority includes decisions around access to and distribution of the vaccine as well as establishing priority groups to receive the vaccine. We did not review state plans to assess their reported coordination efforts with tribal nations, including for outreach to tribal populations. ↩︎

Health care workers face potential COVID-19 exposure through their job. Data suggest that at least 200,000 health care workers have been infected with coronavirus as of November 2020, but this estimate likely vastly underestimates the number affected due to major gaps in data collection. Data further show that people of color account for the majority of COVID-19 cases and deaths known among health care workers, and that they are more likely to be in health care worker roles and settings that have particularly high risks of workplace exposure. This analysis provides greater insight into COVID-19 risks and impacts among health care workers and how they vary by race and ethnicity. It is based on a KFF analysis of 2019 American Community Survey and publicly available information on COVID-19 impacts among health care workers (see Methods for more details). It finds:

In 2019, there were over 18.6 million people working in the health care industry across a range of occupations and settings. Overall, 60% of health care workers were White and 40% were people of color, including 16% who were Black, 13% who were Hispanic, and 7% who were Asian. However, the racial/ethnic composition of health care workers varied across occupations and settings. Black and Hispanic health care workers made up relatively larger shares of aides and personal care workers and direct contact support workers. Black and Hispanic workers also accounted for larger shares of health care workers in home health care, and Black workers made up a relatively larger share of workers in skilled nursing facility or other residential care settings.

People of color account for the majority of COVID-19 cases and/or deaths known among health care workers for which race/ethnicity data are available. The Centers for Disease Control and Prevention (CDC) reported over 200,000 cases and just over 790 deaths among health care personnel as of November 9, 2020. However, this estimate likely vastly underestimates the number of health care workers affected as health care personnel status was known for only a quarter (25%) of total cases. CDC further found that, as of July 2020, more than half (53%) of confirmed cases among health care personnel were among people of color, including 26% who were Black, 12% who were Hispanic, and 9% who were Asian. Data collected by states, the media, and other organizations similarly find that people of color account for the majority of COVID-19 cases and/or deaths known among health care workers.

Research suggests that health care workers face increased risks of coronavirus exposure and infection, with certain health care workers facing particularly high risks that disproportionately affect people of color. Studies show that health care workers are at increased risk for exposure and infection relative to the general population, with particularly high risks for health care workers who provide direct patient care, work in inpatient hospital or residential or long-term care settings, are in nursing or direct support staff roles, or do not have adequate access to PPE.¹  Research further suggests that, among health care workers, people of color are more likely to report reuse of or inadequate access to PPE and to work in clinical settings with greater exposure to patients with COVID-19. CDC analysis of antibody evidence of previous infection among health care personnel further found higher rates of seropositivity among people or color compared to their White counterparts (9.7% vs. 4.4%), suggesting higher rates of previous infection.

A recent KFF/The Undefeated Survey suggests that the pandemic is taking a disproportionate toll on health care workers, especially Black health care workers and their families. It finds that health care workers are more likely than others to worry about being exposed to the virus through the workplace, to know someone who has died from the virus, to say it has negatively impacted family relationships, and to report someone in their household lost a job or experienced a cutback in hours or income due to the pandemic. Black health care workers and their families are particularly likely to report certain impacts, including knowing someone who has died from the virus and a negative impact on their ability to pay for basic needs.

KFF/The Undefeated Survey data also show that, while health care workers are more likely than others to say they would definitely get a COVID-19 vaccine, substantial shares express vaccine hesitancy, particularly among Black health care workers and their families. Overall, 54% of health care workers say they would definitely get vaccinated if it was available for fee and determined safe and effective by scientists, compared to 33% of adults who do not have a health care worker in their household. However, among adults who are health care workers or who live in a household with a healthcare worker, Black adults are much less likely to say they would definitely get vaccinated compared to White adults (24% vs. 46%), mirroring greater vaccine hesitancy among Black adults more broadly.

Together these findings highlight the importance of focusing on health care workers as part of response efforts to help protect against COVID-19 infection and spread. They can also help target response efforts and distribution of treatments and vaccines as they become available to prioritize health care workers who are facing the highest risks of exposure and infection. Targeting these efforts will also have important implications for health disparities given the disproportionate risks and impacts among health care workers who are people of color, which may compound broader increased health and economic risks that are contributing to the pandemic’s disproportionate toll on people of color overall. This analysis also shows that there remain significant gaps in data to understand COVID-19 impacts by industry and occupation. Increased data would allow for better understanding of work-related risks and outbreaks to help guide response efforts and resources going forward.

Overview of Health Care Workers

As of 2019, there were over 18.6 million people working in the health care industry. Health care workers face potential risk of exposure to COVID-19 through their job, but this risk may vary based on the type and setting of their work. Overall, nearly four in ten (39%) health care workers were health care providers such as nurses, physicians, technicians, and therapists; 22% were aides and personal care workers, such as certified nursing assistants, home health aides, and medical assistants; 8% were direct contact support workers, such as housekeeping and kitchen and cafeteria staff; and 3% were social workers and behavioral health workers (Figure 1). The remaining 28% were other support workers and managers, such as office and administrative managers and staff, who may have less direct contact with patients. Nearly four in ten (39%) worked in a hospital, 16% worked in a skilled nursing facility or other residential care, 11% worked in an outpatient care center, 11% worked in a physician office, 15% worked in home health care, and the remaining 8% worked in other health care service settings such as a dentist, optometrist or chiropractor offices.

The racial/ethnic make-up of health care workers varied by occupation and health care setting. Overall, 60% of health care workers were White and 40% are people of color, including 16% who were Black, 13% who were Hispanic, and 7% who were Asian. However, Black and Hispanic health care workers made up relatively larger shares of aides and personal care workers and direct contact support workers and accounted for fewer health care providers (Figure 2). Similarly, Black and Hispanic workers made up larger shares of health care workers in home health care (23%), and Black workers accounted for over a quarter of workers in skilled nursing facility or other residential settings (26%) (Figure 3).  

COVID-19 Among Health Care Workers

Cases, Hospitalizations, and Deaths

Some federal, state, and other data are available on COVID-19 infections and deaths among health care workers, but significant data gaps remain:

• The Centers for Disease Control and Prevention (CDC) reported over 200,000 cases and just over 790 deaths among health care personnel as of November 9, 2020. However, health care personnel status was only known for less than a quarter of total cases, and death status was available for less than three-quarters of cases among health care personnel.
• KFF review of state websites identified 16 states reporting over 144,000 COVID-19 cases among health care workers as of November 2020.²  However, states varied widely in how they defined and identified health care workers. Further, in most cases, it was not clear what share of total cases had health care worker status known. Some counties also report data for health care workers. For example, Los Angeles County reported over 17,000 positive cases and 105 deaths among health care workers and first responders as of October 29, 2020.
• Media and other organizations have also undertaken efforts to track COVID-19 deaths among health care workers. For example, reporting by Kaiser Health News and the Guardian has identified over 1,300 likely deaths among health care workers related to COVID-19 as of November 9, 2020. National Nurses United estimated that, as of September 16, 2020, 1,718 health care workers, including 213 registered nurses, had died of COVID-19 and related complications based on media reports, social media, obituaries, union memorials, federal and state reporting, and internal reporting.

These data likely underestimate COVID-19 impacts among health care workers given that the majority of cases and deaths are missing information on health care worker status. CDC analysis of antibody evidence of previous infection further suggests that a high proportion of COVID-19 infections among health care personnel go undetected.

People of color accounted for a majority of COVID-19 infections, hospitalizations, and deaths known among health care workers for which race/ethnicity data is available. CDC found that, as of July 2020, more than half (53%) of confirmed cases among health care personnel were among people of color, including 26% who were Black, 12% who were Hispanic, and 9% who were Asian. Separate CDC analysis of hospitalization data, found that most health care personnel hospitalized with COVID-19 were people of color, including over half (52%) who were Black and nearly 9% who were Hispanic. Data from Los Angeles County show that, among the over 17,000 health care workers and first responders who were identified as positive for COVID-19 as of late October 2020, 50% were Hispanic, 15% were Asian, and 7% were Black. Moreover, among the 105 health care workers and first responders who died, 45% were Hispanic and 37% were Asian. Kaiser Health News and the Guardian tracking of health care worker deaths associated with COVID-19 further finds that a majority of deaths were among people of color. Similarly, National Nurses United found that over half (58%) of the 213 registered nurses it had identified as dying due to COVID-19 and related complications were nurses of color, including nearly a third (32%) who were Filipino nurses and 18% who were Black nurses.

Risks of Exposure and Infection

Analysis suggests health care workers are at increased risk for COVID-19 infection relative to the general population and that certain health care workers are at particularly high risk. A United States and United Kingdom study found higher prevalence of COVID-19 infections among frontline health care workers (i.e., those who reported direct patient contact) compared to the general community, with the highest risks for those working in inpatient hospital settings and nursing homes, reporting inadequate personal protective equipment (PPE), and caring for patients with documented COVID-19. CDC analysis of health care providers in Minnesota found that two-thirds (66%) of higher-risk exposures to COVID-19—defined as close contact for 15 minutes or more or during an aerosol-generating procedure—involved direct patient care, while roughly one-third (34%) were through nonpatient contacts, such as interactions with coworkers and social or household contacts. It also found that health care personnel working in congregate living or long-term care settings, including skilled nursing facilities, were less likely to wear appropriate PPE, worked more often while symptomatic, and were more likely to test positive following a higher-risk exposure compared to those working in acute care settings. Other CDC analysis found that more than two-thirds (67%) of health care personnel who were hospitalized with COVID-19 were in roles that likely required direct patient contact, and over one-third (36%) were in nursing-related occupations. Similarly, Kaiser Health News and the Guardian tracking of COVID-19 deaths among health care workers found that nurses and support staff accounted for the largest numbers of deaths.

Research further suggests that, among health care workers, people of color are more likely to face elevated risks of workplace exposure. As noted earlier, Black and Hispanic workers make up relatively larger shares of aides and personal care workers and direct contact support workers who typically are engaged in direct patient care, which is associated with increased risk of infection. Moreover, Black workers make up over a quarter of workers in skilled nursing facility or other residential settings, which pose higher risks of infection and have been sources of a significant share of cases. The United States and United Kingdom study also found that, among frontline health care workers, people of color were at especially high risk of infection and were disproportionately likely to report reuse of or inadequate access to PPE and to work in clinical settings with greater exposure to patients with COVID-19. Further, it found that Black, Asian, and other frontline workers of color had increased risk of a positive COVID-19 test compared to their White counterparts. CDC analysis of antibody evidence of previous infection among health care personnel also found higher rates of seropositivity among people or color compared to their White counterparts (9.7% vs. 4.4%), suggesting higher rates of previous infection.

Health and Financial Impacts of the Pandemic

A recent KFF/The Undefeated Survey suggests that the pandemic is taking a disproportionate toll on health care workers, especially among Black health care workers and their families. Health care workers were more likely than adults who live in a household without any health care workers to be worried that they might be exposed to coronavirus at work (67% vs. 50%), to personally know someone who has died from coronavirus (46% vs. 25%), and to say the pandemic has had a negative impact on their relationships with family members (61% vs. 48%) (Figure 4). Health care workers also were more likely than adults living in a household without a health care worker to say that someone in their household has lost a job, been placed on furlough, or had their hours or income reduced as a result of the pandemic (59% vs. 45%), but they were not more likely to say it had a negative impact on their ability to pay for basic needs (43% vs. 49%). Among adults who are health care workers or who live in a household with a health care worker, Black adults were more likely compared to their White counterparts to report knowing someone who has died from coronavirus (51% vs. 35%) and to say that the pandemic negatively affected their ability to pay for basic necessities (63% vs. 41%).

COVID-19 Vaccine Attitudes

The KFF/The Undefeated survey also found that health care workers are more likely than others to say they would definitely take a vaccine if it was available for fee and determined safe and effective by scientists, but there are still substantial shares who say they would probably or definitely not get vaccinated, particularly among Black adults. Overall, 54% of health care workers say they would definitely get vaccinated, compared to 33% of adults who do not have a health care worker in their household (Figure 5). However, among adults who are health care workers or who live in a household with a healthcare worker, Black adults are much less likely to say they would definitely get vaccinated compared to White adults (24% vs. 46%), mirroring greater vaccine hesitancy among Black adults more broadly. Among health care workers and their family members, Black adults also express less confidence that a vaccine will be tested properly and distributed fairly compared to their White counterparts.

Implications

Health care workers face risk of COVID-19 exposure through their workplace. Data provide some estimates of cases and deaths among health care workers and show that people of color account for the majority of health care workers affected by COVID-19. However, the data likely vastly underestimate impacts among health care workers. Research suggests that health care workers are at increased risk of exposure and infection compared to the general population and that most high-risk exposures among health care workers occur through the workplace. However, risks are not equally shared across health care workers. Analysis suggests that frontline workers providing direct care in certain settings and those with inadequate access to PPE face particularly high risks. Moreover, among health care workers, people of color are more likely to face these elevated workplace risks, which may compound broader increased health and economic risks that are contributing to the pandemic’s disproportionate toll on people of color.

Together these findings highlight the importance of focusing on health care workers as part of response efforts to help protect against infection and spread. They can also help target response efforts and distribution of treatments and vaccines as they become available to prioritize health care workers who are facing the highest risks of exposure and infection. Targeting these efforts will also have important implications for health disparities given the disproportionate risks and impacts among health care workers who are people of color. This analysis also shows that there remain significant gaps in data to understand COVID-19 impacts by industry and occupation. Increased data would allow for better understanding of work-related risks and outbreaks to help guide response efforts and resources going forward.

This analysis is 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 subset used here includes over 170,000 observations. The health care industry is defined as industry codes 7970 through 8290, and does not include the childcare or vocational training industries. For more information see here.

We define the healthcare workforce as all individuals who earned at least $1,000 during the year and indicated that their job was in one of the industry codes listed above. Within these industry groups, we grouped people’s occupations into five different categories based on type of work and level of contact with patients:

• Aides and personal care workers includes certified nursing assistants (CNAs), personal care aides, home health aides, licensed practical nurses (LPNs), OT and PT assistants, medical assistants, and other aides.
• Direct contact support workers includes non-clinical support staff, such as housekeeping and janitorial staff, kitchen and cafeteria staff, recreation workers, laundry workers, security guards, shuttle drivers, clergy, and first-line supervisors of support workers.
• Health care providers includes registered nurses (RNs), physicians, dental assistants, physician therapists, occupational therapists, nurse practitioners, dentist, radiologist, phlebotomists, and various types of technicians that provide direct patient care.
• Other support workers and managers includes office and administrative managers and staff, receptionists, nutritionists, laboratory technicians, office clerks, billing clerks, medical records specialist, human resources, groundskeeping and facilities workers, who are likely to come into regular direct contact with patients less often than other types of health care workers.
• Social Workers and Behavioral health workers includes health professions such as Social workers, Mental health counselors and substance abuse counselors

Note, that this analysis only includes those in the healthcare industry, therefore healthcare professionals working in other care settings, such as school nurses are not included.

1. Long H. Nguyen et al., “Risk of COVID-19 among front-line health-care workers and the general community: a prospective cohort study,” The Lancet 5, no. 9 (September 2020): 475-483,  https://www.thelancet.com/journals/lanpub/article/PIIS2468-2667(20)30164-X/fulltext; . Ashley Fell et al., “SARS-CoV-2 Exposure and Infection Among Health Care Personnel — Minnesota, March 6–July 11, 2020,” Morbidity and Mortality Weekly Report 69, no. 43 (October 2020): 1605-1610, https://www.cdc.gov/mmwr/volumes/69/wr/mm6943a5.htm?s_cid=mm6943a5_w; . Anita K. Kambhampati et al., “COVID-19–Associated Hospitalizations Among Health Care Personnel — COVID-NET, 13 States, March 1–May 31, 2020,” Morbidity and Mortality Weekly Report 69, no. 43 (October 2020): 1576-1583) https://www.cdc.gov/mmwr/volumes/69/wr/mm6943e3.htm?s_cid=mm6943e3_w; . “Lost on the Frontline,” The Guardian, accessed November 9, 2020, https://www.theguardian.com/us-news/ng-interactive/2020/aug/11/lost-on-the-frontline-covid-19-coronavirus-us-healthcare-workers-deaths-database ↩︎
2. States reporting COVID-19 cases among health care workers include: AL, AR, CO, GA, ID, MA, MN, NH, OH, OK, OR, SC, UT, VT, VA, and WA. Dates for which cases are reported through vary across states. Total cases among Colorado health care workers includes confirmed COVID-19 cases among staff in any health care setting, based on active and resolved outbreak data. ↩︎

Recent trends in maternal and infant health and persistent racial disparities in these measures have led to a growing focus on improving health and reducing disparities in these areas, which has been heightened by the COVID-19 pandemic and growing racial justice movement. As a primary source of coverage for pregnant women and children, particularly among people of color, Medicaid can play a key role in helping to improve maternal and infant health and reducing racial disparities. This brief provides a summary of Medicaid’s role for pregnant women and infants and current Medicaid initiatives to improve maternal and infant health. It finds:

Medicaid, along with the Children’s Health Insurance Program (CHIP), provide a nationwide base of coverage for low-income pregnant women and children. Reflecting this coverage, nearly half of births (45%) are covered by Medicaid and nearly half of all infants (46%) are covered by Medicaid or CHIP. The programs play an even larger role for people of color given that they have more limited access to private coverage and lower incomes compared to their White counterparts. For example, Medicaid covers about two-thirds of births among Black, American Indian or Alaska Native (AIAN), and Native Hawaiian or Other Pacific Islander (NHOPI) women and over six in ten Black, Hispanic, and AIAN infants are covered by Medicaid or CHIP.

The Affordable Care Act (ACA) Medicaid expansion has led to improvements in and narrowed racial disparities in maternal and infant health. Through the ACA Medicaid expansion to low-income adults, states have increased coverage options for pregnant women who would otherwise lose eligibility at the end of the 60-day postpartum period, although some still may lose coverage at the end of the period. Studies show that the Medicaid expansion has had positive impacts on maternal and infant access to and use of care and health outcomes and narrowed racial disparities in certain measures including health coverage, maternal mortality, infant mortality, low birthweight, and preterm birth.

There are a range of Medicaid initiatives underway at the state and federal level to improve maternal and infant health. There has been interest at the state and federal level in extending the postpartum Medicaid eligibility period to further reduce coverage losses for women at the end of the period. In addition, there are efforts to expand benefits and implement new payment and delivery models. These efforts may not only contribute to improvements in maternal and infant health but also reduce racial disparities in these areas due to the large role the program plays for people of color.

Introduction

Despite continued advancements in medical care, rates of maternal mortality and morbidity and pre-term birth have been rising in the U.S. Maternal and infant mortality rates in the U.S. are far higher than those in similarly large and wealthy countries and stark racial disparities in maternal and infant health persist. Improving maternal and infant health is key for preventing unnecessary illness and death and advancing overall population health. Moreover, growing calls for racial justice and the disparate impact of the COVID-19 pandemic for people of color have brought a heightened focus to health disparities, including the inequities in maternal and infant health. In particular, there has been broader recognition of the principles of reproductive justice, which emphasize the role that the social determinants of health and other factors play in reproductive health for communities of color.

A range of initiatives are underway that are designed to improve maternal and infant health and reduce disparities. Medicaid is key in these efforts given the substantial role the program plays in covering low-income pregnant women and children, particularly among people of color. This brief provides a summary of Medicaid’s role for pregnant women and infants and key Medicaid initiatives to improve maternal and infant health.

Medicaid’s Role for Pregnant Women and Infants

Medicaid provides a nationwide base of coverage for low-income pregnant women and children. Under federal rules, all states must extend Medicaid eligibility for pregnant women and children to at least 138% of the federal poverty level (FPL) ($29,974 per year for a family of three as of 2020). States can extend eligibility to higher levels through options in Medicaid as well as CHIP. As of January 2020, nearly all states (49 including DC) cover infants with family incomes up to at least 200% FPL ($43,440 per year for a family of three) through Medicaid and CHIP. Moreover, nearly all states (49) extend eligibility for pregnant women beyond the federal minimum of 138% FPL, with 35 extending eligibility to at least 200% FPL. Infants born to mothers on Medicaid are automatically covered for their first of life, while coverage for pregnant women ends after 60 days postpartum.

Reflecting this broad base of eligibility for pregnant women, Medicaid covers 45% of all births. The programs play an even larger role in covering births for women of color given their lower incomes and more limited access to private coverage. Medicaid covers about two-thirds of births among Black, AIAN, and NHOPI women and six in ten births among Hispanic women, compared to one in three births among White women (Figure 1).

Medicaid, along with CHIP, also cover nearly half (46%) of all infants, and the programs play a particularly large role covering infants of color. Over six in ten Black, Hispanic, and AIAN infants are covered by Medicaid and CHIP compared to one-third of White infants (Figure 2). Even with these higher rates of Medicaid and CHIP coverage, Hispanic and AIAN infants remain more likely to be uninsured compared to White infants.

Research shows that coverage before, during, and after pregnancy facilitates access to care that supports healthy pregnancies, as well as positive maternal and infant outcomes after childbirth. For low-income women, Medicaid is comparable to private insurance in terms of many measures of access to care. Research also documents that Medicaid coverage of pregnant women and children has contributed to dramatic declines in infant and child mortality in the United States. A growing number of studies show that Medicaid eligibility during childhood also has long-term positive impacts, including reduced teen mortality, reduced disability, improved long-run educational attainment, and lower rates of emergency department visits and hospitalization in later life.

Medicaid Expansion Effects on Maternal and Infant Health

Through the ACA Medicaid expansion to low-income adults, states have increased coverage options for pregnant women who would otherwise lose eligibility at the end of the postpartum period. As noted, under federal rules, states must extend Medicaid eligibility to pregnant women with incomes up to at least 138% FPL and provide this coverage through 60 days postpartum. Nearly all states have expanded pregnant women eligibility beyond the minimum level, with the median eligibility level at 255% FPL as of January 2020. Prior to the ACA, many pregnant women would lose coverage at the end of the 60-day postpartum period because state eligibility levels for parents were much lower compared to the levels for pregnant women—below half of poverty in many states. The ACA expanded Medicaid eligibility to nearly all adults with incomes up to 138% FPL, increasing coverage options for pregnant women at the end of the postpartum period in expansion states. As of August 2020, 39 states, including DC, have adopted the Medicaid expansion.

Studies suggest that the ACA Medicaid expansion has had positive impacts on maternal and infant access to and use of care and health outcomes and helped to narrow racial disparities in certain measures. For example, one study found increased coverage stability and use of postpartum care during the six months postpartum in a Medicaid expansion state compared to a neighboring non-expansion state.¹  Another study found that infants in non-expansion states are approximately two and half times more likely to be born into a household without health insurance compared to infants in expansion states.²  Several studies suggest that Medicaid expansion has narrowed disparities for Black and Hispanic people in certain measures of maternal and infant health, including health coverage, maternal mortality, infant mortality, low birthweight, and preterm birth.^{3 ,4 , 5 , 6} 

Even with the ACA Medicaid expansion, many women still may lose coverage at the end of the 60-day postpartum coverage period. Eligibility levels for pregnant women remain higher than those for parents in both expansion and non-expansion states, with the starkest differences in non-expansion states (Figure 3). Analysis finds that nearly half of women in non-expansion states and nearly one in three women in expansion states experience an insurance disruption from pre-pregnancy to postpartum.⁷  Another study on maternal insurance status during the preconception, delivery, and postpartum periods found that women of color experienced higher uninsured rates during each period compared to White women, and that disruptions in coverage disproportionately affected Hispanic, Black, and AIAN women.⁸ 

Medicaid Efforts to Improve Maternal and Infant Health

There has been interest at the state and federal level in extending the postpartum Medicaid eligibility period to further reduce coverage losses for women in the postpartum period. Extending the postpartum Medicaid eligibility period would increase state and federal spending, but could help reduce preventable maternal deaths and improve maternal health outcomes considering that approximately 30% of maternal deaths (excluding those caused by suicide or overdose) occur 43 to 365 days postpartum.⁹  One analysis estimates that approximately 217,000 uninsured low-income new mothers would benefit from the extended postpartum period.¹⁰ 

• As of November 2020, several states are pursuing action to extend the postpartum period. In many cases, this activity is still in the planning stage or has been set aside as the COVID-19 pandemic response takes fiscal priority in state budgets. However a few states have developed specific proposals. As of August 1, 2020, California has allocated $34.3 million in state funds to extend postpartum coverage for women diagnosed with a mental health condition. Georgia has allocated $19 million in state funding to extend coverage to 6 months postpartum, and Texas is offering a set of postpartum care services for up to 12 months for women who are eligible for the state’s family planning program. Indiana is requesting Section 1115 waiver authority to extend postpartum coverage to one year for mothers with opioid use disorder.
• Federal legislative proposals also have emerged. The Helping Medicaid Offer Maternity Services (MOMS) Act of 2020, which was passed by the House in September 2020, would provide a new state option to extend coverage for one year postpartum and increase the federal matching rate for states to take up the option. The Congressional Black Maternal Health Caucus has introduced a package of bills known as the Momnibus aimed at stemming maternal health disparities that includes measures such as diversifying the perinatal workforce and greater investment in social determinants of health. Notably, as part of COVID-19 response efforts, legislation requires states to provide continuous enrollment to Medicaid enrollees as a condition of receiving enhanced federal funding. This provision is designed to help protect against coverage losses during the pandemic, and states cannot disenroll pregnant women at the end of the postpartum period for during the public health emergency.

Most state Medicaid programs report being engaged in efforts to advance maternal and infant health. In a recent KFF survey, about two-thirds of states reported new or expanded Medicaid initiatives in FY 2019 or planned for FY 2020 to improve birth outcomes and/or address maternal mortality, with over a quarter of states focused on pregnant women with substance use disorder (SUD). These include efforts to expand eligibility for pregnant women, expand Medicaid coverage for perinatal services, and implement payment and delivery models that incentivize improvements in maternal care and outcomes.¹¹  Some state Medicaid programs also offer benefits specifically for pregnant women such as behavioral health services, dental services, and home visiting services.¹²  Several states are engaged in efforts to include Medicaid coverage for doula services. Research suggests that doula services can improve health outcomes for women and infants, reduce interventions during delivery, and facilitate communication between pregnant women and health care providers.¹³  Having a trained advocate can be particularly important for women of color, who are more likely to encounter discrimination in the health care system. Currently, two states (Oregon, Minnesota) allow doulas to participate in their Medicaid networks statewide and other states are testing pilot programs to assess the feasibility of broader coverage. An important component for incorporating doulas in the Medicaid program is assuring adequate and timely reimbursement, which has been a challenge in some pilot programs.¹⁴ 

The Centers for Medicare and Medicaid Services (CMS) has launched recent initiatives focused on addressing maternal and infant health. In 2019, the Center for Medicare and Medicaid Innovation (CMMI) awarded grants to ten states (Colorado, Indiana, Louisiana, Maryland, Maine, Missouri, New Hampshire, Tennessee, Texas, and West Virginia) for its new Maternal Opioid Misuse Model, which is intended to address the fragmented care of pregnant and postpartum persons with opioid use disorder.¹⁵  It also recently released a request for information seeking input on opportunities to improve health care access, quality, and outcomes for women and infants in rural communities before, during, and after pregnancy. Further, CMS recently released its 2020 Maternity Core Set of 11 measures for voluntary reporting by state Medicaid and CHIP agencies to help evaluate maternal and perinatal health in Medicaid and CHIP.

Outside of Medicaid, the federal government, states, providers and health systems, foundations, and communities also are engaged in a broad range of efforts to advance maternal and child health and reduce disparities. For example, some Medicaid initiatives are part of broader statewide approaches to advance maternal health and reduce disparities. Moreover, outside of Medicaid, the federal government provides funding for and engages in efforts to advance maternal and infant health through the Maternal and Child Health Block Grant, the Health Resources and Services Administration, the CDC, and other agencies. The CDC recently launched the Hear Her campaign to support improved communication between pregnant and postpartum women and maternity providers, which is particularly important given the growing recognition of the role racism plays in contributing to adverse maternal health outcomes. Several states have perinatal and maternal quality collaboratives as well as maternal mortality review committees that collect and analyze data on maternal and infant health outcomes and work to improve health care delivery for women and infants. Several of these committees have focused on collecting local data by race and ethnicity, highlighting differences by both race/ethnicity and geography. Improved data collection and analysis are important tools for identifying and understanding the disparate outcomes between different subpopulations as well as for developing and targeting quality improvement initiatives within the delivery system.¹⁶  In 2019, California became the first state to require perinatal providers to obtain training on implicit bias. Further, the city of San Francisco recently launched a project that gives a group of Black and Pacific Islander pregnant persons an income supplement during pregnancy and through the infant’s first six months of life to help address some of the known health and income inequities.¹⁷ 

Conclusion

Maternal and infant mortality rates in the U.S. are far higher than those in similarly large and wealthy countries, and stark racial disparities in maternal and infant health persist. The COVID-19 pandemic further highlights the urgency and importance of addressing health disparities in health care more broadly, and maternal and infant health specifically.

Healthy birth outcomes and early identification and treatment of health conditions among mothers and infants helps to prevent death and illness and advance overall population health. Healthy People 2030, which provides 10-year national health objectives to set the national public health agenda, identifies the prevention of pregnancy complications and maternal deaths and improvement of women’s health before, during, and after pregnancy as a public health goal.¹⁸  Pregnancy and birth provide opportunities to identify health risks in women and children. Moreover, early identification and treatment of health conditions or complications can prevent death and disability in both mother and child, enable children to reach their full potential, as well as improve overall population health. Recent research finds that as many as 60% of all maternal deaths in the U.S. are preventable and that increasing access to preconception, prenatal, and interconception care can reduce pregnancy-related complications.¹⁹ 

As a primary source of coverage for pregnant women and infants, particularly among people of color, Medicaid is key to improving maternal and infant health and reducing racial disparities. A number of efforts are underway through Medicaid to improve maternal and infant health, including efforts to provide more continuous coverage, expand benefits, and implement new payment and delivery models. However, coverage is only one factor affecting maternal and infant health, and there is growing recognition that it is important for efforts to improve health and reduce racial disparities to address broad social and economic factors that influence health and racism and discrimination.

1. Sarah H. Gordon, Benjamin D. Sommers, Ira B. Wilson, and Amal N. Trivedi, “Effects Of Medicaid Expansion On Postpartum Coverage And Outpatient Utilization,” Health Affairs 39, no. 1 (January 2020): 77-84, https://doi.org/10.1377/hlthaff.2019.00547 ↩︎
2. Scott R. Sanders et al., “Infants without health insurance: Racial/ethnic and rural/urban disparities in infant households’ insurance coverage,” PLOS One 15, no. 1 (January 2020): e0222387, https://doi.org/10.1371/journal.pone.0222387 ↩︎
3. Ibid. ↩︎
4. Chintan Bhatt and Consuelo Beck-Sague, “Medicaid Expansion and Infant Mortality in the United States,” American Journal of Public Health 108, no. 4 (April 2018): 565-567, https://ajph.aphapublications.org/doi/full/10.2105/AJPH.2017.304218 ↩︎
5. Clare Brown et al., “Association of State Medicaid Expansion Status With Low Birth Weight and Preterm Birth,” Journal of the American Medical Association 321, no. 16 (April 2019), https://jamanetwork.com/journals/jama/fullarticle/2731179 ↩︎
6. Erica Eliason, “Adoption of Medicaid Expansion Is Associated with Lower Maternal Mortality,” Women’s Health Issues 30, no. 3 (May-June 2020): 147-152, https://doi.org/10.1016/j.whi.2020.01.005 ↩︎
7. Jamie R. Daw, Katy Backes Kozhimannil, and Lindsay K. Admon, “High Rates of Perinatal Insurance Churn Persist After The ACA,” Health Affairs Blog, September 16, 2019, https://www.healthaffairs.org/do/10.1377/hblog20190913.387157/full/ ↩︎
8. Jamie R. Daw et al., “Racial and Ethnic Disparities in Perinatal Insurance Coverage,” Obstetrics & Gynecology 135, no. 4 (April 2020): 917-924, https://journals.lww.com/greenjournal/Fulltext/2020/04000/Racial_and_Ethnic_Disparities_in_Perinatal.20.aspx ↩︎
9. Donna L. Hoyert and Arialdi M. Miniño, “Maternal Mortality in the United States: Changes in Coding, Publication, and Data Release 2018,” National Vital Statistics Reports 69, no. 2 (January 2020): 1-18, https://www.cdc.gov/nchs/data/nvsr/nvsr69/nvsr69-02-508.pdf ↩︎
10. “Extending Postpartum Medicaid Coverage Beyond 60 Days Could Benefit Over 200,000 Low-Income Uninsured Citizen New Mothers,” The Incidental Economist, February 4, 2020, https://theincidentaleconomist.com/wordpress/extending-postpartum-medicaid/ ↩︎
11. Medicaid and CHIP Payment and Access Commission, Medicaid’s Role in Maternal Health (Washington, DC, June 2020), https://www.macpac.gov/publication/chapter-5-medicaids-role-in-maternal-health/https://www.macpac.gov/wp-content/uploads/2020/06/Chapter-5-Medicaid%E2%80%99s-Role-in-Maternal-Health.pdf ↩︎
12. Ibid. ↩︎
13. Kenneth J. Gruber, Susan H. Cupito, and Christina F. Dobson, “Impact of Doulas on Healthy Birth Outcomes,” Journal of Perinatal Education 22, no. 1 (2013): 49-58, https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3647727/ ↩︎
14. Amy Chen, Alexis Robles-Fradet, and Helen Arega, Building A Successful Program for Medi-Cal Coverage for Doula Care: Findings from A survey of Doulas in California, National Health Law Program, May 21, 2020, https://healthlaw.org/resource/doulareport/ ↩︎
15. “Maternal Opioid Misuse (MOM) Model,” Centers for Medicare & Medicaid Services, accessed January 27, 2020, https://innovation.cms.gov/initiatives/maternal-opioid-misuse-model/ ↩︎
16. Elizabeth Howell et al. “Reduction of Peripartum Racial and Ethnic Disparities,” Obstetrics and Gynecology 131, no. 5 (May 2018): 770-782, https://journals.lww.com/greenjournal/FullText/2018/05000/Reduction_of_Peripartum_Racial_and_Ethnic.4.aspx ↩︎
17. Tessa McLean, “SF announces pilot program to provide basic income to pregnant Black and Pacific Islander women”, SFGate, September 13, 2020, available at https://www.sfgate.com/news/article/SF-announces-basic-income-program-15566923.php ↩︎
18. “Pregnancy and Childbirth”, HealthyPeople.gov, accessed August 27, 2020, https://health.gov/healthypeople/objectives-and-data/browse-objectives/pregnancy-and-childbirth ↩︎
19. Emily E. Petersen et al., “Vital Signs: Pregnancy-Related Deaths, United States, 2011–2015, and Strategies for Prevention, 13 States, 2013-2017”, Morbidity and Mortality Weekly Report 68, no. 18 (May 2019): 423-429, https://www.cdc.gov/mmwr/volumes/68/wr/mm6818e1.htm?s_cid=mm6818e1_w ↩︎