The U.S. Needs a Federal Program To Expand Vaccine Access and Equity for Adults

More than 27 million people are currently uninsured in the United States, and as pandemic-era Medicaid protections begin to unwind this month, up to 15 million people could lose coverage through that program. Despite state and federal efforts to keep people insured, access to COVID-19 and routine vaccines will become more precarious for people with low incomes at a time when vaccines are more important than ever.

Congress should protect the health of all Americans by ensuring that everyone, regardless of insurance coverage, has access to recommended vaccines at no cost. In particular, a new Vaccines for Adults (VFA) program—in line with the Biden administration’s fiscal year 2024 budget proposal—would improve access to vaccines and health by boosting vaccine rates and reducing the number of vaccine-preventable illnesses and deaths.

Established in 1993, the federal Vaccines for Children (VFC) program has secured vaccine access at no cost for almost half of U.S. children and adolescents, saving nearly $2.2 trillion in costs and avoiding more than 1 million deaths. Yet experts have noted that progress on adult immunization is far behind progress on childhood immunization. Amid falling vaccination rates and the persistent health burden from vaccine-preventable illnesses, Congress should establish a similar program for adults.

Rates are lagging for recommended adult immunizations

The public health emergency for COVID-19 will officially end on May 11, 2023, and COVID-19 tests, treatments, and vaccines will transition from being publicly funded to covered by the commercial market as soon as this fall. Yet just 79 percent of U.S. adults over the age of 18 have received the first two doses of the COVID-19 vaccine, and only 20 percent have received the updated bivalent booster.

Medicaid, Medicare, and most private insurance plans will continue to cover the COVID-19 vaccine without cost sharing, along with all vaccines recommended by the Advisory Committee on Immunization Practices (ACIP). Though both Moderna and Pfizer have patient assistance programs, which help uninsured and underinsured patients access certain medications and vaccines at little to no cost, guaranteed access to COVID-19 vaccines is less assured for uninsured Americans.

The Biden administration is planning to stockpile a limited number of COVID-19 vaccines for uninsured individuals, free of charge, through the summer of 2024. Yet with more than 250 Americans dying each day from COVID-19 and experts anticipating at least annual boosters moving forward, continued vaccine access for uninsured adults is vital to both recovering from the pandemic and protecting health.

Although the spotlight has shined most brightly on COVID-19, the COVID-19 vaccine represents just one critical vaccine needed to maintain adult health. A low number of adults are receiving recommended routine vaccinations: Data from 2018 show that 3 in every 4 adults are missing at least one critical routine vaccine, including for influenza, pneumococcal disease, shingles, and Td or Tdap. Moreover, the rate of adults up to date on routine vaccinations is less than half that of school-age children, at only 42 percent. (see Figure 1)

A 2021 study indicates the pandemic may have led to further declines in adult immunizations, making many vulnerable to preventable diseases and potential death. These trends are particularly concerning as diseases that were previously eradicated in the United States, such as polio, resurface and vaccine rates fall below herd immunity thresholds in certain regions. In fact, national rates for several common vaccines have fallen below federal targets.

Annually, vaccine-preventable diseases have notable health and economic impacts: According to data from the Centers for Disease Control and Prevention (CDC), each year, the United States has “approximately 1 million cases of herpes zoster each year, more than 3,000 cases of acute hepatitis B infections, and about 40,000 cases and 4,000 deaths from invasive pneumococcal disease.” Vaccination rates also differ across populations, with Black and Hispanic adults and those with low incomes facing lower vaccination rates, thus deepening health disparities. These disparities indicate the need for policy to boost routine vaccination rates by removing structural barriers and improving access.

All Americans need access to no-cost vaccines

Congress should establish a Vaccines for Adults program to build on the Section 317 program to improve access to and support the sustainability of vaccine programs. Currently, federal spending on vaccines for uninsured adults flows largely through Section 317 of the Public Health Service Act, which established an immunization program to provide the CDC with funding to purchase vaccines for uninsured and underinsured adults at no cost. Section 317 funding also helps build and support operations and public health infrastructure to administer vaccinations, provide vaccine education and communication, modernize immunization data systems, and monitor vaccine effectiveness and outbreaks.

More than 75 percent of the program’s funding is spent on vaccine infrastructure at federal, state, and local levels—including the infrastructure that supports access under the VFC program, a federal entitlement program that purchases and provides no-cost access to ACIP-recommended vaccines for children under age 19 who are uninsured, underinsured, Medicaid eligible, or American Indian or Alaska Native. In FY 2023, Section 317 funding increased by $31 million, from roughly $651 million in FY 2022 to $682 million in FY 2023.

Yet because the Section 317 Immunization Program relies on fixed, discretionary dollars subject to cuts each year, its ability to fully serve those in need is limited. In fact, based on CDC estimates, Section 317 is already severely underfunded by at least $750 million. Declines in Section 317 funding would jeopardize the country’s immunization infrastructure and limit its ability to purchase enough vaccines.

A comprehensive solution to improving immunization rates and expanding adult vaccine access will require both adequately funding the Section 317 program and standing up a Vaccines for Adults program. By covering the cost of vaccine purchasing and administration under VFA, more Section 317 funds could go toward supporting a robust safety net vaccine infrastructure. States could use the additional Section 317 funds to create and manage expanded provider networks reflective of the array of settings in which adults receive care, including pharmacies and specialty care providers. States and localities could also use Section 317 funds to preserve existing community partnerships that helped boost COVID-19 vaccine efforts, expanding those partnerships to incorporate education and outreach for routine immunizations.

A Vaccines for Adults program would complement the successful Vaccines for Children program

In both its FY 2023 budget and FY 2024 budget, the Biden administration called for the establishment of a federal Vaccines for Adults program with mandatory spending capped at $12 billion over 10 years—building on the administration’s Vaccines National Strategic Plan. Such a program would cover outbreak and routine vaccines recommended by the ACIP and should have flexibility to include new immunization therapies for uninsured and underinsured adults over the age of 19 at no cost to the individual. This would provide access to lifesaving vaccines for the more than 24 million uninsured adults who lack coverage—disproportionately people of color, people with low incomes, people in underserved communities, and working families.

Like VFC, the Vaccines for Adults program would operate through state-required participation with oversight and funding from the CDC. The federal government would negotiate with and purchase vaccines directly from manufacturers and then distribute vaccines to states. Provider networks supported by the Section 317 Immunization Program, including some VFC providers, could be readily used to provide routine vaccinations under VFA.

However, unlike VFC, the Biden administration’s VFA proposal includes needed funding for provider fees—including vaccine administration fees—reducing the provider financial cost of maintaining vaccine stock. This reimbursement should be based on methodologies that adequately reflect the cost of administration, storing, and personnel time for managing inventory, in addition to the cost of the vaccine itself, regardless of the type of provider.

A Vaccines for Adults program would save both lives and money

Vaccination is one of the safest, most powerful, and most cost-effective public health tools for disease prevention, improving both individual and community health. Since the introduction of vaccines, more than 100 million cases of vaccine-preventable diseases have been averted in the United States, dramatically reducing the burden of these diseases on mortality and morbidity. Some diseases—including smallpox and rinderpest—have even been completely eradicated as a result of vaccination.

Despite these gains, costly gaps in vaccine coverage remain. There has been a slow resurgence in the incidence of vaccine-preventable diseases in the United States. Even before COVID-19, more than 50,000 adults died of vaccine-preventable diseases or their complications each year. A December 2022 Commonwealth Fund study found that the COVID-19 vaccine alone has saved the United States more than 3 million lives and more than $1 trillion in medical costs. The economic burden of vaccine-preventable diseases in the country, including both the cost of medical treatment and lost productivity, is an estimated $9 billion to $26.5 billion each year—surpassing the annual cost of a VFA program. Beyond reducing the burden on the health care system, vaccination also helps save state, local, and federal public health agencies the cost required to fight outbreaks. Increasing vaccination rates among adults would yield significant benefits, including reducing cases of vaccine-preventable diseases by at least 33 million and saving more than $96 billion in total medical and societal costs. (see Figure 2)

The VFC program has been immensely successful in boosting immunization rates. More than 90 percent of children have had routine vaccinations. Moreover, among children born between 1994—the first programmatic year of VFC—and 2021, CDC estimates show that vaccination will prevent more than 1 million deaths, prevent 472 million illnesses, and save nearly $2.2 trillion in overall costs to society over their lifetime. For some vaccines, such as Hepatitis B and measles, mumps, and rubella (MMR), the VFC program has even helped eliminate differences in vaccination rates among children across income levels. VFC is also cost-effective because the CDC purchases vaccines directly from manufacturers at negotiated prices ranging from 15 to 72 percent below list price, while vaccines purchased through Section 317 are between 24 and 59 percent below list price.

Publicly purchased vaccines—including VFC, Section 317, and state funds—account for half of all childhood vaccine supply, and through contracting, VFC helps encourage vaccine manufacturing. A VFA program modeled after VFC and designed to work in concert with Section 317 has the potential to realize comparable cost-saving and lifesaving benefits, reduce disparities in vaccine rates among adults, and improve overall vaccine supply.

Conclusion

A Vaccines for Adults program is a cost-effective way to expand vaccine access, promote equity, and reduce the health disparities faced by marginalized groups in the country. Now is the time to capitalize on efforts made during the pandemic by securing no-cost vaccine coverage for all Americans.

The author would like to thank Jill Rosenthal and Emily Gee for their thoughtful review of this article, as well as the Association of Immunization Managers for their partnership in identifying supporting data for the article.