With promising early results of a coronavirus vaccine, there is increased excitement among the American public and policy-makers for a possible resolution to the COVID-19 pandemic. Yet, despite cheerleading by the scientific community and industry leaders, numerous uncertainties remain. Even with a favorable trial, the earliest “doable” COVID-19 vaccine, according to Dr. Anthony Fauci, the Director of the National Institute of Allergy and Infectious Diseases, would be in January 2021. And if a viable vaccine is ready by January 2021, the subsequent production of millions (or even billions) of doses will take even more time. Beyond the temporal challenge of expediting safe and effective vaccines, there is uncertainty regarding the cost of vaccine delivery. After vaccines are developed, who will pay for their delivery to the millions of Americans newly without health insurance?
Unlike pediatric vaccination delivery, which is financially buoyed by the 1993 Vaccines for Children federal program, adult vaccines receive no federal support. The cost of adult vaccine procurement and administration is covered by health insurance marketplace plans and private insurance plans. Since nearly half of Americans receive health insurance through their jobs, the recent spike in unemployment will undoubtedly disrupt the ability of millions of Americans to receive health care. In fact, the Robert Wood Johnson Foundation estimates that anywhere from 25 to 43 million Americans either have lost, or may lose their employer-based insurance in the upcoming months. With the advent of the Affordable Care Act, these individuals were supposed to be sustained by Medicaid expansion. However, given that 15 states have not expanded Medicaid – including places severely hit by COVID-19 like Texas, Georgia, and Florida – millions of newly-unemployed individuals may not have access to any health insurance when their unemployment insurance ends in January 2021, the estimated time it is hoped that a COVID-19 vaccine will be ready for large-scale administration. If the most recent Food and Drug Administration-approved vaccine is any indication of the cost of a novel vaccine, immunization against COVID-19 could be cost-prohibitive for millions of Americans who lack health insurance or private funds to pay out-of-pocket for the vaccination.
While we all want to see a vaccine come to light as soon as possible, neglecting the financial and policy implications of vaccine delivery could have massive adverse consequences. As global public health authorities have harkened, the SARS-CoV-2 virus will continue to spread unless the vast majority of the population is vaccinated, and we develop herd immunity. Immunizing only those with adequate health insurance, or cash, will guarantee that millions of Americans will not be immunized and could be future carriers of infection. This situation would unacceptably exacerbate the growing inequalities brought on by COVID-19, particularly in communities of color and low-income communities, who have borne the brunt of the morbidity and mortality of the disease. If we suffer from such myopic funding preparations for vaccine delivery, we risk escalations in COVID-19 cases, even with an effective vaccine. While the cost of vaccinating every individual would be significant, the cost of not vaccinating everyone could be even greater.
We can turn to the Vaccines for Children (VFC) program, which has been deemed overwhelmingly successful, for guidance. Under the VFC, the federal government covers the cost of the vaccine product for childhood vaccines. This type of financial commitment should be applied to any new COVID-19 vaccine as well. However, the VFC program is not perfect. Administration fees and practice overhead costs for the delivery of these childhood vaccines are not federally covered. While state Medicaid programs often pay some of these administrative costs, in some areas they only cover $3.30, meaning clinic practices often lose $5-$15 for each vaccine administered. This difference is inadequate at baseline, but given the financial burden of COVID-19 on primary care clinics – over 40% of primary care clinics have had to furlough staff and nearly half may not financially survive the crisis – it is imperative that COVID-19 vaccine payment is re-structured to be fully covered; failing to do so could jeopardize delivery of the vaccine at primary care clinics across the country.
To facilitate a smooth vaccination process, health care providers need the federal government to commit to covering the costs of vaccine products for all Americans. Furthermore, with state governments in financial distress due to an inability to incur debt, the federal government should commit to covering the administrative overhead of all COVID-19 vaccine delivery, ensuring all Americans, regardless of whether they have insurance or live in a state with Medicaid expansion, can receive immunizations in a safe and timely manner. Such a commitment is a necessary first step to address the growing inequities brought on by COVID-19.
Ultimately, we have a moral imperative to ensure equitable vaccine coverage against this pandemic. To do so, we must commit to not only developing a vaccine, but also to pay for everyone to receive it.
Daniel H. Low is a family physician. Amish Dave is a rheumatologist. Rajneet Lamba is an internal medicine physician. Nancy Belcher is executive director, King’s County Medical Society.
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