Strategies for States to Drive Equitable Vaccine Distribution and Administration

Editor’s Note: In a new issue brief—prepared in partnership with Families USA and Health Equity Solutions—Manatt Health outlines key barriers states face in their efforts to increase vaccination rates among black, indigenous and people of color (BIPOC) and highlights strategies states are pursuing in partnership with community-based organizations (CBOs) to address these challenges. Drawing on insights learned through discussions with state officials, input from grassroots community organizations and a review of the literature, the issue brief also considers future phases of the COVID-19 vaccine rollout and planning. Highlights are summarized below. Click here to download a free copy of the full issue brief.

Since December 2020, the United States has administered more than 330 million COVID-19 vaccine doses, with 163 million people, or 49 percent of the population, completing a full vaccine series.¹ While these results show significant progress by the federal government, states, local governments and their community partners to reduce COVID-19 transmission, hospitalizations and deaths, efforts to date have not produced equitable outcomes.² Rates of COVID-19 vaccination vary widely within and across states, communities, and racial and ethnic groups, with those communities that are disproportionately experiencing the negative impacts of COVID-19 often having the lowest rates of vaccination.

Across 40 states with available data, the percentage of people who are white and have received at least one COVID-19 vaccine dose was roughly 1.4 times higher than the rate for people who are black and 1.2 times higher than the rate for people who are Latino(a), as of early July.³ These gaps began to close in recent weeks, however, as BIPOC comprised a greater share of newly administered vaccinations.^{4, 5}

Early vaccine distribution efforts successfully reached those most eager and able to access the vaccines, but efforts going forward must address the wide range of reasons why people have not received a COVID-19 vaccine on a neighborhood or an individual basis. State and local government and community leaders have the opportunity to address these barriers at the community level by leveraging a range of policy, data, outreach and financing levers to drive access and vaccine adoption among BIPOC.

A common thread across both near- and long-term state strategies to overcome barriers is meaningfully engaging, fostering and funding close partnerships with CBOs and other community partners as a cornerstone for success. Community partners can help states understand barriers to vaccine uptake across communities and implement focused and tailored strategies that address concerns at the individual level, in the near term, while building the necessary structures to reimagine and rebuild a public health system that fosters trust, centers on the community, and addresses long-standing and underlying social drivers of health (SDOH) inequities.

Key Barriers to Equitable Vaccine Distribution and Administration to Date

People who remain unvaccinated have diverse and multifaceted reasons for doing so, which vary across age, race and ethnicity, geography, and political ideology, among other factors. The table below outlines common barriers that have inhibited vaccination uptake and equity.

Strategies to Drive Equitable COVID-19 Vaccine Distribution and Administration

States, in partnership with local governments and community partners, can pursue a range of strategies aimed at addressing barriers and improving equity in vaccination rates for BIPOC. Strategies will vary based on different individuals’ and communities’ reasons for not getting vaccinated. While states used mass vaccination sites and centralized vaccination efforts and resources to reach those most eager and able to receive the vaccines, reaching those who have less confidence in or access to the vaccines will be more challenging and require a new set of engagement, communication and distribution strategies specific to the needs of each community.

1. Strategies for Addressing Barriers to Vaccine Access

In this new phase of vaccine distribution, reaching those who face structural barriers to accessing the vaccines will require hyperlocalized strategies tailored to individual needs. Key strategies include:

• Stand up vaccination sites in trusted and convenient locations based on community input. By launching vaccination sites where people work, live and engage, states are reaching individuals who may not otherwise actively seek a vaccine. States have launched vaccination clinics in collaboration with CBOs at employment sites, places of worship, libraries, festivals and community events, among others.
• Fund mobile or pop-up clinics in neighborhoods and communities disproportionately impacted by COVID-19, staffed by trusted entities with strong community connections, such as local municipalities and CBOs. A broad range of states have established mobile and pop-up clinics and continue to scale these efforts, anecdotally reporting that community members feel comfortable talking to mobile staff on their own terms.
• Drive education and access through local clinics, independent pharmacies, and family physician and pediatrician offices. For most adults, physicians and nurses are their most trusted sources of information on COVID-19 and other medical information. Leveraging health care professionals’ expertise and leadership can help build trust within communities and expand access to vaccines for people who are in the wait-and-see camp.
• Partner with and fund community health workers and other community-based providers to offer home-based vaccinations. Home-based vaccinations can support access, not only for individuals who are homebound for physical or mental health reasons, but also for those who face access barriers such as lack of transportation, lack of child care or other constraints.
• Encourage or incentivize employers to provide paid time off (PTO) to employees to get vaccinated and recover from any side effects (and lead by state example). Lack of PTO remains a significant barrier to vaccination, with only half of workers overall reporting that their employer provides PTO to receive or recover from a COVID-19 vaccine, according to recent polling from the Kaiser Family Foundation. Lack of PTO has a disparate impact on BIPOC, low-income individuals and those who lack health insurance coverage.
• Subsidize child care/elder care to help parents and other family caregivers get vaccinated. According to recent Kaiser Family Foundation polling, approximately 13 percent of unvaccinated parents would consider getting vaccinated if they had access to free child care options. To support parents and caretakers in their efforts to get vaccinated, states can establish free caregiving programs or subsidize caregiver costs for those in need, including by partnering with private caregiving companies to provide these services.
• Provide or pay for transportation to and from vaccination sites. While a number of states are offering subsidized transportation to support vaccinations by partnering with local public transportation agencies or ride-share companies, transportation barriers still exist, particularly in rural areas that do not have public transportation and are out of service areas for ride-share companies.⁷

2. Strategies for Combating Misinformation and Building Vaccine Confidence

To achieve herd immunity, the country must overcome a long history of structural racism in the health care system and public hesitancy toward vaccines that has increased over the past decade.^{8, 9} To address concerns about the vaccines, help people understand the benefits of vaccination, and counter misinformation, states can fund CBOs as essential partners in building trust and conducting outreach. Key strategies include:

• Engage, learn from and fund trusted leaders and organizations to provide consistent messaging in local communities. Partnering with local leaders and organizations and listening to concerns among community members can help states improve vaccine confidence and vaccination rates.

• Work with CBOs and community leaders to design messaging and modes of engagement tailored to specific communities of focus. Given the diverse range of concerns and questions about the vaccines across demographic groups, strategies should be tailored to the individual needs of the community.
• Make communication materials and outreach efforts accessible to all. This includes people who do not speak or read English as their primary language; who lack access to and familiarity with technology; and who have differing visual, learning and physical abilities.
• If pursuing incentives to encourage vaccine take-up, work with communities of focus to design incentives that resonate, are empowering and are noncoercive. As vaccination rates have slowed, a growing number of states, companies and organizations are establishing incentives to encourage vaccine uptake.¹⁰ These strategies may be effective if states deploy incentives that resonate with the community and are both empowering and noncoercive (such as transportation vouchers; paid leave; and free state university, community college or trade school credits).

3. Strategies for Addressing Data and Operational Challenges

Given the varying barriers to vaccination and reasons why people are not getting vaccinated that exist across communities, understanding and analyzing data at the local level in real time is critical to helping identify the most effective strategies to increase vaccine uptake. However, states have faced challenges collecting and reporting race and ethnicity data throughout the pandemic. As a result, in many states, high shares of vaccination data may be missing race/ethnicity information or have data classified as “other,” limiting states’ ability to interpret results.^{11, 12}

Given the limitations in available quantitative data, states can supplement quantitative data with qualitative data from ongoing county, local and community-based efforts. Ultimately, quantitative and qualitative data, when used together, can help states build, improve and scale vaccine distribution and equity efforts. Key strategies for improving quantitative and qualitative data collection include:

• Track vaccination data in real time and at granular geographic and demographic levels. Strong data at the local level supports efforts to identify opportunities to improve vaccination rates and evaluate the effectiveness of ongoing policies and programs. In particular, all states should require reporting and disaggregation of data for key demographic variables (such as gender, race and ethnicity) and geography (such as at the ZIP code level).
• Engage local leaders through focus groups and listening sessions; include them in a meaningful way on state and local task forces, commissions and COVID-19 response teams. To administer and distribute COVID-19 vaccines, states have employed strategies in collaboration with governments and organizations at the federal, state, county, local and community levels. Close coordination and collaboration across organizations can help states understand the successes or challenges of current outreach and distribution efforts and learn how to best evaluate and scale current strategies.
• Fund community leaders and CBOs to ensure their engagement in quantitative and qualitative data-gathering efforts. States have faced operational challenges in their efforts to disseminate dollars to CBOs, in part due to complex state procurement processes. To address these challenges, states leveraged existing vendors to subcontract with CBOs to the extent possible and expedited or streamlined portions of state procurement requirements, as feasible based on underlying authorities.

The Next Phase of the COVID-19 Vaccine Rollout and Long-Term Strategies to Advance Health Equity

Beyond improving equitable vaccine distribution and administration for adults, states can look ahead to establish strategies to vaccinate children and adolescents and build sustainable infrastructure and capacity to advance health equity within state and local public health and health care delivery systems.

State Challenges and Strategies to Roll Out the Vaccine to Children and Youth

With Emergency Use Authorizations (EUAs) already in place to administer COVID-19 vaccines to children and adolescents age 12 and older and EUAs expected for children as young as age 5 early this fall, a current and near-term focus for states will be developing robust vaccine distribution efforts for children and adolescents that advance health equity and do not perpetuate the access and uptake disparities seen among adults who are BIPOC.¹³ Overall, experts anticipate lower vaccine uptake among children and adolescents given their relatively low risk of severe disease or mortality from COVID-19 and fear among parents and guardians of potential adverse outcomes from the vaccines for their children.¹⁴

Leveraging trusted resources in communities will be vital to help parents and guardians understand the benefits of the vaccines for children and adolescents. Pediatric health care providers will play a vital role in helping parents and guardians understand the importance of the COVID-19 vaccines for children, weigh potential risks, and address lingering questions or concerns.¹⁵

Schools are another critical partner in vaccination efforts for children and adolescents, including advancing equitable vaccine distribution and administration. Given the role they play in the lives of children and adolescents, schools are in a unique position to reach and educate parents and guardians and administer the vaccines.¹⁶

When developing and implementing strategies to vaccinate children and adolescents, states should pay special attention to developing an equitable and accessible approach to vaccinating children and adolescents who reside in congregate or group settings, such as residential treatment facilities or homeless shelters. These populations of focus are at greater risk of exposure to COVID-19 and are more likely to have underlying health complications that make them particularly vulnerable to adverse outcomes from COVID-19.

Long-Term Organizational, Policy or Other Structural Opportunities to Address Health Equity

Since the start of the pandemic, COVID-19 response efforts, including vaccine distribution, have demonstrated the importance of strong public health infrastructure for addressing new and existing threats to the health of our communities and reducing long-standing health disparities. The fragility of and structural racism in these current structures and systems have also been laid bare by the pandemic.

A robust body of evidence shows that investments in public health infrastructure have a strong return on investment. Studies show that higher levels of public health investment are associated with reduced Medicare utilization, improvements in communities with higher poverty levels, and reduced morbidity and mortality from a variety of causes^{17, 18, 19} Despite these benefits, public health funding has declined in recent years at both the state and federal levels.²⁰

In response to the COVID-19 pandemic, the federal government created time-limited funding opportunities to infuse dollars into public health infrastructure, including the investments outlined in the American Rescue Plan Act (ARPA) and the COVID-19 stimulus bills. These investments provide an opportunity for states to begin to rebuild more resilient public health workforces, infrastructure systems and processes. As states enhance their public health infrastructure as part of ARPA or other efforts, it will be critical to build on the successes and lessons learned from their vaccine distribution and outreach efforts, with an explicit focus on advancing health equity.

_{¹ Centers for Disease Control and Prevention. 2021. “COVID-19 Vaccinations in the United States.” https://covid.cdc.gov/covid-data-tracker/#vaccinations.}

_{² Centers for Disease Control and Prevention. 2021. “COVID-19 Vaccinations in the United States.” https://covid.cdc.gov/covid-data-tracker/#vaccinations.}

_{³ Artiga, Samantha, Hill, Latoya, Ndugga, Nambi, et al. 2021. “Latest Data on COVID-19 Vaccinations by Race/Ethnicity.” Kaiser Family Foundation. Accessed July 22, 2021. https://www.kff.org/coronavirus-covid-19/issue-brief/latest-data-on-covid-19-vaccinations-race-ethnicity/.}

_{⁴ Artiga, Samantha, Hill, Latoya, Ndugga, Nambi, et al. 2021. Latest Data on COVID-19 Vaccinations.}

_{⁵ Artiga, Samantha, Goldhaber-Fiebert, Jeremy, Joseph, Neesha, et al. 2021. “Disparities in Reaching COVID-19 Vaccination Benchmarks: Projected Vaccination Rates by Race/Ethnicity as of July 4.” Kaiser Family Foundation, June 14. Accessed July 22, 2021. https://www.kff.org/racial-equity-and-health-policy/issue-brief/disparities-in-reaching-covid-19-vaccination-benchmarks-projected-vaccination-rates-by-race-ethnicity-as-of-july-4/.}

_{⁶ Akhtar, Alanna. 2021. “Biden’s COVID-19 task force chief warns anti-vaxxers are targeting Black people.” Business Insider, February 24. Accessed July 27, 2021. https://www.businessinsider.com/joe-bidens-covid-19-advisor-anti-vaxxers-targeting-black-americans-2021-2.}

_{⁷ Goldberg, Dan, Roubein, Rachel. 2021. “Rush to close vaccination gap for Hispanics.” Politico, June 27. Accessed July 26, 2021. https://www.politico.com/news/2021/06/27/hispanic-vaccination-gap-covid-barriers-496394.}

_{⁸ Andrasik, Michele P, Quinn, Sandra C. 2021. “Addressing Vaccine Hesitancy in BIPOC Communities— Toward Trustworthiness, Partnership, and Reciprocity.” New England Journal of Medicine. https://www.nejm.org/doi/pdf/10.1056/NEJMp2103104?articleTools=true. doi: 10.1056/NEJMp2103104.}

_{⁹ Laurencin, Cato T. 2021. “Addressing Justified Vaccine Hesitancy in the Black Community.” NCBI. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8009077/. doi: 10.1007/s40615-021-01025-4.}

_{¹⁰ National Governors Association. 2021. “COVID-19 Vaccine Incentives.” https://www.nga.org/center/publications/covid-19-vaccine-incentives/.}

_{¹¹ Artiga, Samantha, Ndugga, Nambi, Pham, Olivia. 2021. How are States Addressing Racial Equity in COVID-19 Vaccine Efforts?}

_{¹² Artiga, Samantha, Hill, Latoya, Ndugga, Nambi, et al. 2021. Latest Data on COVID-19 Vaccinations by Race/Ethnicity.}

_{¹³ Advisory Board. 2021. “Covid-19 roundup: When could children under 12 get vaccinated? Here’s what Pfizer and Moderna say.” June 11. Accessed July 26, 2021. https://www.advisory.com/daily-briefing/2021/06/11/covid-roundup.}

_{¹⁴ Artiga, Samantha, Kates, Jennifer, Michaud, Josh, et al. 2021. “COVID-19 Vaccines for 12-15-Year-Olds: Considerations for Vaccine Roll-Out.” Kaiser Family Foundation, May 10. Accessed July 26, 2021. https://www.kff.org/policy-watch/covid-19-vaccines-for-12-15-year-olds-considerations-for-vaccine-roll-out/.}

_{¹⁵ Centers for Disease Control and Prevention. 2021. “Pediatric Healthcare Professionals COVID-19 Vaccination Toolkit.” https://www.cdc.gov/coronavirus/2019-ncov/vaccines/toolkits/pediatrician.html.}

_{¹⁶ State Health and Value Strategies Roundtable Discussion on Equitable Solutions for Advancing Vaccine Equity, June 21, 2021.}

_{¹⁷ Galea, Sandro, Maani, Nason. 2020.}

_{¹⁸ Mays, Glen P, Smith, Sharla A. 2011. “Evidence Links Increases In Public Health Spending To Declines In Preventable Deaths.” Health Affairs, vol. 30, no. 8. https://www.healthaffairs.org/doi/abs/10.1377/hlthaff.2011.0196.}

_{¹⁹ Erwin, Paul Campbell, Mays, Glen P, Riley, William J. 2012. “Resources That May Matter: The Impact of Local Health Department Expenditures on Health Status.” NCBI. doi: 10.1177/003335491212700110.}

_{²⁰ Bailey, Susan R. 2021. “Pandemic exposes dire need to rebuild public health infrastructure.” American Medical Association, February 10.}