COVID vaccines: It's not just politics keeping people away

Although it's clear that misinformation and political polarization deterred many from getting the vaccine, my colleagues and I recently published new findings that shed light on another major factor: Adults who had health insurance, a "usual" place of care (meaning they said they visited the same doctor's office or clinic when they became sick or injured), and had visited a physician in the past year were 45 to 60 percent more likely to get vaccinated and to get vaccinated early (within the first six months after the vaccine was released) — when it mattered most. This association persisted even after accounting for factors like education level, income, and geographic location, all of which can be predictors of vaccine hesitancy .

We were surprised. The vaccine was free and widely available outside doctors' offices in 2021 — so why did having an established primary care doctor, for example, matter? Couldn't people just head over to their local CVS and get one for free?

Well, yes. But there are a few reasons why people who go to the doctor regularly were more likely to get the COVID vaccine. First and foremost, we think it's because these people have a trusted clinician who could provide advice and information on the effectiveness and safety of the vaccine. That advice may have reduced vaccine hesitancy and distrust. Also, primary care clinics administer about half of all routine vaccines — from those for childhood measles to our annual flu shots — and indeed, our Boston-area community clinics served as credible, accessible, and convenient locations for getting the COVID vaccine.

Further, many pharmacies and health care providers asked patients for their insurance information even though vaccines were provided free to anyone in 2021. That could have deterred some uninsured people from seeking the vaccine. To be sure, we're not saying that free vaccines aren't important, but our study shows they aren't enough to keep Americans vaccinated against COVID. People need to have a relationship with their health care providers in order to trust them and to keep on top of their health needs. But more and more people don't have a trusted provider they see regularly: They now number more than 100 million . There's a shortage of primary care physicians, and this problem is only getting worse.

Although COVID deaths have decreased significantly since the early pandemic, cases continue to surge each winter and to cause serious illness and death among immunocompromised patients . Even so, booster COVID shots are still unpopular: Only 22 percent of eligible adults have received the most recently updated vaccine.

The federal government's free COVID vaccination program ended in early October 2023. Since then, Americans have generally paid for the vaccine out of pocket, used their insurance coverage, or relied on the Centers for Disease Control and Prevention's Bridge Access Program, which began covering the cost of COVID vaccination when the public health emergency expired. But the Bridge program is scheduled to end in December, just in time for next winter's COVID surge.

Removing financial barriers to COVID vaccination is crucial, but our study shows that offering free vaccines alone is not enough. To achieve the highest vaccination rates, we must provide free vaccines ensure access to trusted health care providers who can educate and vaccinate patients in their offices.

Medicaid goes a long way toward providing better access to primary care, but many low- to moderate-income people remain ineligible for the program, even with Obama-era expansions. Some of these people have private insurance but can't afford the copays and deductibles, so they avoid the doctor's office.

Pandemic-era policies made it easier to enroll in and keep Medicaid benefits, and these expired in March 2023. Since then, Medicaid enrollment has fallen by at least 10 percent. This drop is mainly because of the difficulties people have in completing the complicated paperwork needed to maintain their enrollment. From year to year, Medicaid-eligible individuals and families lose their health coverage if they move and their reenrollment forms are sent to the wrong address, or if their eligibility changes at frequent intervals because of fluctuating income. All of this throws up barriers to maintaining health insurance and getting regular health care and, by extension, vaccinations.

Extending the CDC's Bridge Access Program and reinstating automatic, continuous enrollment for Medicaid could make a big difference in getting COVID vaccines to more people. Ultimately, our findings emphasize that unfettered access to health insurance and to a primary care provider matter the most for improving Americans' motivation to get vaccinated.