El Buen Samaritano, an Episcopal outreach ministry in Texas, serves the east side of Austin, the poorer of the two sides of the city split by I-35. There are fewer services there, including many neighborhoods that don’t have a health center. The population is mainly people of color, many whose first language is Spanish. It’s the kind of population that has low Covid vaccination rates.
But El Buen has been able to prove that at least as far as Austin goes, the issue is not fear of the vaccine itself. “This is all about access,” Luis Garcia, director of technology and analytics for El Buen, told me. Its food pantry gets about 200 visits every day it’s open, many from families who return week after week. Each of those food pickups is a chance for El Buen staff members to talk to them about the vaccine, Mr. Garcia speaking in Spanish as he hands them bags of groceries and whole watermelons. The organization has also plastered social media, put out radio spots in Spanish and hung fliers in other food pantries.
Every month the organization holds a vaccination event. Other sites might ask for an ID or health insurance and usually demand an online appointment that requires internet access and often a computer, things that people in this community frequently don’t have. El Buen gives out shots on the spot, no questions asked.
Even though the event El Buen did in September didn’t start until 3 p.m., a couple of hundred people had lined up by 1:30, the cars crawling down the quiet residential street it sits on to a six-lane road a third of a mile away. One person waited in the line for an hour, and at 7 p.m. Mr. Garcia told him he’d have to come back to the next one. El Buen put 324 shots in arms that day.
About 20 percent of those who come are still getting their first shot, but El Buen is also doling out the recently released bivalent boosters that protect against Omicron variants, as well as vaccinating children 6 months and older. What El Buen is doing “shows that hesitancy is not such a thing,” Mr. Garcia said. “It shows they couldn’t get it before.”
When the first round of Covid shots became available, income disparities in vaccination rates quickly reared their heads. Instead of throwing every idea at the problem, by mid-2021 the Biden administration had started to grumble that people who hadn’t gotten the shot were “unbothered and unconvinced,” arguing, in essence, that every American was individually responsible for seeking out the shots. And yet at that time three-quarters of unvaccinated adults lived in a household earning less than $75,000, and many of them said they wanted to get vaccinated.
Now there are brand-new boosters that promise to protect people against the variants that are spreading now, as well as the original strain. They are quite likely to keep lots of people from getting infected, helping to reduce spread even as a winter surge in cases looms. They will significantly reduce the risk of severe illness and death for those who still get sick and they could potentially do the same when we face new variants in the future.
But this time around we’re doing even less to get these incredible shots to the least advantaged. “The barriers are the exact same,” Rhea Boyd, a pediatrician and public health advocate, told me. “We’ve known them the entire time.” Democrats cut Covid funding from a March spending package in response to Republican opposition, and the ongoing lack of funding means there’s little to push shots out and ensure people can get them easily and affordably.
That means dwindling numbers of vaccine sites, less outreach and certainly fewer creative solutions for raising awareness and increasing access. There is $550 million for FEMA vaccination efforts this year, compared with $8.5 billion last year. Gone are funds to create pop-up vaccination sites in communities, give people transportation to and from appointments, offer free child care or bring shots to their doors.
Instead of people being able to walk to a nearby mobile vaccine clinic, vaccination duties have been absorbed by the medical system and “all the barriers, transportation and costs, associated with that,” Dr. Boyd said. Many low-income people don’t have a primary care provider who can talk to them about the vaccines and give them shots. They may not have the insurance to visit a doctor regularly or the transportation to get there.
In a Centers for Disease Control and Prevention survey, nearly three-quarters of Americans said that they were likely to get the new booster. And yet roughly 7 percent of the eligible population has gotten it so far.
The rates look even worse when broken down by income. According to the Census Bureau’s Household Pulse Survey, those earning the least are also the least likely to have been vaccinated or boosted. Six percent of people in households earning $200,000 a year or more are unvaccinated, and 12 percent haven’t received a booster, bivalent or otherwise. On the other hand, one in five of those in households earning less than $50,000 a year haven’t been vaccinated at all, and another 28 percent haven’t been boosted. In a July survey by the Kaiser Family Foundation, about a third of people who had been vaccinated but not boosted listed not having the time as a reason, while 15 percent were worried about missing work.
“Low-income people throughout have been willing to get vaccinated but haven’t been vaccinated yet, and that really shows a need for more delivery,” said Julia Raifman, assistant professor at the Boston University School of Public Health.
That means that they are most likely to shoulder higher rates of disease and death. They also suffer other costs, like missing work when they get sick with Covid. Low-income workers saw the biggest increases in unpaid work absences in the first two years of the pandemic; those in households earning less than $25,000 a year were more than three times as likely to miss work without pay than those earning $100,000 or more. People who are boosted are less likely to miss work because of Covid than those who aren’t.
There are certainly people in every income bracket who are ideologically opposed to the vaccine or misinformed about the risks. A recent study found that after the vaccines were rolled out, Republicans were much more likely to die from Covid. What that study doesn’t tell us is whether people were subjected to lower rates of vaccine access thanks to the partisan makeup of the state and local officials in charge. A different study found that the presence of a vaccination site increases doses administered by about 26 percent, which in turn reduces Covid cases, hospitalizations and deaths.
Other people are worried about side effects. That’s understandable for low-income Americans who can’t afford unpaid time off to recover. While the Biden administration’s American Rescue Plan originally gave businesses tax credits for offering paid leave for vaccination, those credits ended a year ago. Instead the administration is asking employers to voluntarily step up, but we know that the lowest-income workers are already the least likely to get paid sick leave from their employers.
All of this is “a problem that’s fixable,” Dr. Boyd said.
First, the government needs to get the word out about how great the bivalent boosters are, even if you’ve been previously infected, even if you’re young and healthy. “So few people know that they’re even available,” Dr. Boyd pointed out. And yet there is little money to spread the word. Worse, President Biden sent the opposite signal when he recently claimed that “the pandemic is over.” He could instead tell us that if everyone gets the new bivalent boosters, that’s the way to achieve what we all want: a full return to normal life.
If lawmakers are willing to be creative and address people’s needs, they could conduct a successful vaccination campaign that reaches far more people. They could designate a national vaccine day with easy locations for everyone to get a first shot or booster. They could bring vaccines to workplaces, particularly for frontline workers. They could fund local health departments to deliver bivalent boosters door to door the way they did with the first round of shots. They could get the word out with campaigns featuring stars from movies, music and sports. Ads can feature people who have experienced the adverse effects of not being vaccinated, particularly representatives of groups with low vaccination rates like police officers or long-term care workers. This is the “moment to reinvigorate it,” Dr. Raifman said.
All of these steps can help Covid vaccines reach a broader range of people. But they are also measures that can help with plenty of other public health goals as routine as the annual flu shot, which is itself no public health success story. About half of adults got their shots last year. Flu shots, as with all other immunizations, are considered preventive care that health insurance plans must cover no-cost in network. But many people have reported this year that they’ve been told that, even with insurance, they have to pay steep co-pays to get their shots.
The earlier model of Covid vaccination distribution should be revived and replicated: making vaccines and the counseling about whether to get them free. That’s “very low-hanging fruit,” Dr. Boyd said. Then it becomes part of the system, and the culture, anytime other vaccines have to be rolled out for future outbreaks or pandemics — like, say, of monkeypox or polio.
We also need a better system to get vaccines out. “Routine delivery requires investment in infrastructure and public health departments,” Dr. Raifman said. A lot of Covid vaccine funding went to contractors, not local public health institutions. The money needs to instead go to these longstanding organizations. The government should fund and staff mobile vaccination campaigns for the long term, not just for Covid shots but other vaccines, both routine and emergency. “Having public health rapid response capability means you can make sure people are getting their Covid and flu vaccines right now,” Dr. Raifman said. When another variant springs up, or there’s another disease outbreak, “it really sets you up to be able to act fast.”
Sometimes effective interventions aren’t all that complicated. The B Healthy Back to School Vaccination event in Boston was held on a Saturday in mid-September at a sports center. People who got vaccinated were given $75 Visa gift cards and back-to-school supplies. For the family of Dorothy Stringer, that money went toward buying groceries amid high inflation. “I am very proud. I got the whole family done,” she told CBS News Boston. More than 600 people got vaccinated that day. When the city held a second event in October, 780 people got vaccinated.
But such efforts are now few and far between. “We can do so much better than this, and yes, it requires some standards and some investment,” Dr. Raifman said. “But it makes society more livable for everyone, and isn’t that the function of government?”
Graphics by Sara Chodosh.
Bryce Covert (@brycecovert) is a journalist who focuses on the economy, with an emphasis on policies that affect workers and families.
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