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COVID-19
February 17, 2021

Medicaid and COVID-19 Vaccination—Translating Equitable Allocation Into Equitable Administration

Author Affiliations
  • 1Virginia Department of Medical Assistance Services, Richmond
  • 2Virginia Commonwealth University School of Medicine, Richmond
  • 3Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia
  • 4Massachusetts Medicaid MassHealth, Boston
  • 5Washington Health Care Authority, Olympia
JAMA Health Forum. 2021;2(2):e210114. doi:10.1001/jamahealthforum.2021.0114

The risk of infection, morbidity, and mortality—and ultimately suffering—from coronavirus disease 2019 (COVID-19) has been borne unevenly. A disproportionate burden of disease has been shouldered by low-income and marginalized populations, many of whom rely on the Medicaid program for access to health care.1 Medicaid provides health coverage for more than 75 million individuals, including those receiving community-based long-term services and supports, those with developmental disabilities, those residing in low-resource neighborhoods, and an estimated 10% of all essential and front-line workers.2

The rapid development and approval of COVID-19 vaccines present a remarkable opportunity to limit suffering from the COVID-19 crisis. To date, states have primarily focused on making thoughtful allocation decisions for a limited vaccine supply based on feedback from stakeholders and the principles of advancing health, equity, and trust. While federal recommendations and state distribution decisions take equity into consideration, much work is needed to realize these plans.

During the course of the pandemic, individuals and communities with higher risk have been less likely to receive critical resources, including COVID-19 testing, novel COVID-19 therapies, and support services.3 In this context, Medicaid programs must ensure equitable administration of COVID-19 vaccines.4 We highlight 3 strategies to achieve this aim: (1) make it easy for Medicaid members to access COVID-19 vaccines; (2) build trust through clear, consistent, and inclusive messaging; and (3) partner widely to ensure successful implementation.

Make It Easy to Access COVID-19 Vaccines

As a condition of receiving enhanced federal funding during the public health emergency, Medicaid programs are required to provide COVID-19 vaccines without patient cost-sharing. Medicaid must clearly communicate that COVID-19 vaccines are free for members. Medicaid managed care networks are often a source of confusion, and Medicaid programs should work with their managed care plans to suspend limits on out-of-network coverage to ensure members can receive COVID-19 vaccines from in-network as well as out-of-network services.

The implementation details of vaccine allocation decisions are critical. For example, many states are planning to allocate COVID-19 vaccines to individuals with high-risk conditions. However, requiring physician attestation may inadvertently disadvantage those who have higher rates of undiagnosed chronic disease because of barriers to accessing care. In addition, vaccine distribution policies will vary across and within states, so it may be daunting for individuals to understand when they are eligible. Medicaid can empower members by proactively communicating when they are eligible and where they can access vaccines through online navigation tools such as the CDC-funded Vaccine Finder.

Medicaid programs can reduce geographic barriers by meeting people where they are and delivering COVID-19 vaccines at local pharmacies, grocery stores, community health centers, doctors’ offices, senior centers, and schools. Already, national pharmacy chains have been recruited to assist with administering COVID-19 vaccines in long-term care facilities. These partnerships should be expanded given that 90% of Americans live within 5 miles of a community pharmacy. Medicaid programs are required to provide a nonemergency medical transportation benefit and can waive copays or prior authorizations for those who need rides to COVID-19 administration sites.

Build Trust Through Clear, Consistent, and Inclusive Messaging

According to a recent survey,5 27% of US residents probably or definitely would not get a COVID-19 vaccine, and these numbers are higher among rural-dwelling and Black populations. More than half of this group cites concerns about possible adverse effects, the role of politics in vaccine development, and overall mistrust in the government. How can trust in COVID-19 vaccines among Medicaid members be enhanced?

During the pandemic, Medicaid programs have coordinated with state public health departments to deliver messages on COVID-19 prevention, testing, and treatment through letters, emails, text messages, phone calls, and social media. Medicaid programs must continue this work by delivering clear, consistent, and culturally inclusive messaging about COVID-19 vaccines. Building trust is not a linear process and will require partnering with trusted messengers to deliver trusted messages. Medicaid programs can post testimonial videos and messages about why to get vaccinated from respected leaders in faith and minority communities who may share experiences with Medicaid members.

Partner Widely to Ensure Successful Implementation

The strategies outlined above will require state Medicaid programs to effectively partner with state and local public health departments, health care professionals and systems, and Medicaid members. In most states, COVID-19 vaccine messaging, allocation decisions, and administration monitoring are being led through public health departments. Medicaid programs can play a valuable role in refining and amplifying public health messaging and data sharing and strategy. To ensure the translation of equitable allocation into equitable administration, timely and transparent metrics must be developed. No single database in any state will hold all of the needed information, such as occupation, comorbidities, age, socioeconomic status, race, ethnicity, language, and geography.

Medicaid programs should work with state agencies and clinical partners to share these data securely and to develop metrics to ensure groups eligible for vaccinations receive them. These metrics can serve as a foundation for productive partnerships. For instance, if vaccine uptake is limited among those with substance use disorder in a particular geographic area, Medicaid and public health departments can work with harm reduction programs and addiction clinics to colocate vaccine administration to improve vaccine access for this group.

Conclusion

COVID-19 vaccines represent a beacon of hope amid a crisis that has revealed and exacerbated structural inequities in health. The burden of the pandemic has fallen hardest on individuals and communities with the highest risk—many of whom rely on Medicaid for access to care. The anticipated scope of COVID-19 vaccine implementation is unprecedented, and unforeseen obstacles will be experienced most profoundly by those experiencing the most marginalization. Therefore, Medicaid programs must partner, listen, and innovate to meet the needs of their members and ensure equitable implementation of COVID-19 vaccines. The health and lives of the Medicaid members with the most risk depend on it.

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Article Information

Open Access: This is an open access article distributed under the terms of the CC-BY License. © 2021 Bachireddy C et al. JAMA Health Forum.

Corresponding Author: Chethan Bachireddy, MD, MSc, Virginia Department of Medical Assistance Services, 600 E Broad St, Richmond, VA, 23219 (chethan.bachireddy@dmas.virginia.gov).

Conflict of Interest Disclosures: None reported.

Disclaimer: The opinions expressed in this article are those of the authors and do not necessarily reflect those of an individual Medicaid or state agency.

Additional Contributions: The authors would like to acknowledge and thank Julie Donohue, Susan Kennedy, and Sunita Krishnan for their review and feedback.

References
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Broaddus  M. 5 Million essential and front-line workers get health coverage through Medicaid. Center on Budget and Policy Priorities. Published August 4, 2020. Accessed February 8, 2021. https://www.cbpp.org/blog/5-million-essential-and-front-line-workers-get-health-coverage-through-medicaid
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Lieberman-Cribbin  W, Tuminello  S, Flores  RM, Taioli  E.  Disparities in COVID-19 testing and positivity in New York City.   Am J Prev Med. 2020 Sep;59(3):326-332. doi:10.1016/j.amepre.2020.06.005.Google ScholarCrossref
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Bachireddy  C, Chen  C, Dar  M.  Securing the safety net and protecting public health during a pandemic: Medicaid’s response to COVID-19.   JAMA. 2020;323(20):2009-2010. doi:10.1001/jama.2020.4272Google ScholarCrossref
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Hamel  L, Kirzinger  A, Muñana  C, Brodie  M. KFF COVID-19 vaccine monitor: December 2020. Kaiser Family Foundation. Published December 15, 2020. Accessed February 8, 2021. https://www.kff.org/coronavirus-covid-19/report/kff-covid-19-vaccine-monitor-december-2020/
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