Blog & News
COVID-19 Vaccination Rates: State-level and Subpopulation Evidence from the Household Pulse Survey (Update 2: Feb 3 to Feb 15)
February 25, 2021:Newly available COVID-19 vaccines promise to help protect individual Americans against infection and eventually provide population-level herd immunity. The pace of the COVID-19 vaccination rollout in the United States has been somewhat erratic—with reports of slow early going before picking up somewhat in following weeks, only to be hampered by recent storms across the southern region. However, signs of vaccination progress are appearing on the horizon once again, with manufacturers ramping up production, shipping getting back on track after the recent roadblocks, and early positive news from the FDA regarding Johnson & Johnson’s single-shot vaccine. The initial groups prioritized for vaccination were health care workers on the front lines of the pandemic and nursing facility residents, many of whom are especially vulnerable to COVID-19 infection and severe outcomes.
While these groups continue to hold priority in vaccination slots, many states have expanded vaccine access to other (still high-priority) segments of the general population such as older adults, K-12 and child care workers, essential workers, and those with high-risk medical conditions. However, there are concerns that these prioritization decisions and the existing mechanisms of the vaccine rollout—in addition to evidence that lower-income individuals, people of color, and individuals without strong connections to the health care system are less likely to get vaccinated—are inadequate to narrow the clear disparities in the vaccine rollout so far and could worsen existing pandemic-related health inequities.
The available data have not assuaged these concerns, and show patterns of lower vaccination rates among people with lower incomes and levels of education, and marginalized racial and ethnic groups. The U.S. Census Bureau recently released updated data on take-up of COVID-19 vaccines from the most recent wave of its Household Pulse Survey (HPS), collected February 3-15, 2021.1 The HPS is an ongoing, weekly tracking survey designed to measure impacts of the COVID-19 pandemic. These data provide an updated snapshot of COVID-19 vaccination rates and are the only data source to do so at the state level by subpopulation. This blog post presents top-level findings from these new data, focusing on rates of vaccination (one or more doses) among U.S. adults (age 18 and older) living in households and comparing to results from the most recent wave of the HPS, collected January 20-February 1, 2021.2
Nearly one in five adults had received a vaccination, but this varied by state
According to the new HPS data, 19.9% of U.S. adults had received one or more COVID-19 vaccinations during this two-week period in the first half of February, though this varied by state from a low of 16.3% in the District of Columbia (D.C.) to a high of 31.9% in Alaska. More than one in four adults had received a vaccine in three states: Alaska, Hawaii, and New Mexico.
Vaccination rates increased substantially across nearly all states; states with lower rates catching up
Nationally, adult vaccination rates were up from the previous wave of the HPS, increasing from 13.2% during January 20-February 1, 2021, to 19.9% during February 3-15, 2021. Most states also experienced increases in their vaccination rates, though again the size of these increases varied across the states, from an increase of 1.5 percentage points (PP) in Vermont to an increase of 10.9 PP in Wisconsin.
Percent of Adults Who Had Received a COVID-19 Vaccine
States that had previously had below-average vaccination rates caught up somewhat to the higher-performing states. The states that were below the national average in late January, such as California and Wisconsin, saw larger increases in their vaccination rates compared with the states that were above the national average in late January, so that by the middle of February, vaccination rates were somewhat more even across the states, with most states hovering just above or below 20% of their adult populations vaccinated.
Disparities in vaccination rates remain largely unchanged
COVID vaccination rates continued to vary to a great degree by demographic and socioeconomic factors, though disparities narrowed slightly from previous weeks. This narrowing could be due to the expansion of priority groups to include a broader share of the population over this period; however, progress has remained limited in getting vaccines to certain groups such as low-income, Hispanic, and Black adults, for instance, and new vaccination strategies may be needed to reach the hardest-to-reach groups such as these.
By race and ethnicity, non-Hispanic Asian and non-Hispanic White adults continued to have above-average vaccination rates at 25.3% and 21.5%, respectively. Vaccination rates among non-Hispanic adults identifying with “Multiple” races or “Some other” race, which had previously increased relative to the average, fell behind pace and rose to just 16.3%, below the national average of 19.9%. Rates among non-Hispanic Black adults (16.2%) and Hispanic/Latino adults of any race (15.0%) remained below the national average.
Percent of Adults Who Had Received a COVID-19 Vaccine by Race/Ethnicity
Disparities in vaccination rates by income continued to narrow, though rates among those with the lowest incomes remained far below the average. Adults with household incomes of less than $25,000 were nearly half as likely to have received a vaccine compared with all adults (10.7% vs. 19.9%). This gap was largely unchanged from previous weeks, even as the gap between other lower-income groups and the average steadily narrowed from early January.
Percent of Adults Who Had Received a COVID-19 Vaccine by Income
Disparities by level of education remained, with adults holding a bachelor’s degree or higher continued to have the highest vaccination rate at 28.2%, and adults without a high school diploma having the lowest vaccination rates at 12.2%. However, disparities by education did narrow somewhat, and vaccination rates among both adults with a high school diploma or equivalent and adults with less than a high school education increased faster than the overall adult rate.
Percent of Adults Who Had Received a COVID-19 Vaccine by Education
Nearly 2 in 5 older adults received a COVID vaccine as the U.S., and many states, continued to make large progress in vaccinating older adults
Nationally, 38.5% of older adults (age 65 and older) had received at least one dose of the COVID-19 vaccine, which was 18.6 percentage points higher than the rate among all adults (19.9%). Vaccination rates for older adults ranged from 17.6% in Rhode Island to 60.5% in Alaska. Older adult vaccination rates were below 25% in four states (New Hampshire, Oregon, Rhode Island, and Vermont) and at or above 50% in five states (Alaska, Georgia, Indiana, Mississippi, and Oklahoma) and in D.C.
Percent of Adults Age 65+ Who Had Received a COVID-19 Vaccine
As in the previous period, states continued to make large progress in rates of vaccination among older adults. Compared to the end of January, 19 states more than doubled their 65+ vaccination rates, and three states (Minnesota, Wisconsin, and Nebraska) more than tripled their 65+ vaccination rates, with Minnesota nearly quadrupling its rate (from 8.5% to 33.7%). Only a handful of states failed to make substantial progress in increasing vaccination rates among older adults.
Notes about the Household Pulse Survey Data
The estimated rates presented in this post were calculated from the count estimates published by the Census Bureau. Though these counts are accompanied by standard errors, standard errors are not able to be accurately calculated for rate estimates. Therefore, we are not able to determine if the differences we found in our analysis are statistically significant or if the estimates themselves are statistically reliable. Estimates and differences for subpopulations at the state level should be assumed to have large confidence intervals around them and caution should be taken when drawing strong conclusions from this analysis. However, the fact that patterns of inequities in other vaccination rates are mirrored by these early indications of COVID-19 vaccination inequities demonstrates reason for concern.
Though produced by the U.S. Census Bureau, the HPS is considered an “experimental” survey and does not necessarily meet the Census’s high standards for data quality and statistical reliability. For example, the survey has relatively low response rates (7.3% for February 3-15), and sampled individuals are contacted via email and text message, asking them to complete an internet-based survey. These issues in particular could be potential sources of bias, but come with the tradeoffs of increased speed and flexibility in data collection as well as lower costs. A future post will investigate differences between COVID vaccination rates estimated from survey data (such as the HPS) and administrative sources. The estimates presented this post are based on responses from 77,122 adults. More information about the data and methods for the Household Pulse Survey can be found in a previous SHADAC blog post.
Previous Blogs in the Series
COVID-19 Vaccination Rates: New State-level and Subpopulation Evidence from the Household Pulse Survey (Update: Jan 10 to Feb 1)
COVID-19 Vaccination Rates: New State-level and Subpopulation Evidence from the Household Pulse Survey (Jan 6 to Jan 18)
Related Reading
State-level Flu Vaccination Rates among Key Population Subgroups (50-state profiles) (SHADAC Infographics)
50-State Infographics: A State-level Look at Flu Vaccination Rates among Key Population Subgroups (SHADAC Blog)
Anticipating COVID-19 Vaccination Challenges through Flu Vaccination Patterns (SHADAC Brief)
New Brief Examines Flu Vaccine Patterns as a Proxy for COVID – Anticipating and Addressing Coronavirus Vaccination Campaign Challenges at the National and State Level (SHADAC Blog)
Ensuring Equity: State Strategies for Monitoring COVID-19 Vaccination Rates by Race and Other Priority Populations (Expert Perspective for State Health & Value Strategies)
SHADAC Webinar - Anticipating COVID-19 Vaccination Challenges through Flu Vaccination Patterns (February 4th) (SHADAC Webinar)
Blog & News
COVID-19 Vaccination Rates: New State-level and Subpopulation Evidence from the Household Pulse Survey (Jan 6 to Jan 18)
January 29, 2021:Newly available COVID-19 vaccines promise to help protect individual Americans against infection and eventually provide population-level herd immunity. However, the rollout of the COVID-19 vaccines thus far—largely delegated to the states—has been slow and inconsistent. The initial groups prioritized for vaccination were health care workers on the front lines of the pandemic and nursing facility residents, many of whom are especially vulnerable to COVID-19 infection and severe outcomes. However, there are concerns that these prioritization decisions—in addition to evidence that lower-income individuals, people of color, and individuals without strong connections to the health care system are less likely to get vaccinated—could worsen existing pandemic-related health inequities.
Preliminary data have unfortunately reinforced these concerns, showing patterns of lower vaccination rates among people with lower incomes and levels of education, and marginalized racial and ethnic groups. The U.S. Census Bureau recently released new data on take-up of COVID-19 vaccines from the most recent wave of its Household Pulse Survey (HPS), collected January 6-18, 2021. The HPS is an ongoing, weekly tracking survey designed to measure impacts of the COVID-19 pandemic. These data are the first to provide estimates of COVID-19 vaccination rates at the state level and by subpopulation. This blog post presents top-level findings from these new data, focusing on rates of vaccination (one or more doses) among U.S. adults (age 18 and older) living in a household unit.1
Roughly eight percent of adults had received a vaccination, but this varies by state
According to the new HPS data, 7.7% of U.S. adults had received one or more COVID-19 vaccinations during this two week period in January, though this varied by state from a low of 5.4% in California to a high of 13.7% in Hawaii. More than one in ten adults had received a vaccine in nine states: Alaska, Hawaii, Montana, New Mexico, North Dakota, Oklahoma, South Dakota, Texas, and Vermont.
Disparities in vaccination rates reflect concerns about harder-to-reach groups and groups prioritized for initial round of vaccinations
Vaccination rates also varied substantially by a number of demographic and socioeconomic factors. These could be partly a result of decisions to prioritize health care workers, who tend to be less racially and ethnically diverse than the overall population, and who often have higher incomes and levels of education.
By race and ethnicity, non-Hispanic Asian adults had the highest vaccination rates at 13.1%, followed by non-Hispanic White adults at 8.0%. Hispanic/Latino adults (any race), non-Hispanic Black adults, and non-Hispanic adults identifying with multiple races or some other race had lower vaccination rates (5.8%, 5.8%, and 6.2%, respectively). A similar pattern was seen across many states, with Asian and White adults often more likely to have received a vaccine than Black and Hispanic adults.
Large disparities in vaccination rates by income were also apparent, with the highest income groups reporting higher rates of vaccination compared to those with lower incomes, and rates increasing steadily in correlation with income. Of adults with household incomes of $100,000 or higher, 12.0% had received a COVID-19 vaccine, which was nearly 2.5x higher than the rate among those with incomes below $25,000.
Nearly half of all adults who had received a COVID-19 vaccine have incomes of at least $100,000, despite making up only three in ten adults in the overall population.
Similar patterns by income were seen across the states. For example, in 17 states, adults in the highest income category were at least 5x more likely to have been vaccinated than those in the lowest income category.
Patterns of vaccination by education were similar to those by income, with adults with less education being less likely to have received a vaccine compared to adults with more education. Nationally, 12.2% of adults with a bachelor’s degree or higher have received a vaccine compared with 3.7% of adults with less than a high school education.
More progress is needed in vaccinating the older adult population most vulnerable to severe COVID-19 morbidity and mortality
Nationally, older adults (age 65 older) were no more likely to have received a COVID-19 vaccine than the overall adult population. During the period of January 6 through January 18, 7.1% of older adults had received a vaccine compared with 7.7% of all adults. This may be of concern because older adults are more likely to develop severe COVID-19 cases or die from the disease compared to the general population. Consequently, many states have given precedence to vaccinations for older adults, but these early data don’t show that prioritization is resulting in higher vaccination rates.
Vaccination rates for older adults ranged from 1.7% in Nevada to 21.9% in Alaska. Vaccination rates were below five percent in 15 states and were above ten percent in seven states. Older adults were more likely to have received a vaccine than the overall population in just 11 states
Notes about the Household Pulse Survey Data
Many of the estimates published by the Census Bureau and presented here were not accompanied by standard errors. Therefore, we are not able to determine if the differences we found in our analysis are statistically significant or if the estimates themselves are statistically reliable. Estimates and differences should be assumed to have large confidence intervals around them—especially for subpopulations at the state level—and caution should be taken when drawing strong conclusions from this analysis. However, the fact that patterns of inequities in other vaccination rates are mirrored by these early indications of COVID-19 vaccination inequities demonstrates reason for concern.
Though produced by the U.S. Census Bureau, the HPS is considered an “experimental” survey and does not necessarily meet the Census’s high standards for data quality and statistical reliability. For example, the survey has relatively low response rates (6.5% for January 6–18) and sampled individuals are contacted via email and text message, asking them to complete an internet-based survey. These issues in particular could be potential sources of bias, but come with the tradeoffs of increased speed and flexibility in data collection as well as lower costs. The estimates presented this post are based on responses from 68,348 adults. More information about the data and methods for the Household Pulse Survey can be found in a previous SHADAC blog post.
Related Reading
Anticipating COVID-19 Vaccination Challenges through Flu Vaccination Patterns (SHADAC Brief)
New Brief Examines Flu Vaccine Patterns as a Proxy for COVID – Anticipating and Addressing Coronavirus Vaccination Campaign Challenges at the National and State Level (SHADAC Blog)
Ensuring Equity: State Strategies for Monitoring COVID-19 Vaccination Rates by Race and Other Priority Populations (Expert Perspective for State Health & Value Strategies)
Upcoming SHADAC Webinar - Anticipating COVID-19 Vaccination Challenges through Flu Vaccination Patterns (February 4th) (SHADAC Webinar)
1 It is important to mention that the HPS does not collect data for institutionalized adults, such as those living in nursing facilities. These individuals were commonly prioritized for the first rounds of COVID-19 vaccines, so the estimates of vaccination rates presented here are likely an undercount of population-wide vaccination rates. This undercount could be more pronounced among the total 65-and-older population, as they are disproportionately likely to reside in institutions. Further, these data do not represent adults in correctional facilities such as prisons or jails—another group of adults who are also at increased risk of contracting COVID-19.
Blog & News
Spotlight on Health Behaviors: Adult Who Forgo Needed Medical Care and Adults Who Have No Personal Doctor
December 21, 2020:Prior to the arrival of the novel coronavirus, much of American consumer health care concerns surrounded rising costs of care. With health care spending rising a reported 4.6 percent in 2018 and the Centers for Medicare and Medicaid Services (CMS) Office of the Actuary projecting an average annual increase of 5.4 percent for 2019 to hit a record $3.82 trillion or around $11,559 per person—this issue will remain at the forefront of concern for the foreseeable future.1
Compounding these trends in spending, the continued rise in the share of Americans without health insurance coverage has left more individuals without a means of protecting themselves or their families from the financial burden of illness or injury and without strong ties to health care providers and the health care system to access care.
The effects of rising health care spending and rising rates of uninsurance can be seen in direct measures of actual dollars, such as Medical Out-of-Pocket Spending and Percent of Individuals with High Medical Care Cost Burden, but also in more indirect avenues, such as changes in health behaviors and access to care.
Two measures of such behaviors, Adults Who Forgo Needed Medical Care and Adults with No Personal Doctor, are housed on SHADAC’s State Health Compare and have been recently updated with 2019 data from the Center for Disease Control's Behavioral Risk Factor Surveillance System (BRFSS). This blog provides an analysis of these indirect costs of rising health care spending and uninsurance in the year prior to the COVID-19 pandemic and examines overall national and state-level trends as well as comparisons across race/ethnicity and educational attainment.
Adults Who Forgo Needed Care
Across the nation, progress was made in reducing the percentage of adults who forgo needed medical care in the years following the passage of the Affordable Care Act (ACA). However, that progress began to flatten out by 2016 and has now begun to reverse course and display a trend of smaller but significant increases in recent years, such as the growth from 12.9% in 2018 to 13.4% in 2019 at the national level.
Trends by Education and Race/Ethnicity
Examining forgone care by individual breakdowns showed that disparities by education level and race/ethnicity, found in a previous SHADAC analysis, have persisted from the year before.
Across the U.S., adults with less than a high school degree saw their rates of forgone care hit 22.2% in 2019 from 21.1% in 2018;i a figure nearly triple the rate among adults with a bachelor’s degree, who saw their rate of forgone care rise to 7.9% in 2019 (up from 7.4% in 2018).
Nationally, Hispanic/Latino adults experienced the largest increase in rates of forgone care, rising to 21.4% in 2019 from 20.2% in 2018. African-American/Black and Hispanic/Latino adults were also significantly more likely to report going without needed medical care than White adults, with the former being 1.5 times more likely (15.7% vs. 10.9%) and the latter nearly twice as likely (21.4% vs. 10.9%).
State Trends
At the state level, the trends in forgone care are varied. Despite increasing national trends, some states, such as Florida and Michigan, have continued to make steady progress in reducing forgone care. Florida saw their overall rates drop by 5.9 percentage points,ii from 22.0% in 2011 to 16.0% in 2019, and Michigan saw a similarly steady drop in rates of forgone care from 16.5% in 2011 to 11.7% in 2019.
Unfortunately, progress in reducing the number of adults who report going without needed medical care has stalled in many states—California and Kentucky being two such examples. The former state has seen relatively unchanged rates of forgone care since 2016 (11.4%, 11.8% in 2017, and 11.9% in 2018 and 2019). The percentage of adults who have gone without needed medical care in Kentucky has likewise remained nearly unchanged from 2015 to 2019 (12.3% and 12.1%, respectively).
In other states, such as Kansas and Maine, rates of forgone care have followed the national trend and in 2015 begun reversing course on previous gains. The state of Kansas saw a 2.1 percentage-point increase from 2015 to 2019 (11.0% to 13.1%) and Maine saw a concerning increase of 2.9 percentage points during the same time period (9.4% in 2015 to 12.3% in 2019).
It is important to remember that these increases in forgone care occurred in the context of an economy that was growing steadily before the COVID recession. Though the release of 2020 data is at least another year away, early studies and surveys have given some indications as to the impact of the COVID-19 pandemic on health behaviors. SHADAC conducted a survey in April 2020 in which over half of U.S. adults (51.1 percent) said they had delayed or canceled health care appointments due to the pandemic.2
Adults With No Personal Doctor
As with the measure of forgone medical care, more adults reported having a usual source of care after the passage of the ACA. However, once again this promising trend reversed itself in 2015, after which the percent of adults with no personal doctor or health care provider has increased each year, nearly reaching its pre-ACA peak in 2019 at 23.4% (23.8% in 2013). Both of these increasing trends have paralleled an increase in the rate of the uninsured across the nation, from 8.6% in 2016 to 9.2% in 2019.3
Trends by Education and Race/Ethnicity
Significant disparities by education level and race/ethnicity were again present for this measure in 2019.
At the national level, adults with less than a high school education were more than twice as likely as adults with a bachelor’s degree to report not having a regular doctor (34.7% versus 16.0%). This pattern was consistent across more than half of states, as adults with less than a high school degree were more than twice as likely to report having no doctor as those with a bachelor’s degree in 26 states, and more than three times as likely in 5 states (Connecticut, Delaware, Maryland, Nebraska, and New Hampshire). There was no statistical difference between these educational groups in D.C. and 6 states (Kentucky, Mississippi, North Dakota, Tennessee, Vermont and West Virginia).
Nationally, Hispanic/Latino and Black adults were both significantly more likely to report not having a regular doctor as compared to White adults. Hispanic/Latino adults were more than twice as likely as White adults to report not having a personal doctor (40.5% vs. 18.7%), and African-American/Black adults were more than 1.2 times as likely as White adults to report not having a personal doctor (22.7% vs. 18.7%). Again this pattern persisted among over half of the nation, as Hispanic/Latino adults were more than twice as likely to report not having a regular doctor as White adults in 28 states, and more than three times as likely to report the same in 3 states (Delaware, Maryland, and Nebraska). African-American/Black adults were at least 1.2 times as likely to report not having a regular doctor as White adults in 17 states, and this gap measured 1.5 times or larger in 6 states (Nebraska, Iowa, Kansas, Massachusetts, Michigan and Utah).
Related Reading
Affordability and Access to Care in 2018: Examining Racial and Educational Inequities across the United States (Infographic)
Most U.S. Adults Report Reduced Access to Health Care due to Coronavirus Pandemic
Eleven Updated Measures are Now Available on State Health Compare
1 Hartman, M., Martin, A.B., Benson, J., & Catlin, A. (2019, December 5). National Health Care Spending in 2018: Growth Driven by Accelerations in Medicare and Private Insurance Spending. HealthAffairs, 39(1). https://doi.org/10.1377/hlthaff.2019.01451
Keehan, S.P., Cuckler, G.A., Poisal, J.A., Sisko, A.M., Smith, S.D., Madison, A.J., Rennie, K.E., Fiore, J.A., & Hardesty, J.C. (2020, March 24). National Health Expenditure Projections, 2019–28: Expected Rebound in Prices Drives Rising Spending Growth. HealthAffairs, 39(4). https://doi.org/10.1377/hlthaff.2020.00094
California Health Care Foundation (CHCF). (2019). Health Care Costs 101: Spending Keeps Growing. California Health Care Almanac. https://www.chcf.org/wp-content/uploads/2019/05/HealthCareCostsAlmanac2019.pdf
2 Planalp, C., Alarcon, G., & Blewett, L.A. (2020). Coronavirus pandemic caused more than 10 million U.S. adults to lose health insurance. https://shadac.org/news/SHADAC_COVID19_AmeriSpeak-Survey
3 State Health Access Data Assistance Center (SHADAC). (2020). 2019 ACS: Rising National Uninsured Rate Echoed Across 19 States; Virginia Only State to See Decrease (Infographics). https://www.shadac.org/sites/default/files/ACS_Estimates-2019-Infographic.pdf
Publication
SHADAC Article in Journal of Aging & Social Policy Urges States to Use COVID-19 Flexible Medicaid Authority for LTSS Eligibility
In response to the current public health emergency presented by COVID-19, especially the health risks pertaining to low-income older adults and disabled persons, states have been given new authority with regard to Medicaid in order to ease traditional complications and restrictions surrounding eligibility. A new article from SHADAC Director and UMN School of Public Health Professor Lynn A. Blewett, PhD, and SHADAC Research Fellow Robert Hest, MPP, focuses specifically on how this state-level Medicaid program flexibility, along with recent emergency waivers, can expand Medicaid financial eligibility for long-term supports and services (LTSS) for these at-risk individuals.
Traditionally, Medicaid LTSS eligibility criteria for states (though federal standards are also a key component) have been based on financial rules and functional needs assessments. Due to complexities surrounding these eligibility requirements, many beneficiaries are at risk of losing coverage throughout the year. Under public health emergency authority granted to states during the COVID-19 pandemic, however, mechanisms such as state plan amendments (SPAs), section 1115 and 1135 waivers, and 1915(c) Appendix K can be used by states to ease these difficulties and ensure that eligible individuals get coverage, including:
- Reducing administrative burdens for applicants
- Streamlining eligibility redeterminations
- Extending deadlines to conduct evaluations/assessments
- Temporarily suspending authorization requirements
- Relaxing eligibility requirements
While states are adopting these flexible measures to expand eligibility, they are simultaneously facing increasing pressures to curb state spending as budgets are constrained during the pandemic. Medicaid spending, most especially for LTSS, is a prime target for cuts as it accounts for a large majority of states’ budgets. However, the article argues that LTSS provided by Medicaid is an essential service for low-income older adults and disabled individuals who are at particular risk from COVID-19, and therefore it is critical that eligibility and flexibility be maintained in order to meet the increasing demand for services created by the coronavirus.
Read the full article in the Journal of Aging & Social Policy.