Adult Vaccination Policy: Gaps, Hesitancy, and Reform

Introduction: The Case for Adult Vaccination Policy

Vaccines and immunizations are critical components of routine healthcare for children and adults in the United States. They offer protection against vaccine-preventable diseases and help prevent severe illness, disability, and death. Despite their importance, between 50,000 and 90,000 adults die annually from vaccine-preventable diseases, and the rate of hospitalizations from these diseases has increased tremendously since 2010. For instance, the CDC estimates that influenza has contributed to between 140,000 and 810,000 hospitalizations each year since 2010 (Lu et al., 2021). Based on all age-appropriate vaccination data across age groups, vaccination and immunization rates remain significantly low. New public health policy that incorporates education and publicity, routine evaluation of vaccinations, and increased availability of vaccines would significantly improve adult vaccination coverage and reduce deaths from vaccine-preventable diseases.

Vaccines and immunizations are major achievements of modern medicine that have made enormous contributions to saving millions of lives across the globe. Vaccinations are one of the few public health measures with significant impact on disease prevention, as they have substantially lessened disease, disability, and death from several infectious diseases (Orenstein & Ahmed, 2017). As noted by Nandi & Shet (2020), vaccines and immunizations have reduced the spread and effect of infectious diseases by over 90%. Childhood vaccinations save approximately 2–3 million lives across the globe annually and have contributed to a reduction in the global infant mortality rate from 65 to 29 per 1,000 live births between 1990 and 2018. The Centers for Disease Control and Prevention (2020) reports that vaccines have helped effectively control and/or eradicate polio, tetanus, influenza, rubella, measles, Haemophilus influenzae type b (Hib), Hepatitis A, Hepatitis B, pneumococcal disease, mumps, rotavirus, whooping cough, diphtheria, and chickenpox.

Vaccine-preventable hospitalizations and deaths remain a major public health concern. The National Vaccine Program Office (2020) reports that adult vaccination rates in the United States remain significantly below the Healthy People 2020 targets. While safe and effective vaccines with a solid track record are available, many adults do not stay up-to-date with their vaccinations and immunizations. The rate of vaccine hesitancy among adults appears to increase with age. It is estimated that the health and productivity costs of vaccine-preventable diseases such as influenza total approximately $87 billion annually. According to the CDC, nearly 40,000 cases and 4,000 deaths among adults are caused by invasive pneumococcal disease each year—a condition that is entirely vaccine-preventable (The National Vaccine Program Office, 2020).

Most adults in the United States remain unprotected against diseases that could be prevented by vaccines. The CDC reports that few adults aged 19 years or older have received age-appropriate vaccines, which is an indicator of low vaccination coverage in this population (Lu et al., 2021). It is estimated that between 20.1% and 87.5% of U.S. adults have not received recommended vaccinations, either for all individuals or those with specific conditions (Lu et al., 2021). While modest gains occurred for hepatitis B and HPV adult vaccinations between 2017 and 2018, individual adult vaccination coverage across the country remains low, and coverage for other diseases did not improve during the same period. Given the aging of the U.S. population, the percentage of adults unprotected against vaccine-preventable diseases is expected to grow, increasing the healthcare burden these diseases impose.

Current Federal and State Vaccination Policies

Public health policies have played an important role in promoting vaccination and immunization across the United States. Public health agencies such as the CDC have enhanced their collaboration with the private sector to improve and sustain adult immunization coverage and evaluate vaccine safety. Through such partnerships, public health agencies and the private sector have enacted health policies that seek to enhance adult vaccination coverage (CDC, 2018). Vaccination policies and laws are used to help maintain low rates of vaccine-preventable diseases.

A variety of federal and state vaccination laws have been enacted as part of public policy measures to maintain low rates of vaccine-preventable diseases among children and adults. State vaccination policies include requirements for children in private and public schools (CDC, 2018). In addition, these policies incorporate vaccination requirements for healthcare workers, college and university students, and patients in certain facilities. Generally, all states have enacted policies requiring children to be vaccinated against specific communicable diseases in order to attend school, effectively mandating vaccination for certain vaccine-preventable diseases. State vaccination policies affect coverage by shaping decisions about whether providing immunizations falls within a healthcare provider's scope of practice. At the federal level, vaccination policy is grounded in the Affordable Care Act, which was enacted into law in March 2010.

The enactment of the Affordable Care Act in 2010 was an important landmark in adult vaccination policy. According to the National Vaccine Program Office (2020), this policy played an important role in adult vaccination by expanding health insurance to millions of previously underinsured or uninsured Americans. In efforts to improve vaccination coverage, the law requires that certain recommended clinical preventive services—including vaccines—be covered without cost-sharing for individuals who obtain health insurance through Medicaid and most private health insurance plans. For individuals enrolled in traditional Medicaid and Medicare plans, vaccination coverage did not change. At the state level, the Affordable Care Act authorizes the use of funds to purchase vaccines for adults at federally negotiated prices. The law has helped improve adult vaccination by removing some monetary barriers to access.

Gaps and Failures in the Affordable Care Act

Despite the enactment of the Affordable Care Act, challenges in adult vaccination remain, as evidenced by persistently low vaccination coverage rates. This policy, alongside state policies, has failed to effectively improve adult vaccination coverage despite removing certain financial barriers. The National Vaccine Program Office (2020) reports that many adults continue to face challenges in accessing and paying for recommended vaccines regardless of the policy measures adopted. These challenges are largely attributable to ongoing difficulties in obtaining health insurance. Many adults still lack coverage, making it difficult for them to access and pay for vaccines. This suggests that current federal and state policies are insufficiently effective in improving adult vaccination coverage.

The Affordable Care Act does not address payments to healthcare providers for vaccine purchase and administration (Hurley et al., 2016). While the law mandates private health insurance plans to cover Advisory Committee on Immunization Practices (ACIP)-recommended vaccines without cost-sharing for patients, it fails to address how providers are compensated for purchasing and administering those vaccines. The policy is therefore characterized by significant gaps in the financial framework for adult vaccine delivery.

These gaps have contributed to serious challenges in vaccine purchase and administration by healthcare providers. Physicians in particular have experienced financial difficulties relating to the provision of vaccines to Medicaid patients (Hurley et al., 2016). These challenges persisted and worsened despite a temporary increase in Medicaid reimbursement for vaccine administration to Medicare levels. As a result, many physicians are not recommending vaccines to adult patients, citing financial disincentives created by the law's requirements and provisions.

Most physicians are dissatisfied with payments for vaccine purchase and administration as structured by the Affordable Care Act. Physicians who are knowledgeable about reimbursement rates report being very dissatisfied with payments across all payer types, particularly public insurance (Hurley et al., 2016). As a result, many physicians have either stopped or are seriously considering halting vaccine purchase and administration. Some defer adult vaccines they deem generally more expensive, such as the zoster and HPV vaccines.

Public health policies like the Affordable Care Act have also contributed to poor public attitudes toward vaccines. Gonzalez et al. (2021) report that low vaccination rates and vaccine hesitancy have become major public health problems despite the enactment of policy measures intended to improve adult vaccination coverage. More patients refuse vaccines when visiting healthcare providers due to financial concerns (Hurley et al., 2016). A perception exists among the public that vaccines are expensive, which contributes to low adult vaccination coverage. Consequently, many adults have limited opportunities for vaccination because of the poor financial framework governing vaccine purchase and administration.

The existing healthcare policies on vaccination are associated with unexpected outcomes. One such outcome is increased physician dissatisfaction regarding payments for vaccine purchase and administration. While policies like the Affordable Care Act were intended to eliminate financial barriers, they have generated unprecedented consequences through gaps in the financial framework (Hurley et al., 2016). According to Aris et al. (2020), healthcare providers appear to lack adequate support for vaccination, which makes it difficult for them to administer vaccines to a wide range of patients. A second unexpected outcome is the difficulty many patients face in accessing and paying for recommended vaccinations. A significant portion of the population remains underinsured or uninsured, meaning that despite the Affordable Care Act's intent to eliminate financial barriers, many adults still consider vaccinations expensive, inaccessible, and unaffordable.

Existing vaccination health policies have also been characterized by implementation challenges that reduce their effectiveness. As noted by the National Vaccine Program Office (2020), some public health stakeholders have raised concerns about administrative difficulties in implementing certain policy provisions. For instance, some stakeholders have reported challenges in implementing Medicare Part D and recommended measures to enhance access to Part D vaccinations. While the Centers for Medicare and Medicaid Services has issued guidance to address these challenges, additional steps are needed. These implementation challenges reflect a poorly developed adult immunization infrastructure that does not effectively support those who need vaccinations or providers who purchase and administer them.