Ohio GOP Gov. Mike DeWine announced in May that COVID-19 vaccine uptake among Medicaid enrollees was 22 percent, compared with 45 percent of Ohioans overall — despite recent headlines about new incentives to get a shot, including a statewide $1 million lottery.

“Obviously, that’s not a number we’re happy with,” said DeWine. “We must get these numbers up. It’s simply unacceptable.”

Health inequities were brought to the forefront during the COVID-19 pandemic, amplified by socioeconomic barriers. Now, as the supply of COVID-19 vaccines in the United States remains stable and eligibility has been extended to almost all Americans, local data shows that Medicaid beneficiaries are getting vaccinated at lower rates than the general population.

This worries experts because the nation’s poorest individuals have historically faced worse health outcomes, including shorter life expectancy. 

The reasons why vaccination is lower for this population are complex but could include economic barriers like lack of access to transportation and child care or less flexible work schedules.

A nationwide poll also showed higher levels of vaccine hesitancy among lower-income individuals. The poll, released in mid-June by the African American Research Collaborative and the Commonwealth Fund, found that 45 percent of individuals earning under $50,000 said they were both unvaccinated and hesitant to get vaccinated. That number dropped to 35 percent for individuals earning $50,000 to $79,000 and to 26 percent for those earning more than $80,000.

States, localities and even the private sector are providing a variety of incentives to boost vaccination. 

Beyond Ohio’s Vax-a-Million lottery, DeWine also urged Medicaid managed care organizations to address barriers such as lack of transportation or inflexible appointment times. Meanwhile, West Virginia led the launch of guaranteed $100 savings bonds for all individuals who got vaccinated.

Businesses nationwide offer vaccinated individuals everything from free beer and doughnuts to a chance at free cruises and flights.

“You can think about those smaller incentives as a way of reimbursing people for expenses,” such as babysitting or transportation, said Kevin Volpp, a professor of medicine and health care management at the University of Pennsylvania. 

“A chance at winning a huge lottery is exciting but doesn’t do that, and so there are pros and cons of different approaches. Then there’s also some states that are doing a combination.”

Volpp said that to his knowledge, no state had ever previously offered a million-dollar incentive for healthy behavior, so the impact is difficult to predict.

“Conceptually, I would say that it certainly seems that if we consider there are a lot of people out there who, for whatever reason, have declined to get vaccinated to this point, the large high-stakes-type lottery approaches are much more likely to get people’s attention and generate a sense of excitement,” he said.

Robin Rudowitz, vice president of the Henry J. Kaiser Family Foundation, said many Medicaid recipients are in high-risk groups and hard to reach.

“We know from other polling that there’s a lot of concern about people missing work and not having time off to get their vaccine and recover from some of the side effects,” she said, adding that many recipients work low-wage jobs without flexible leave.

Disparities in who gets a shot

The Centers for Medicare and Medicaid Services is currently working with states to collect available COVID-19 vaccination data for Medicaid enrollees in order to start making meaningful national statistics available, a spokesperson said.

Local snapshots confirm that lower-income people are less likely to get a shot. If more of them get vaccinated, that could boost national immunity. 

Data provided to CQ Roll Call from the Georgia Department of Community Health shows that only 10.14 percent of Georgia Medicaid members — about 249,000 residents — were fully vaccinated by May 31. Compare that with Georgia Department of Public Health data that shows for the same date, about 33.9 percent of all residents were fully vaccinated.

Idaho Department of Health and Welfare information shows that 20 percent of Medicaid enrollees ages 18 to 64 were fully vaccinated as of June 1. Idaho’s statewide vaccination rate for people 18 or older who were fully vaccinated as of June 1 was 43.8 percent, according to the Centers for Disease Control and Prevention.

A CQ Roll Call analysis using data from the South Carolina Department of Health and Environmental Control and the South Carolina Department of Revenue found a strong correlation between per capita income and the vaccination rate.

South Carolina does not collect insurance status in administering the COVID-19 vaccine. But Charleston County boasts the highest per capita income, and 9.9 percent of its residents receive Medicaid. It has a 43.1 percent vaccination rate.

Dillon County has the lowest per capita income, with 25.6 percent of residents in Medicaid, and only a 27.1 percent vaccination rate. 

Carol Sloan, a public information officer for the California Department of Health Care Services, also acknowledged “gaps” in vaccination rates for its Medicaid population in a “significant portion of the state.”

California provided a breakdown by county comparing the percentage range of how many Californians 12 and older received at least one shot with the percentage of Medicaid beneficiaries in that age. 

The contrast is stark. Only one county, Lassen County, had an overall rate at or below 25 percent for Californians as of mid-June. When looking at just Medicaid recipients, that jumps to seven counties.

Meanwhile, more than half of California’s 58 counties have vaccinated 55.1 to 100 percent of all residents age 12 and up. For Medicaid beneficiaries alone, only four counties reached that threshold.

Los Angeles County has a rate of 55.1 to 100 percent for residents, but that falls to 35.1 to 45 percent for Medicaid beneficiaries.

Targeted initiatives

States have taken some action to address depressed vaccination rates among lower-income populations.

Ohio’s push through managed care providers includes identifying individuals who can’t leave their homes and finding ways to bring vaccines to them. The state also worked with providers to offer appointments outside of regular business hours.

Utah’s multipronged approach to improving vaccination rates among Medicaid members includes a weekly email to agencies about which members have or have not been vaccinated to improve outreach.

Utah Medicaid partnered with contact tracing staff at the Utah Department of Health to offer appointment scheduling guidance and outreach to specific populations. Kolbi Young, a UDOH Division of Medicaid and Health Financing public information officer, said that approach alone resulted in more than 2,000 members getting vaccinated after they were reached.

State data showed that the percentage of adult Medicaid beneficiaries who were fully vaccinated rose from 6.3 percent in March to 32 percent as of early June. For beneficiaries who were 12 or older in early June, that number was 26.1 percent.

That rate was 40.2 percent for all Utahns 12 and older and 44.6 percent for all Utah adults on June 2.

Virginia focused on raising rates in high-risk Medicaid populations, including by providing vaccine administration in patients’ homes.

“Over the past two months, Virginia Medicaid worked with the Virginia Department of Health and local health districts in an outreach initiative to homebound Medicaid members that has resulted in significant progress in ensuring access to the COVID-19 vaccines for this high-risk population,” said Christina Nuckols, director of strategic communications for the Virginia Department of Medical Assistance Services.

Nuckols said that increased the vaccination rate for the Virginia Medicaid homebound population from 4 percent to 53 percent in one month.

For all Virginia Medicaid members who are 12 or older, she said the vaccination rate is 33 percent, compared with 69 percent for homebound members.

“There is still a long way to go to approach herd immunity,” said Volpp. “States and cities are watching this very closely.”