Dear Deputy Director Young,
The Adult Vaccine Access Coalition (AVAC) welcomes the opportunity to respond to the Request for Information posed by the Office of Management and Budget (OMB). We recognize the importance of equitable access to health care and are committed to far-reaching policies, programs, and partnerships that increase equitable service delivery.
AVAC consists of over 60 organizational leaders in health and public health that are committed to driving federal policy changes that will strengthen and enhance access to adult vaccines and awareness of the importance of adult immunization. AVAC works towards common legislative and regulatory solutions through a consensus process with the goal of enabling the range of stakeholders to have a voice in the effort to improve access and utilization of adult immunizations.
Even before the COVID-19 pandemic, vaccine preventable illness devastated the lives of thousands of adults each year, particularly older adults and those with underlying health conditions. Vaccine preventable conditions not only affect the patient but also their family members, caregivers and friends. Despite the well-known benefits of immunizations, more than 50,000 adults die from vaccine-preventable diseases while adult coverage has lagged Healthy People targets for most commonly recommended vaccines. Disparities in adult vaccination coverage rates are even more acute when broken down by age, race, ethnicity, socioeconomic status and geography.
The COVID-19 pandemic has brought these inequities to the forefront, with the CDC reporting as of June 7, that of the 57% of recipients disclosing their ethnicity when receiving their COVID-19 vaccine, 61% were White, 9% were Black, 15% were Hispanic, and 6% were Asian. The relatively low representation of ethnic minorities among COVID-19 vaccine recipients is the most recent example of disparities in vaccination coverage across socio-economic strata. While the pandemic has brought attention to these disparities, the unfortunate reality is that they are not new. Inequities in vaccination rates of minority communities are seen across numerous preventive vaccines. Further, lack of access to care sites has contributed to lower immunization rates in rural compared to urban areas. The impact of immunization on population health is well known, and ensuring that all populations, including the most vulnerable, have access to vaccination is a critical step in ensuring equitable primary health care.
OMB has requested comments on “methods for assessing whether agency policies and actions (e.g., programs, services, processes, and operations) equitably serve all eligible individuals and communities, particularly those that are currently and historically underserved”. AVAC has provided comments in response to 4 of OMB’s specific areas of feedback in greater detail below:
- Area 1: Holistic and program- or policy-specific assessments of equity for public sector entities;
- Area 2: Remedying barriers, burdens, and inequities in public service delivery access;
- Area 4: Assessing equity in procurement and contracting processes;
- Area 5: Accessible and meaningful agency engagement with underserved communities.
Area 1: Holistic and program- or policy-specific assessments of equity for public sector entities
To ensure equity in all public sector policies and programs, thorough assessment is required to identify areas of weakness and monitor the progress of proposed solutions. To conduct such assessments, it is critical to have robust monitoring infrastructure, committees, and processes in place. To this end, AVAC suggests the following steps to assess equity in access to vaccinations:
- Assess equity in vaccination rates among beneficiaries of public insurance programs to understand areas of inequity that can be addressed through policy changes. Currently, over a quarter of the U.S. population relies on a public program for health coverage, and thus the government represents a significant access point for preventive services. In 2016, immunization rates for Medicaid beneficiaries were up to 12% lower than for commercially insured patients. Inequalities of immunization access persist for our nation’s most vulnerable population that will require additional investigation to properly assess and address.
- Invest in improving Immunization Information Systems (“IIS”) to more effectively track and assess inequities in immunization uptake. The CDC and other public health stakeholders must compile vaccination records from a range of IIS across states and jurisdictions in order to depict a comprehensive picture of vaccine coverage and uptake. AVAC strongly supports modernizing and strengthening the capabilities of IIS to capture and share vaccination information in a uniform way. Robust IIS data capture and reporting are critical to understanding patterns in vaccination rates, including disparities by race, socioeconomic status, insurance type, and/or region that perpetuate health inequities.
- Encouraging the COVID-19 Health Equity Task Force to transition into a permanent task force that includes a focus on vaccination. This multi-agency and multi-disciplinary Task Force was established to provide specific recommendations to the Administration for mitigating inequities caused or exacerbated by the pandemic. It continues to be essential that all communities have equitable access to COVID-19 vaccinations and booster shots. It is also critical that individuals get caught-up on routine and recommended vaccinations, particularly as students return to in person learning, adults return to the workplace, and people of all ages begin socializing in groups. We recommend that this Task Force continue its work, with an additional goal of on recovering and sustaining high vaccination rates for all vaccines.
Area 2: Remedying barriers, burdens, and inequities in public service delivery access
Multiple barriers to vaccine access remain in the US and disproportionately affect low-income populations who rely on public programs and coverage through Medicare, Medicaid, and those with subsidized commercial insurance. Systemically addressing barriers to vaccine access and promoting culturally competent service delivery can generate vaccine acceptance and demand among at-risk and underserved communities and, ultimately, better protect them against vaccine-preventable diseases. AVAC urges OMB to consider the following steps to address the barriers to vaccine access that perpetuate health inequities:
- Utilize health literacy reviews of all vaccine-related information released by the Administration to ensure information is accessible. The Administration routinely publishes critical vaccine-related information. Oftentimes these materials are not written in a reader-centered manner, leading to a lack of understanding among patients and potential missed vaccination opportunities. There is an outstanding need to ensure that all patients can access and understand the policies and requirements that impact their access to healthcare. To that end, we recommend implementing health literacy reviews for all vaccine-related information released by the Administration to ensure that published material is reader-centered and easily understood.
Area 4: Assessing equity in the administration of agency grant programs and other forms of financial assistance
Grant programs and other forms of financial assistance are critical to immunization service delivery and present an important means to promote equitable access and uptake of vaccination. It is critical that immunization-related grant programs both promote vaccine equity and are administered equitably. AVAC recommends the following process changes to promote immunization equity via public sector grant programs and financial assistance:
Conduct a systematic review of all grants that use or could incorporate vaccine equity. The American Rescue Plan and Coronavirus Response and Relief Supplemental Appropriations Act direct funds to promoting COVID-19 vaccine access, acceptance, and uptake among racial and ethnic minority communities. Despite these efforts, vaccination uptake in some communities remains lower than others, suggesting a need for sustained outreach. Future ARP related immunization grants issued should be prioritized based on their ability to successfully promote vaccination to underserved communities. This assessment should be made public so that best practices can be implemented across the country.
Area 5: Accessible and meaningful agency engagement with underserved communities
Achieving equity in immunization access and uptake requires a thorough understanding of the unique needs and access barriers experienced by at-risk and underserved communities. This understanding can only be gained through direct engagement. It then must be applied to create culturally competent, tailored solutions that meet communities’ specific needs. AVAC recommends the following community engagement initiatives:
- Engage community-based organizations to identify policy changes that can improve access and uptake of vaccinations. To ensure representation of community voices in the National Vaccine Program planning and execution processes, AVAC recommends the establishment of a community advisory subcommittee that could be formed under the National Vaccine Advisory Committee (NVAC). This advisory group consisting of representatives from community-based organizations could be directed to review and recommend additional vaccine equity goals for federally supported immunization programs, review progress toward those goals, and recommend policy changes to improve equity in access and uptake.
We appreciate the opportunity to provide our perspective on the federal government’s methods to equitably reach all eligible individuals with life-saving vaccines. We would be happy to answer any questions or provide additional information. Please contact an AVAC manager.
Alliance for Aging Research
American Lung Association
Association of Asian Pacific Community Health Organizations (AAPCHO)
Immunization Action Coalition
March of Dimes
National Viral Hepatitis Roundtable
The Gerontological Society of America
Trust for America’s Health