One of the many achievements in the Inflation Reduction Act (IRA), which President Biden signed into law in August, is aligning Medicare’s vaccine coverage with that of all private health insurance in the United States.
Once implemented, nearly 9 out of 10 of Americans will have access to vaccines with no cost sharing, or what’s known as first-dollar coverage — copays, deductibles, or coinsurance do not apply for receiving any vaccine recommended by the CDC’s Advisory Committee on Immunization Practices.
The Covid-19 pandemic demonstrated both the possibility and the challenges of reaching every American with a vaccine. As the pandemic slowly recedes, new outbreaks like monkeypox emerge, and nearly forgotten diseases like polio reemerge, vaccine advocates should stay vigilant in addressing gaps and strengthening systems so every American has access to seasonal and routine vaccinations. Specifically, the patchwork of publicly financed vaccine procurement and private insurance coverage must be thoughtfully synchronized.
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The IRA marks a third major milestone in the advancement of vaccine finance and coverage over the past three decades:
In 1993, the Vaccines for Children Program was established to give first-dollar coverage to children whose families couldn’t pay for vaccinations. Today, it covers at least 40 million low-income children. While school-entry requirement policies drove vaccination uptake in the 20th century, the 1980s saw persistent barriers to vaccine access in low-income and minority children. In addition to providing free vaccine doses to pediatricians, the Vaccines for Children Program also bolstered the national pediatric vaccination infrastructure.
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In 2010, the Affordable Care Act guaranteed coverage of vaccines without cost sharing for about 200 million Americans who are either privately insured or newly covered in states that expanded Medicaid. Mandatory coverage of recommended vaccinations and the elimination of cost sharing were major steps toward achieving greater uptake of adult vaccines.
Now the IRA has extended first-dollar coverage to the approximately 50 million older Americans enrolled in Medicare Part D, and it provides states with the incentive to implement the same coverage for adults in traditional Medicaid. The access barriers for these vulnerable older and low-income adults have been well documented and the IRA is a major step toward finally eliminating them.
These three policies align all sources of health coverage in the U.S. to guarantee vaccine coverage for about 300 million Americans. But that leaves 30 million uninsured Americans without guaranteed access to vaccines.
I see several important opportunities to close the gaps and extend vaccine access to every American:
Encourage states to adopt the IRA’s Medicaid coverage extension so low-income adults, particularly pregnant people, would have first-dollar vaccine coverage under traditional Medicaid coverage. The IRA provides a carrot to states — increased federal matching of states’ funds — to incentivize them to provide coverage to adult beneficiaries in traditional Medicaid, a population segment where coverage has been inconsistent across states.
Establish a true vaccine safety net for the 14% of Americans between the ages of 18 and 64 without health insurance, including those in the 12 states that have not expanded Medicaid. Building a meaningful vaccine safety net is about much more than providing free vaccine doses.
The establishment of the Vaccines for Children Program forged an immunization delivery backbone in pediatric offices. An equivalent backbone is needed for adults, who receive primary care less frequently and through a much wider array of provider types. As one CDC official recently estimated, only 3% of its vaccine infrastructure expenditures are devoted to adult vaccine access. Greater infrastructure investment will be required to make meaningful progress toward a true safety net.
The effort to vaccinate every American against Covid-19 was undertaken without this backbone, but the pandemic served as a catalyst that surmounted many obstacles. The President’s budget for 2023 proposed the creation of a Vaccines for Adults Program that would combine the provision of free doses with needed investments in infrastructure to enable comprehensive vaccine access. Any such program must emphasize infrastructure investment to succeed in creating an effective safety net.
Eliminate remaining vaccine coverage inequality in Medicare. While the IRA ensures that all Medicare-covered vaccines are provided without cost sharing, coverage of some vaccines under Medicare Part B (the physician benefit) and others under Medicare Part D (the prescription drug benefit) continues to pose an access barrier, especially for D-covered vaccines that could otherwise be administered in physician offices and the approximately 10 million older adults enrolled in Medicare who do not opt into Part D coverage. Coverage of all vaccines under Part B or under both parts would potentially improve access to vaccines across settings of care.
Vaccine coverage is a microcosm of the U.S. health care system’s complexities. Achieving universal vaccine access requires an unparalleled level of coordination between health care delivery systems and public health. Immunization stakeholders should prioritize the opportunities to close remaining vaccine access gaps.
Richard Hughes IV is a partner at Epstein Becker Green, a national law firm focused on health care and the life sciences; a professorial lecturer in law at The George Washington University Law School; and the former vice president of public policy at Moderna.