Low Reimbursement, Coverage Restrictions Hinder Access to Vaccines
Researchers reviewed Medicaid policies to understand vaccine coverage and reimbursement rates among physicians and pharmacists.
Low Medicare reimbursement rates coupled with state pharmacist restrictions have created the potential for a significant impact on vaccine accessibility across the US. Despite laws requiring state Medicaid programs to offer all recommended adult vaccines administered by physicians, systemic barriers have taken away pharmacists’ and physicians’ ability to administer vaccines.
“Notably, vaccination rates among adults with private health coverage tend to be higher than for the 47 million adults enrolled in Medicaid, a joint federal-state health coverage program for low- and middle-income people. These disparate vaccination rates reflect a combination of factors, including individual factors such as vaccine hesitancy as well as systemic access barriers such as financial burdens on patients and providers,” wrote authors of a study published in AJPM Focus.1
Researchers focused on the cost and coverage barriers that relate to overall vaccine access. | image credit: 楠 刘 / stock.adobe.com
While vaccine hesitancy is a noticeable indicator of declining immunization rates, researchers focused on the cost and coverage barriers that relate to overall vaccine access. Physicians and pharmacists alike are equipped with the knowledge to help patients combat their vaccine hesitancy. However, with systemic barriers branching from state and federal legislation, researchers attempted to find the overarching mechanism impeding on vaccine uptake.
READ MORE: Pharmacy-Driven Vaccine Clinic to Reduce Number of Children Missing School | ASHP Midyear
One of the more notable federal provisions designed to increase vaccination rates is the Inflation Reduction Act (IRA) of 2022. Among a plethora of laws and regulations within the IRA, policymakers included requirements for state Medicaid programs to cover all recommended vaccines for no out-of-pocket cost.
This provision went into effect in October of 2023, but vaccination rates continue to decline. Based on 2024 CDC data as recent as December 20, just 20.9% of adults received their updated 2024─25 COVID-19 vaccine. Those with their updated influenza and respiratory syncytial virus (RSV) vaccines were sitting at just over 40% for US adults over 18.2
“This study provides an updated overview of Medicaid coverage and reimbursement policies for routine adult vaccines in the US on the eve of the IRA's implementation,” wrote authors of the study.1 “The study covers publicly available Medicaid policies to assess coverage gaps for traditionally eligible adults, in both fee-for-service (FFS) programs and privately administered Medicaid MCOs, regarding 3 vaccines: hepatitis A (HepA), 9-valent human papilloma virus (HPV), and 23-valent pneumococcal polysaccharide (PPV).”
Furthermore, researchers went into depth on the FFS Medicaid data specifically, addressing overall FFS coverage for pharmacist-administered vaccines, as well as FFS reimbursement for both pharmacists and physicians. Researchers examined public Medicaid policies for adult vaccination of the 3 vaccines mentioned between March and September of 2022.
For all 50 state Medicaid programs, a total of 7 (14%) did not allow coverage for HepA, HPV, and PPV vaccines administered by physicians, while even more states (30%) did the same for vaccines administered by pharmacists.
“Median physician reimbursement rate was below the private sector rate for [HepA] (89%) and [HPV] (94%) but above the rate for [PPV] (108%),” continued the authors.1 “Median physician reimbursement for vaccine administration during an office visit was $11.86; the median pharmacist administration fee was $10.67.”
As previously mentioned, state Medicaid programs have used policy to restrict vaccination access and offer lower reimbursement rates to physicians and pharmacists, compared with reimbursements from private insurers and Medicare plan sponsors.
“This study found that approximately 1 year before the IRA closed the remaining vaccine coverage gaps for adult Medicaid enrollees under federal law, 6 states imposed restrictions on 1 or more vaccines discussed in this paper, demonstrating the law's value in closing those remaining gaps,” they wrote.1 “Although all state Medicaid programs must now cover adult vaccinations for all enrollees without cost sharing when administered by physicians, this study finds that 20 of 50 states (40%) restrict coverage for at least some vaccines when administered by pharmacists.”
The key takeaways from the researchers’ study were that federal legislation, supported by the IRA as just 1 example, has significant power in deciding what state plans and insurers are required to do regarding vaccination coverage. However, despite legislation designed to combat coverage gaps and increasing costs, states were still able to avoid covering the required vaccines. As more knowledge and awareness circulates regarding these disparities, researchers believe vaccination uptake will be less of an issue in the future.
“Medicaid-eligible individuals are, by definition, low income, and they are also disproportionately likely to be members of historically marginalized and underserved communities and may face other compounding social determinants of health or health-related social needs that can impact access and utilization of vaccination services. Ultimately, addressing the barriers identified in this study is a critical step toward addressing the vaccination disparities that exist between Medicaid and commercially insured beneficiaries—which have only widened during the course of the COVID-19 pandemic,” concluded the authors.2
READ MORE: Immunization Resource Center
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