HEALTH POLICY CENTER Support for this research was provided by the Robert Wood Johnson Foundation. The views expressed here do not necessarily reflect the views of the Foundation. Few Unvaccinated Adults Have Talked to Their Doctors about the COVID-19 Vaccines Findings from the April 2021 Health Reform Monitoring Survey Michael Karpman and Stephen Zuckerman May 2021 Though more than half of US adults have received a COVID-19 vaccine, the slowing pace of vaccinations hampers efforts to contain the pandemic.1 Many adults remain skeptical of the vaccines’ benefits and concerned about their risks.2 In response, federal and state officials are using new strategies to overcome hesitancy toward and expand access to the vaccines, including marketing campaigns, cash incentives for vaccinated people, and additional walk-in vaccination sites.3 Efforts are also underway to increase vaccine distribution through health clinics and other primary care providers, who are among the most trusted sources of information on the vaccines.4 In this study, however, we find that few unvaccinated adults had received information about the vaccines from their health care providers as of April 2021. Our analysis uses data from the Urban Institute’s Health Reform Monitoring Survey, a nationally representative survey of more than 9,000 adults ages 18 to 64 conducted between April 2 and 20, 2021.5 Some states had already expanded vaccine eligibility to all residents ages 16 and older before April 2, and the remainder did so by April 19.6 The survey asked participants about their uptake of and perceived eligibility for the vaccines and whether they had attempted to get vaccinated, either by trying to schedule an appointment or visiting a drop-in site. This brief focuses on adults who reported they were eligible for a vaccine but had not tried to get one. We find the following: ◼ In early to mid-April 2021, one in five adults (20 percent) ages 18 to 64 reported they were eligible for a COVID-19 vaccine but had not tried to get vaccinated. The most common reasons for not doing so were being concerned about long-term side effects, being concerned the vaccines were developed too quickly or not tested enough, and wanting to know more about how well the vaccines protect people from COVID-19. ◼ Two-thirds of self-reported eligible adults who did not try to get vaccinated reported having a doctor or health care provider they considered to be their personal provider. Of those adults, 73 percent reported trusting their providers for information about COVID-19 vaccines, but only 19 percent had ever received information about the vaccines from their providers. ◼ About half of self-reported eligible adults who did not try to get vaccinated trusted other doctors and providers in the community (56 percent), family and friends (53 percent), and pharmacists (49 percent) for vaccine information. Smaller shares trusted other community sources, such as religious leaders, elected officials, and social service, neighborhood, or civic organizations. The large gap between the share of unvaccinated adults who trust their health care providers and the share who received information about the vaccines from their providers reveals a significant opportunity to address hesitancy toward and expand access to the vaccines. Providers are in a key position to listen to patients’ specific concerns about the vaccines, discuss the risks and benefits of vaccination, and potentially provide a shot. States and insurers can assist providers in fostering these conversations by ensuring adequate reimbursement for patient education and counseling. States can also help providers leverage data from immunization registries for outreach to unvaccinated patients, engage more primary care providers in vaccine distribution, and support partnerships among providers, community health workers, and community-based organizations for reaching out to vaccine-hesitant adults. Results In early to mid-April 2021, one in five adults ages 18 to 64 reported they were eligible for a COVID-19 vaccine but had not tried to get vaccinated. The most common reasons for not doing so were being concerned about long-term side effects, being concerned the vaccines were developed too quickly or not tested enough, and wanting to know more about how well the vaccines protect people from COVID-19. When the survey was fielded, one in five nonelderly adults (20 percent) reported they were eligible for a COVID-19 vaccine but had not tried to get one (figure 1). Half of adults reported they got or tried to get vaccinated; this group includes 42 percent of adults who received at least one vaccine dose and 9 percent of adults who reported they were eligible for and had tried to receive a vaccine, either by trying to schedule an appointment or by going to a drop-in vaccination site (data not shown). The remaining 29 percent of adults reported they were ineligible or unsure if they were eligible. Among adults who reported they were ineligible, about two-thirds indicated they would definitely or probably get the vaccine when they become eligible (data not shown). 2 FEW UNVACCINATED ADULTS HAVE TALKED TO THEIR DOCTORS ABOUT VACCINES FIGURE 1 Self-Reported Eligibility for and Uptake of COVID-19 Vaccines among Adults Ages 18 to 64, April 2021 Got or tried to get vaccine Eligible and did not try to get vaccine Ineligible or unsure if eligible All Alladults adults 50% 20% 29% Race/ethnicity White^ 51% 21% 27% Black 43%*** 26%** 30% Hispanic/Latinx 49% 16%*** 35%*** Other 59%*** 10%*** 31% Residence Urban^ 52% 19% 29% Rural 41%*** 28%*** 30% URBAN INSTITUTE Source: Health Reform Monitoring Survey, April 2021. Notes: Estimates are not shown for the 0.5 percent of adults who did not report whether they were eligible to get or had tried to get vaccinated. “Other” refers to non-Hispanic/Latinx adults who are not Black or white or are more than one race. “Urban” describes adults who live in metropolitan statistical areas. */**/*** Estimate differs significantly from that for the reference group (^) at the 0.10/0.05/0.01 level, using two-tailed tests. Consistent with other surveys, vaccine uptake varied by race and ethnicity and geography.7 White adults were more likely than Black adults to have been vaccinated or to have tried to get vaccinated (51 percent versus 43 percent) and less likely to report they were eligible but had not tried to get vaccinated (21 percent versus 26 percent). Hispanic/Latinx adults reported getting or trying to get vaccinated at similar rates as white adults, but they were more likely to report they were ineligible or unsure if they were eligible (35 percent versus 27 percent).* Adults in urban areas were more likely than adults in rural areas to report they had gotten or tried to get vaccinated (52 percent versus 41 percent) and were less likely to report they were eligible but had not tried to get vaccinated (19 percent versus 28 percent). Though vaccine uptake rates differed by race, ethnicity, and geography, most adults who reported they were eligible and did not try to get vaccinated were white (64 percent) and lived in urban areas (82 percent; data not shown), because these groups constitute large majorities of the nonelderly adult population. * We use “Hispanic/Latinx” throughout this brief to reflect the different ways in which people self-identify. The US Census Bureau uses the term “Hispanic.” The terms “white” and “Black” refer to adults who do not identify as Hispanic or Latinx. FEW UNVACCINATED ADULTS HAVE TALKED TO THEIR DOCTORS ABOUT VACCINES 3 The survey asked self-reported eligible adults who did not try to get vaccinated if they had not done so because of concerns about vaccine safety and effectiveness. They could also provide a written response describing other reasons for not trying to get vaccinated. As shown in figure 2, more than two- thirds of these adults were concerned about long-term side effects from the vaccines (71 percent) or that the vaccines were developed too quickly or not tested enough (68 percent). Respondents’ next most common reasons were wanting to know more about how well the vaccines protect people from COVID-19 (58 percent), being concerned about allergic reactions or short-term side effects (55 percent), and wanting to know about vaccine safety and effectiveness for people with their same health conditions (54 percent). Nearly half did not trust the government or pharmaceutical companies (48 percent), and 44 percent did not believe they needed a vaccine. About 1 in 10 adults reported other reasons for not trying to get vaccinated, such as lacking time or transportation, not knowing where to get a vaccine, waiting for more appointments or a specific brand of vaccine to become available, or waiting to recover from COVID-19. FIGURE 2 Reasons for Not Trying to Get a COVID-19 Vaccine among Adults Ages 18 to 64 Who Reported Being Eligible for and Not Trying to Get a Vaccine, April 2021 Concerned about long-term side effects 71% Concerned vaccines were developed too quickly or not 68% tested long enough Wants to know more about how well vaccines protect 58% people from COVID-19 Concerned about allergic reactions or short-term side 55% effects Wants to know whether vaccines are safe and effective 54% for people with the same health conditions Does not trust government or pharmaceutical companies 48% Does not believe vaccine is needed 44% Other reason 10% No reported reason 10% URBAN INSTITUTE Source: Health Reform Monitoring Survey, April 2021. Note: Respondents could report more than one reason for not trying to get a COVID-19 vaccine. 4 FEW UNVACCINATED ADULTS HAVE TALKED TO THEIR DOCTORS ABOUT VACCINES Two-thirds of self-reported eligible adults who did not try to get vaccinated reported having a doctor or health care provider they considered to be their personal provider. Of those adults, 73 percent reported trusting their providers for information about COVID-19 vaccines, but only 19 percent had ever received information about the vaccines from their providers. Among adults who reported they were eligible for a vaccine and had not tried to get one, 67 percent reported having a doctor or other health care provider they considered to be their personal provider (data not shown). Nearly all of these providers were in primary care settings and included general doctors, nurse practitioners, and physician assistants. Access to providers varied by ethnicity: eligible Hispanic/Latinx adults who had not tried to get vaccinated were less likely than white adults and Black adults to have a personal health care provider (56 percent versus 71 percent and 66 percent; data not shown). Of the self-reported eligible adults who did not try to get vaccinated and had a personal provider, nearly three in four (73 percent) reported they would strongly or somewhat trust their provider for information about a COVID-19 vaccine (figure 3). However, only about one in five (19 percent) reported having obtained information about the vaccines from their provider. This includes 14 percent of adults in rural areas and 20 percent in urban areas (data not shown). Those who obtained information from their providers appeared to find it helpful: eighty-eight percent reported the provider answered their questions about the vaccines (data not shown). FIGURE 3 Trust in and Receipt of Vaccine Information from Personal Health Care Providers among Adults Ages 18 to 64 Who Have a Personal Health Care Provider and Reported Being Eligible for but Not Trying to Get a COVID-19 Vaccine, April 2021 Trusts provider for COVID-19 vaccine information 73% Ever obtained COVID-19 vaccine information from 19% provider URBAN INSTITUTE Source: Health Reform Monitoring Survey, April 2021. Note: Those trusting providers for information about the vaccines reported strongly or somewhat trusting their providers. FEW UNVACCINATED ADULTS HAVE TALKED TO THEIR DOCTORS ABOUT VACCINES 5 About half of self-reported eligible adults who did not try to get vaccinated trusted other doctors and providers in the community, family and friends, and pharmacists for vaccine information. Smaller shares trusted other community sources, such as religious leaders, elected officials, and social service, neighborhood, or civic organizations. Table 1 shows the share of self-reported eligible adults who did not try to get vaccinated—both those with and without a personal health care provider—who trusted various sources in their communities for information about COVID-19 vaccines. About half of these adults trusted other doctors or health care providers (56 percent), family and friends (53 percent), and pharmacists (49 percent). Some adults also reported trusting leaders of their religious groups (29 percent); social service, neighborhood, or civic organizations (25 percent); and local elected officials (20 percent). Trust in these other sources differed by race and ethnicity but not by urban/rural residence. Black adults were more likely than white adults to report trusting religious leaders (40 percent versus 27 percent), and both Black and Hispanic/Latinx adults were more likely than white adults to trust social service, neighborhood, or civic organizations and local elected officials. TABLE 1 Trusted Community Sources of Information on COVID-19 Vaccines among Adults Ages 18 to 64 Who Reported Being Eligible for and Not Trying to Get a Vaccine, April 2021 By Race/Ethnicity Hispanic/ All White Black Latinx Share who trust the following for information on COVID-19 vaccines Doctors or health care providers (excluding personal providers) 56% 55% 54% 58% Family and friends 53% 52% 57% 56% Pharmacists 49% 50% 46% 45% Religious leaders 29% 27% 40%*** 31% Social service, neighborhood, or civic organizations 25% 22% 35%*** 31%** Local elected officials 20% 16% 27%*** 28%*** Sample size 1,843 1,226 252 266 Source: Health Reform Monitoring Survey, April 2021. Notes: Those trusting providers for information about the vaccines reported strongly or somewhat trusting their providers. Adults who reported trust in leaders of their religious groups was not applicable are included in our estimates and counted as not trusting religious leaders. */**/*** Estimate differs significantly from that for white adults at the 0.10/0.05/0.01 level, using two-tailed tests. 6 FEW UNVACCINATED ADULTS HAVE TALKED TO THEIR DOCTORS ABOUT VACCINES Discussion In April 2021, two-thirds of adults who believed they were eligible for a COVID-19 vaccine and had not tried to get one reported having a personal doctor or health care provider, mostly in primary care settings. Nearly three in four of these adults trusted their providers for information about the vaccines, but only one in five had obtained such information from their providers. Those who received information from their providers generally found it helpful. Most adults who reported being eligible but not trying to get vaccinated questioned the vaccines’ safety and effectiveness, which were more common reasons for not trying to get vaccinated than believing one does not need a vaccine. Health care providers are in a key position to address these concerns and potentially help increase vaccine uptake. States and insurers can help facilitate conversations about the COVID-19 vaccines between health care providers and their patients. For instance, state Medicaid programs and private payers can ensure providers receive adequate reimbursement and incentives for patient education and counseling and can disseminate information on billing to providers.8 Some state health departments are encouraging providers to use immunization registries for identifying and reaching out to patients who have not been vaccinated.9 The Biden administration and several states are also shifting vaccine distribution away from mass vaccination sites toward more accessible community settings, including doctors’ offices and community health centers, where providers can have more personal interactions with patients, answer their questions about the vaccines, and provide the shots at the same time. Support from the American Rescue Plan Act can fund provider partnerships with community health workers and community-based organizations to increase outreach to hesitant groups.10 Some unvaccinated adults do not have a personal health care provider, and evidence shows that provider access varies by race and ethnicity. Trusted community resources, such as pharmacists, faith leaders, and local organizations, can help reach adults disconnected from the health care system, which may, in turn, help reduce racial and ethnic gaps in COVID-19 vaccine uptake. Identifying and implementing effective vaccine outreach strategies will accelerate progress toward herd immunity, which will help slow transmission of the virus and bolster the economic recovery. Data and Methods This brief draws on data from the April 2021 round of the Urban Institute’s Health Reform Monitoring Survey (HRMS), a nationally representative, internet-based survey of adults ages 18 to 64. Launched in 2013, the HRMS was originally designed to provide timely information on the Affordable Care Act before federal survey data became available. In 2020, the Urban Institute updated the design and content of the HRMS to focus on the impact of the COVID-19 pandemic and support analyses of vulnerable populations so that the survey continues to provide timely data on critical policy issues. A total of 9,067 adults participated in the most recent round of the HRMS between April 2 and 20, 2021, and 82 percent of respondents completed the survey by April 8. FEW UNVACCINATED ADULTS HAVE TALKED TO THEIR DOCTORS ABOUT VACCINES 7 For each round of the HRMS, we draw a stratified, random sample of nonelderly adults from Ipsos’s KnowledgePanel, the nation’s largest probability-based online panel. Members of the panel are recruited from an address-based sampling frame covering approximately 97 percent of US households, including those without internet access. If needed, panel members are given internet access and web- enabled devices to facilitate their participation. The April 2021 round of the HRMS includes oversamples of adults in low- and moderate-income households, nonwhite and Hispanic/Latinx adults, and young adults. Survey weights adjust for unequal selection probabilities and are poststratified to the characteristics of the national nonelderly adult population, based on benchmarks from the Current Population Survey and American Community Survey. Participants can take the survey in English or Spanish, and the survey takes a median of 15 minutes to complete. The margin of sampling error, including the design effect, for the full sample of adults is plus or minus 1.2 percentage points for a 50 percent statistic at the 95 percent confidence level. Additional information about the HRMS can be found at hrms.urban.org. Notes 1 “COVID-19 Vaccinations in the United States,” Centers for Disease Control and Prevention, accessed May 6, 2021, https://covid.cdc.gov/covid-data-tracker/#vaccinations. 2 Liz Hamel and Mollyann Brodie, “KFF COVID-19 Vaccine Monitor: What We’ve Learned,” Kaiser Family Foundation, April 16, 2021, https://www.kff.org/coronavirus-covid-19/poll-finding/kff-covid-19-vaccine- monitor-what-weve-learned-april-2021/; and “Household Pulse Survey COVID-19 Vaccination Tracker,” US Census Bureau, May 5, 2021, https://www.census.gov/library/visualizations/interactive/household-pulse- survey-covid-19-vaccination-tracker.html. 3 Lynn Vavreck, “$100 as an Incentive to Get a Shot? Experiment Suggests It Can Pay Off,” New York Times, May 4, 2021, https://www.nytimes.com/2021/05/04/upshot/vaccine-incentive-experiment.html; Dan Diamond, “The Coronavirus Vaccine Skeptics Who Changed Their Minds,” Washington Post, May 3, 2021, https://www.washingtonpost.com/health/2021/05/03/vaccine-hesitant-americans-change-minds- debeaumont-foundation/; and the White House, “FACT SHEET: President Biden to Announce Goal to Administer at Least One Vaccine Shot to 70% of the U.S. Adult Population by July 4th,” news release, May 4, 2021, https://www.whitehouse.gov/briefing-room/statements-releases/2021/05/04/fact-sheet-president- biden-to-announce-goal-to-administer-at-least-one-vaccine-shot-to-70-of-the-u-s-adult-population-by-july- 4th/. 4 White House, “FACT SHEET: President Biden to Announce Goal to Administer at Least One Vaccine Shot to 70% of the U.S. Adult Population by July 4th;” Rebecca Tan, “To Broaden Vaccine Access, Maryland Turns to Doctors’ Offices,” Washington Post, March 30, 2021, https://www.washingtonpost.com/local/coronavirus-vaccine- maryland-doctors/2021/03/29/d899987c-8d80-11eb-a6bd-0eb91c03305a_story.html; Nik DeCosta-Klipa, “Massachusetts Is Ramping Down Its Mass Vaccination Sites as Rollout Enters New Phase,” Boston.com, May 3, 2021, https://www.boston.com/news/coronavirus/2021/05/03/massachusetts-vaccine-rollout-new-phase- mass-vax-sites-close; and Drew Altman, “Why Doctors and Nurses Can Be Vital Vaccine Messengers,” Kaiser Family Foundation, April 5, 2021, https://www.kff.org/coronavirus-covid-19/perspective/why-doctors-and- nurses-can-be-vital-vaccine-messengers/. 5 Eighty-two percent of respondents completed the survey by April 8, 2021. 6 Jacqueline Howard, “All 50 States Now Have Expanded or Will Expand Covid Vaccine Eligibility to Everyone 16 and Up,” CNN, April 5, 2021, https://www.cnn.com/2021/03/30/health/states-covid-19-vaccine-eligibility- bn/index.html; and Darlene Superville and Alexandra Jaffe, “Biden Makes All Adults Eligible for a Vaccine on April 19,” Associated Press, April 6, 2021, https://apnews.com/article/biden-move-vaccine-eligibility-date-april- 19-021157c7bdf964181e3b63f51b89601e. 8 FEW UNVACCINATED ADULTS HAVE TALKED TO THEIR DOCTORS ABOUT VACCINES 7 For instance, tabulations of data from the US Census Bureau’s March 17–29, 2021, Household Pulse Survey show the shares of adults ages 18 to 64 who had received a vaccine were 39 percent for white adults, 34 percent for Black adults, 33 percent for Hispanic/Latinx adults, and 42 percent for non-Hispanic/Latinx adults who are not Black or white or are more than one race. Also in March of this year, the Kaiser Family Foundation’s Vaccine Monitor found gaps in vaccine uptake by race and ethnicity and residence in rural and urban areas; see Liz Hamel, Lunna Lopes, Andrey Kearney, and Mollyann Brodie, “KFF COVID-19 Vaccine Monitor: March 2021,” Kaiser Family Foundation, March 30, 2021, https://www.kff.org/coronavirus-covid-19/poll-finding/kff-covid- 19-vaccine-monitor-march-2021/. 8 Melisa Byrd (senior deputy director, Department of Health Care Finance, Government of the District of Columbia, and state Medicaid director), memorandum to District of Columbia Medicaid providers, regarding provider-to-beneficiary education and counseling for the COVID-19 vaccine, April 15, 2021, https://www.dc- medicaid.com/dcwebportal/documentInformation/getDocument/25256; Jacob Wallace, Jason L. Schwartz, and Walter A. Orenstein, “Promoting Equitable Access to COVID-19 Vaccines – The Role of Medicaid,” Health Affairs Blog, September 15, 2020, https://www.healthaffairs.org/do/10.1377/hblog20200910.575538/full/; and Elizabeth Hinton, Lina Stolyar, and Robin Rudowitz, “A Look at How Medicaid Agencies Are Assisting with the COVID-19 Vaccine Rollout” (San Francisco: Kaiser Family Foundation, 2021). 9 Maryland Department of Health, “Maryland Department of Health Expands Primary Care COVID-19 Vaccination Program, Bringing More Vaccine to Local Communities,” news release, April 30, 2021, https://health.maryland.gov/newsroom/Pages/Maryland-Department-of-Health-expands-Primary-Care- COVID-19-Vaccination-Program,-bringing-more-vaccine-to-local-communities.aspx. 10 Michele Cohen Marill, “Community Health Workers, Often Overlooked, Bring Trust to the Pandemic Fight,” Kaiser Health News, February 8, 2021, https://khn.org/news/article/community-health-workers-often- overlooked-bring-trust-to-the-pandemic-fight/; and the White House, “FACT SHEET: Biden Administration Announces Historic $10 Billion Investment to Expand Access to COVID-19 Vaccines and Build Vaccine Confidence in Hardest-Hit and Highest-Risk Communities,” news release, March 25, 2021, https://www.whitehouse.gov/briefing-room/statements-releases/2021/03/25/fact-sheet-biden- administration-announces-historic-10-billion-investment-to-expand-access-to-covid-19-vaccines-and-build- vaccine-confidence-in-hardest-hit-and-highest-risk-communities/. About the Authors Michael Karpman is a senior research associate in the Health Policy Center at the Urban Institute. His work focuses primarily on the implications of the Affordable Care Act, including quantitative analysis related to health insurance coverage, access to and affordability of health care, use of health care services, and health status. His work includes overseeing and analyzing data from the Urban Institute’s Health Reform Monitoring Survey and Well-Being and Basic Needs Survey. Before joining Urban in 2013, Karpman was a senior associate at the National League of Cities Institute for Youth, Education, and Families. He received his MPP from Georgetown University. Stephen Zuckerman is a senior fellow and vice president for health policy at the Urban Institute. He has studied health economics and health policy for 30 years and is a national expert on Medicare and Medicaid physician payment, including how payments affect enrollee access to care and the volume of services they receive. He is currently examining how payment and delivery system reforms can affect the availability of primary care services and studying the implementation and impact of the Affordable Care Act. Before joining Urban, Zuckerman worked at the American Medical Association’s Center for Health Policy Research. He received his PhD in economics from Columbia University. FEW UNVACCINATED ADULTS HAVE TALKED TO THEIR DOCTORS ABOUT VACCINES 9 Acknowledgments This brief was funded by the Robert Wood Johnson Foundation. The views expressed here do not necessarily reflect the views of the Foundation. The views expressed are those of the authors and should not be attributed to the Urban Institute, its trustees, or its funders. Funders do not determine research findings or the insights and recommendations of Urban experts. Further information on the Urban Institute’s funding principles is available at urban.org/fundingprinciples. The authors gratefully acknowledge Joshua Aarons for tabulating data from the Census Bureau’s Household Pulse Survey; Dulce Gonzalez, Jennifer Haley, Genevieve M. Kenney, and Monique King- Viehland for helpful feedback; and Rachel Kenney for her careful editing. ABOUT THE URBAN INSTITUTE The nonprofit Urban Institute is a leading research organization dedicated to developing evidence-based insights that improve people’s lives and strengthen communities. For 50 years, Urban has been the trusted source for rigorous analysis of complex social and economic issues; strategic advice to policymakers, philanthropists, and practitioners; and new, promising ideas that expand opportunities for all. Our work inspires effective decisions that advance fairness and 500 L’Enfant Plaza SW enhance the well-being of people and places. Washington, DC 20024 Copyright © May 2021. Urban Institute. Permission is granted for reproduction of www.urban.org this file, with attribution to the Urban Institute. 10 FEW UNVACCINATED ADULTS HAVE TALKED TO THEIR DOCTORS ABOUT VACCINES