Letter to the Hon. Gene L. Dodaro, Comptroller General of the United States - Underwood Leads Congressional Effort Calling for Gao Review of Disparities in Vaccination Coverage

Letter

Dear Comptroller General Dodaro:

We write to request that the Government Accountability Office (GAO) conduct a review of the current state of Medicaid immunization coverage and any resulting racial, ethnic, or geographic disparities in vaccination rates as a result of gaps in coverage. Throughout the COVID-19 pandemic, we have seen declines in vaccination rates and we fear a surge in vaccine-preventable diseases (VPDs) as a result. A GAO review of vaccination coverage for children and adults across state Medicaid and Children's Health Insurance Program (CHIP) programs will help Congress understand disparities in coverage, identify inequities in vaccination rates, and chart a path forward for ensuring an equitable vaccination program.

The need for this study arises from widespread disparities in vaccination rates, including influenza vaccines. According to the Centers for Disease Control and Prevention (CDC), Black adults are approximately ten percentage points less likely to receive an influenza vaccine than white adults. Although it is important for Americans to get their flu shots every year, the need is even greater now as our nation confronts COVID-19: as CDC Director Dr. Robert Redfield has warned, the converging public health crises of "the flu epidemic and the coronavirus epidemic at the same time" could result in even greater devastation than the first peak of COVID-19 cases in the spring. Given the disproportionate impacts of COVID-19 on Black adults, lower influenza vaccination rates could exacerbate disparities in adverse health outcomes during the pandemic.

In addition to disparities based on race and ethnicity, vaccination rates are also lower in rural areas compared to urban areas.5 Given Medicaid's critical role in providing access to care for underserved populations, fully understanding the current landscape of beneficiaries' access to vaccinations is essential to inform future efforts to increase immunization rates and decrease prevalence of VPDs in vulnerable communities.

Existing research shows that one potential explanation for lower immunization rates among adults could be the lack of financial incentives for health care providers to administer vaccines: one study found that the two most commonly reported reasons for physicians referring patients elsewhere for vaccines were lack of insurance coverage for the patient and inadequate reimbursement for the provider.6 Illinois offers one example of the impact of vaccination coverage policies: after a 2014 CDC policy change, Illinois had to stop offering free vaccines to health care providers for CHIP patients, resulting in delayed provider reimbursements for vaccines and ultimately, providers turning away children with CHIP coverage, threatening immunization rates for vulnerable young people in the state.

Additionally, without a separate billing code for vaccine counseling, financial incentives might not be sufficiently aligned for providers to spend the time with patients that would be required to build vaccine confidence. Understanding Medicaid reimbursement mechanisms related to vaccinations will be essential to increasing vaccination rates and reducing disparities.

For these reasons, we request that GAO examine how state Medicaid and CHIP programs cover vaccinations across the lifespan, with a specific focus on racial, ethnic, and geographic disparities in immunization rates. This study could include, but is not limited to:

What is known about trends in provider enrollment in Medicaid, and the Vaccines for Children program, and the potential impact of the COVID-19 pandemic on these trends;
What is known about state trends in Medicaid beneficiary out-of-pocket costs for recommended vaccine coverage, including administration fees and any related costs, for various eligible populations, including pregnant people and other eligible adults, with distinctions between the VIII Group and adults in other populations, and the potential impact of the COVID-19 pandemic on these trends;
What is known about state vaccine policies for children, including financial or other barriers for patients under CHIP, reimbursement rates for providers under CHIP and the Vaccines for Children program, and eligibility for the Vaccines for Children program;
The extent to which states are providing coverage for vaccines to populations for which such coverage is optional and the levels of federal support that states are receiving for vaccinations under Medicaid, CHIP, and the Vaccines for Children program; and
For non-Medicaid-expansion states, what is known about individuals in the Medicaid coverage gap population (adults with incomes above Medicaid eligibility limits but below 133 percent of the federal poverty level), who might have limited access to affordable vaccines (including access to immunizations for pregnant and postpartum individuals who lack another source of coverage).
A GAO review of these issues will be an important step toward avoiding a surge in VPDs during and after COVID-19, and in promoting equity in vaccination rates in every state.

Thank you for considering this request.

Sincerely,