key: cord-0908743-t9n6xogo
authors: Gaffney, Adam W; Woolhandler, Steffie; Himmelstein, David U.
title: Association of Uninsurance and VA Coverage with the Uptake and Equity of COVID-19 Vaccination: January–March 2021
date: 2022-01-11
journal: J Gen Intern Med
DOI: 10.1007/s11606-021-07332-0
sha: 9d68d19f6e17d21b3fa791f30ffb860c881dea7d
doc_id: 908743
cord_uid: t9n6xogo

nan

We analyzed the Census Bureau's nationally representative Household Pulse Survey (Phase 3) fielded biweekly January 6-March 29, 2021 (response rate 6.4-7.5%). 1 We examined receipt of ≥ 1 dose of a COVID-19 vaccine according to three mutually exclusive insurance coverage groups 1 : any VA coverage or use, 2 only non-VA coverage, and 3 uninsured. All information was self-reported. Respondents' missing data for vaccination or coverage (n = 82,021 [18% of sample]) were excluded.

We tabulated respondent characteristics by insurance coverage, and weekly trends in vaccination by insurance and race/ethnicity. We performed 2 multivariable logistic regressions adjusted for age, gender, and insurance. Model 1 additionally included survey-week and a survey-week*insurance interaction term; Model 2 was restricted to the final surveyweek and additionally included race/ethnicity and a race/ethnicity*insurance interaction term. These allowed estimation of the predicted probabilities of vaccination by insurance and time (Model 1) and by insurance and race/ethnicity (Model 2).

We used Stata/SE 16.1 (and Stata's margins commands) and Census Bureau-provided weights and replicate weights to calculate nationally representative estimates and standard errors.

Our final sample included 377,214 adults. Compared to those with non-VA coverage (mean age 49.9 years), uninsured individuals were younger (40.3 years) and VA-covered individuals older (58.7 years). Of respondents with non-VA coverage, 53.8% were female vs. 44.5% of the uninsured and 31.7% of those with VA coverage. Figure 1 provides unadjusted (panel 1) and age-and genderadjusted (panel 2) estimates of vaccination by insurance status over the study period. In mid-January, adjusted vaccination rates were similar for VA-(7.2%) and non-VA-(8.0%) covered adults, but lower among the uninsured (4.2%). Vaccination rates subsequently rose fastest among VA-covered individuals and slowest among the uninsured. By late March, the adjusted vaccination rate was 55.3% for the VA coverage group vs. 50.1% for those with non-VA coverage and 30.4% among the uninsured. Relative to those with non-VA coverage, persons with VA coverage had an adjusted 5.9 percentage point greater increase in vaccination rates between mid-January and late March (95% CI 2.1, 9.6; p = 0.002), with a significantly slower increase among the uninsured. Table 1 presents adjusted vaccination rates by race in the final survey sample. Relative to Whites, vaccination rates for Blacks and Hispanics were lower among those with non-VA coverage but higher among those with VA-coverage; Asians had the highest rates in both settings. Relative to Whites, VA coverage vs. non-VA coverage was associated with markedly higher rates of vaccination among Blacks (13.5 percentage points; 95% CI 5.4, 21.7) and Asians.

From January to March 2021, SARS-Co-V-2 vaccination rates increased more slowly among the uninsured relative to the insured, and more equitably among those with VA relative to non-VA coverage.

The federal government made COVID vaccination free. However, uninsured persons may have harbored concerns about costs because of past experiences. 2 Moreover, those who lack coverage are less likely to have an established relationship with a primary care provider 3 -an important potential source of information on vaccines. Census Bureau's classification scheme, we categorized individuals as "uninsured" if they were without any public coverage (Medicare, Medicaid, or TRICARE/other military) and without private insurance (employer-provided or direct purchase); those with only Indian Health Service (IHS) or "other" coverage" were considered uninsured. We used code provided by the Stata Corporation for the calculation of margin standard errors that reflect successive difference replication (SDR) variance.

Equitable access to VA facilities, greater vaccine supply, and direct outreach efforts-e.g., using mobile vaccination units 4 and air-lifting vaccine teams to remote areas 5 -may have contributed to the more equitable and faster vaccine uptake among those with VA access.

Our study has limitations. VA enrollment was self-reported and although our nationwide estimate of enrollment (8.6 million) appears reasonably accurate, some of these respondents might not be current enrollees/users, and our sample included a disproportionately large number of female veterans, limiting generalizability. The total number of persons who reported having been vaccinated in late March (116.5 million) exceeded the CDC's March 26 estimate of 101 million, 6 which might reflect inaccuracies in participants' recall, sampling error, or incomplete reporting to the CDC. Finally, many who reported VA coverage were likely vaccinated at non-VA facilities.

The relative success of the VA's vaccination roll-out could help inform ongoing and future vaccination efforts. Universal, comprehensive coverage, meanwhile, would likely mitigate disparities in uptake of services, including vaccination. , and an insurance status*race/ ethnicity interaction term. The "Adjusted effect of coverage status" represents the difference in the probability of vaccination between those with VA coverage (or uninsured) relative to those with non-VA coverage within each race/ethnicity group (e.g., Blacks with VA coverage relative to Blacks with non-VA coverage = 0.57 − 0.45 = 0.12). The "adjusted effect of coverage status * race" represents the difference in the probability of vaccination between those with VA coverage (or uninsured) relative to those with non-VA coverage, for each non-whiterace/ethnicity group, relative to the corresponding difference among whites (e.g., 

Source of the Data and Accuracy of the Estimates for the Household Pulse Survey

The Covid Vaccine Is Free, but Not Everyone Believes That. The New York Times

Characteristics of Americans With Primary Care and Changes Over Time

Many veterans don't trust coronavirus vaccines. For a VA crew in the rural West, that means changing minds, one by one

As rural as you can get": Montana VA flies coronavirus vaccine to eager veterans

Centers for Disease Control and Prevention

Acknowledgements: Adam Gaffney, David Himmelstein, and Steffie