Purva Rawal, Jennifer Rak, Elizabeth Docteur, Lu Zawistowich

The COVID-19 era poses new challenges for vaccine access that must be met with creative policy solutions and partnerships that leverage community-based assets. To ensure timely and equitable access to vaccines essential to preventing and containing old and new infectious disease outbreaks, the health care delivery system must reconfigure resources and make additional investments. This blog post describes three existing community-based sites that policy makers and stakeholders should build on through additional support and partnership:

  • Mobile health clinics (MHCs),
  • Drive-thru testing and immunization sites, and
  • School-based health centers (SBHCs).

States and cities face pressure to find solutions in light of evolving needs and guidelines for pandemic control. Policy makers and stakeholders should devise plans to make maximum use of community-based sites to meet the dual challenges of ensuring children and adults are up to date on vaccines recommended by the Advisory Committee on Immunization Practices (ACIP) and that they also have access to a future COVID-19 vaccine.

Vaccination Policy Goals And Environmental Challenges

The pandemic has undermined delivery of routine vaccines recommended by the ACIP for both adults and children, and there is mounting concern about readiness for the upcoming flu season, which is expected to be compounded by COVID-19. Looking ahead, the disproportionate impact of the virus on communities of color also creates a new urgency to ensure equitable distribution of a COVID-19 vaccine when one becomes available. Evidence on the emerging problems includes:

  • A mid-May Primary Care Collaborative survey of primary care practices indicated that 81 percent of responding practices had limited wellness and chronic care visits and 70 percent reported that patients were delaying these visits in mid-May.
  • Data from a company that provides vaccine management tools to providers and public health departments found that vaccinations had fallen across all age groups by 49 percent from late March through mid-April.
  • The Centers for Disease Control and Prevention (CDC) published studies this spring that highlight the need to ensure children are up to date on their vaccination schedule. From mid-March to mid-April, 5 million fewer doses of non-influenza vaccines recommended by the ACIP and 250,000 fewer doses of measles-containing vaccines were ordered by the Vaccines for Children Program compared to 2019. An analysis of immunization rates among children in Michigan found that they had fallen below 50 percent for children up to two years of age.
  • According to the Centers for Medicare and Medicaid Services, COVID-19 cases among Black Medicare beneficiaries were nearly 2.5 times higher than White beneficiaries and 40 percent higher among Hispanic beneficiaries as of mid-July.

To ensure timely and equitable vaccine access, policy makers should address key obstacles including: the pandemic has disrupted typical preventive health care patterns, including reduced access to traditional settings of care such as physician offices and community health centers; people are reluctant to see their regular health care provider in an office-based setting, due to risk of contagion; COVID-19 is exacerbating existing inequities in access to health care services and social determinants of health. On top of these challenges, there remains a persistent, ongoing cultural problem in terms of trust in the public health value of vaccination.

The CDC also recently released guidance for public and private organizations to plan vaccination clinics at satellite, temporary, or off-site locations, including at the sites explored in this blog post as well as churches and community centers. As policy makers, payers, health systems, and providers consider comprehensive plans to address these immunization challenges, partnering with and supporting these and other community-based sites could increase the number of children and adults who are up to date on ACIP-recommended vaccines and help prepare for the mass distribution of a future COVID-19 vaccine—especially to priority populations and high-risk communities. However, for seniors and adults who face barriers to accessing community-based sites due to disability, medical frailty, or other risk factors, additional strategies will be needed—such as home-based immunization services—to ensure vaccination.

Mobile Health Clinics

An estimated 2,000 MHCs operate across all 50 states and the District of Columbia, and deliver approximately 6.5 million visits annually. They provide a range of services including primary care, preventive screenings, disease management, behavioral health, dental care, prenatal care, and pediatric care. Patients report that MHCs help them navigate the broader health care system and connect them to resources to address both their medical and social needs, which both play a large role in health outcomes. Furthermore, if the MHCs are able to work with community partners, including churches, faith-based institutions, and community centers, they could build on and extend their trusted relationships with patients.

MHCs can flexibly deliver care to underserved communities based on their needs, which could be critical in expanding access to COVID-19 testing and immunizations when available. Sixty percent of those served by MHCs are uninsured; 31 percent have Medicare, Medicaid, or Children’s Health Insurance Program (CHIP); and 9 percent have private insurance, and the majority of the patients identify as minorities (40 percent Latino/Hispanic and 30 percent Black/African American). MHCs primarily provide care to children and adults younger than age 65, with 42 percent younger than age 18 years and 50 percent ages 18 to 65.

To expand MHCs’ reach into underserved communities, policy makers should consider their organizational and funding structures. A recent study of MHCs indicated that 33 percent were independent, 29 percent were affiliated with a hospital or health system, and 24 percent were affiliated with a university. Slightly more than half receive philanthropic support, and fewer than half (45 percent) receive federal funds. Importantly for public and private payers, research indicates that MHCs are also cost-effective, with a return on investment of 12:1. Federal, state, provider, and payer investments in MHCs could have far-reaching positive impacts on underserved communities.

Drive-Thru Testing And Immunization Sites

A July 2020 white paper released by the Health, Education, Labor, and Pensions Committee’s Ranking Member Patty Murray calls for $25 billion in congressional support for the development and distribution of a COVID-19 vaccine. It specifically cites a need for supporting supplemental vaccine administration sites, including drive-thru clinics. In particular, the widespread use of COVID-19 drive-thru testing sites could provide an infrastructure for eventual vaccination.

While less common, there are successful examples of drive-thru vaccination clinics. One of the earliest was established in 1995 by the University of Louisville to provide influenza vaccinations and also provided H1N1 vaccines in 2009. Other examples of drive-thru vaccination programs include ones associated with local Veterans Affairs programs and pediatric health systems. Experience with local drive-thru immunization efforts, coupled with new COVID-19 drive-thru testing sites, could inform scaling and deployment of these models—especially in high-risk communities.

School-Based Health Centers

SBHCs provide a broad range of services, including primary care and prevention, behavioral health, and oral health care in partnership with other providers and community-based organizations. There are more than 2,500 SBCHs operating in 48 states and the District of Columbia. A 2016–17 SBHC survey indicated that 77 percent of SBHCs serve Title I schools and are located in schools where 70 percent of students were eligible for free or reduced-price lunch. More than 38 percent of SBHC patients were Hispanic/Latino, and 24 percent were Black/African American, compared to 22 percent and 14 percent, respectively, for schools without access to SBHCs. However, school closures and limited reopenings are compromising access to a critical setting in underserved communities. Experts have recommended that school districts consider allowing SBHCs to remain open to support child health and well-being even if the schools themselves are not fully staffed.

The vast majority of SBHCs provide at least some immunizations—86 percent offer flu vaccines and 78 percent offer Tdap. Other vaccines offered include human papillomavirus (HPV), hepatitis B, polio, varicella vaccines, meningitis, and measles. The presence of SBHCs is also associated with significant improvements in preventive service use, including immunizations. In 2016, the CDC’s Community Preventive Services Task Force recommended the “implementation and maintenance of SBHCs in low-income communities, based on sufficient evidence of effectiveness in improving educational and health outcomes.”

SBHCs receive support from a variety of sources, including patient revenues from third-party insurers and patient fees, grants, partner contributions, and private funding in some cases as well. Importantly, 82 percent report billing Medicaid, 64 percent report billing commercial insurance, 63 percent report billing CHIP, and 50 percent report collecting patient fees. Based on a 2016–17 survey, 51 percent of SBHCs were sponsored by a federally qualified health center, giving them an important link to the broader community.

Given the role they play in delivering care—and their potential to address lagging immunization rates and support a universal vaccination campaign—additional funding could help them remain open and expand capacity to meet current immunization challenges. In 2010, Congress appropriated $200 million in the Affordable Care Act for construction, renovation, and equipment for SBHCs—which led the Department of Health and Human Services to make 520 awards across 47 states, the District of Columbia, and Puerto Rico. Similarly, Congress could provide additional support either through Medicaid, CHIP, and/or appropriations to ensure that SBHCs are able to remain open—and perhaps even to expand their capacity to serve low-income and medically underserved children and adolescents during and after the current public health crisis.

Conclusion

Even before the COVID-19 pandemic began, the nation’s immunization infrastructure required strengthening. However, the challenges of ensuring that children and adults are up to date with ACIP-recommended vaccines and ensuring access to an eventual COVID-19 vaccine—especially for communities that are most affected—call for innovative solutions and partnerships to expand immunization sites. While the appropriate mix of alternative sites may vary across and within states—depending on their unique circumstances and needs—MHCs, drive-thru sites, and SBHCs could address some of the obstacles to meeting these dual vaccination goals with coordinated federal and state support, in conjunction with new partnerships and financial support from payers and providers.

Authors’ Note

CapView Strategies provides policy consulting services to a wide range of health care industry stakeholders who may be impacted by vaccination policies.