Millions of uninsured Americans seeking a COVID-19 vaccine could be on the hook for a fee if health care providers charge to administer it.
So even while the federal government has purchased millions of doses of vaccine in deals worth billions of dollars, it’s not clear everyone will be able to get one for free.
Even if pharmacists and doctors don’t charge for a vaccine itself, they can charge an “administrative fee.”
This fee offers a financial incentive to provide the vaccine, and covers costs associated with storage and the health care providers’ time, but it also imposes another barrier to vaccination, according to Claire Hannan, executive director of the Association of Immunization Managers, which works with the Centers for Disease Control and Prevention and states to implement immunization.
Though the fees are likely to be capped by federal officials, any fee will frustrate uninsured Americans and reduce vaccination rates among some of the same people most exposed to infection.
By May, an estimated 27 million newly unemployed people had lost their health insurance due to the economic collapse, according to a report by the nonpartisan Kaiser Family Foundation. About 28 million people already lacked health insurance before the pandemic.
Millions of people are making agonizing decisions about whether to fill a prescription, pay a phone bill or make rent.
How much providers can charge, and whether people who can’t afford to pay for a vaccine can be turned away, will be determined by the federal government in the coming weeks.
An administrative fee could be a barrier to stopping the virus’ spread.
“A small fee may not be small to vulnerable populations, and will probably reduce uptake,” said Dorit Reiss, a professor at the UC Hastings College of the Law who studies vaccines.
Advocates and experts in medical ethics argue there is a moral obligation to provide vaccines without delivery costs.
“Food, shelter, diapers, other medicines should never be a financial competitor with vaccine protection,” said Steven Wakefield, an activist and former director at the HIV Vaccine Trials Network.
Harald Schmidt, a medical ethicist and researcher in vaccination at the University of Pennsylvania, said making a vaccine freely available is needed to begin to abate the pandemic’s devastation among front-line workers and people of color.
“Reducing financial barriers is one critical element, as research shows that even small copayments can deter people from seeking needed care,” he said.
Some advocates express dismay that Americans essentially could end up paying for a vaccine multiple times: with billions in taxpayers' funds to purchase the doses of any vaccine, on top of billions of public tax dollars for research and development and manufacturing, then once again at the pharmacy when they receive a shot.
After a protest outside Moderna’s headquarters last week, the company released a statement saying its vaccine, if authorized or approved by the Food and Drug Administration, would be available at no cost to consumers.
“But we’ve already paid $2.5 billion for [Moderna’s investigational vaccine] so ‘no cost’ is not really the case,” said Merith Basey, an executive director at Universities Allied for Essential Medicines, which participated in the protest. “You could say potentially that it will be free at the point of delivery, but we’re not even sure if that’s true yet. … What about administration? distribution?”
Lack of details
Senior administration officials with Operation Warp Speed have said on calls with reporters and with immunization planners that the administrative fee will be covered through a provider relief fund created by the massive March coronavirus relief law.
In April, Trump said some of that money should go to reimbursing uninsured patients for care related to COVID-19. But billions from that pot of funds have already been distributed to providers, and it’s unclear how much relief has been offered to uninsured patients. According to press reports, the emergency fund's implementation has been flawed, with many COVID-19 patients excluded from eligibility and some providers opting out of participation.
About $56.6 billion remains in the fund, while the Kaiser Family Foundation estimates that $13.9 billion to $41.8 billion would be needed to reimburse hospital bills for uninsured patients alone.
The HHS website specifies getting care covered is “subject to available funding.”
“Reimbursement is subject to availability, so if the fund runs out there’s no more reimbursement,” said Karyn Schwartz, a senior Kaiser Family Foundation fellow.
The cost of covering vaccines for uninsured patients will become more clear after Department of Health and Human Services officials determine how much providers are allowed to charge.
When the CDC launches a mass vaccination effort, it first negotiates a “provider agreement” with major pharmacy giants like Walgreens and CVS, which lays out the requirements for participating providers, according to Kelly L. Moore, associate director at Immunization Action Coalition, which also works with the CDC on immunization. That typically includes the amount they can bill. The Centers for Medicare and Medicaid Services could also be involved, since it sets administrative fees in government health care entitlement programs, Moore said.
Two provider agreements the CDC previously used model opposite approaches toward people unable to pay, Moore noted. Under the Vaccines for Children Program, CDC’s program providing routine childhood vaccinations, the provider agreement says that a vaccine should never be denied to any family that cannot pay.
The requirement to provide children with vaccines is not a big burden on providers though, Moore said. Children born into low income families are typically covered by Medicaid, so few needy families would be required to pay out of pocket anyway. But poor adults are less likely to be covered by Medicaid.
On the other hand, during the 2009 H1N1 influenza pandemic, the provider agreement stated that health care providers "may" administer a vaccine for free, not that they "must." It suggests people who cannot afford the fee at a pharmacy or doctor’s office can be directed to public health departments.
One solution is standing up specialized vaccination clinics, Hannan said. This will probably be how federal and state governments distribute the first doses of any vaccine to priority populations.
But as the pandemic continues, if many people are turned away at the pharmacy, standup clinics and public health departments could be overwhelmed. That could lead to the same long lines that plagued many testing sites. That could hurt vaccination rates, too, Hannan said.
These clinics would also need to be deemed network providers with insurance companies.
These questions are being worked out by Trump administration officials now.
State public health departments can’t begin enrolling providers into the campaign until the provider agreement is finalized by the CDC, so Hannan and Moore expect one soon.
“States need to enroll providers sooner rather than later, because it takes time to do this and it takes staff resources to approve and train these providers,” Hannan said.