Vaccines are the strongest bulwark against the Covid-19 pandemic. They’re highly effective at preventing deaths and hospitalizations, free in the US, and all residents over the age of 12 are eligible. But even with the highly transmissible delta variant gaining ground and new Covid-19 cases on the rise, vaccinations have reached a stubborn plateau. About 67 percent of eligible US residents have received at least one dose, and the rate of new vaccinations has fallen drastically since the spring. From a peak of 3.4 million shots per day in April, the number of daily new injections is down to around 600,000.
Now some parts of the country are reimposing pandemic restrictions like mask mandates, and the spread of Covid-19 among the unvaccinated is starting to threaten people who have been vaccinated, contributing to breakthrough infections. The Centers for Disease Control and Prevention has revised its guidelines to include masking even for vaccinated people in some circumstances. The rise in new infections is frustrating for those who are immunized and a grave danger for those who aren’t.
So who isn’t getting a vaccine, and why? And can they be persuaded to get their shots?
Some distinct patterns have emerged. “The most obvious and blatant, and the one I’ve got the most attention for, is the partisan link,” said Charles Gaba, a health care data analyst who has made several charts tracking vaccination that have been widely shared across social media.
Regions where large majorities backed Donald Trump in the 2020 presidential election have far lower vaccination rates than people in areas that voted for Joe Biden. The effect is visible at the state level and the county level, and it scales with the share of the vote. Almost all US counties below 20 percent vaccination rates lean Republican, and almost all above 65 percent lean Democratic.
But there are other fault lines as well. “There have really been persistent gaps between white people compared to Black and Hispanic people, with Black and Hispanic rates lagging behind pretty consistently across states,” said Samantha Artiga, vice president and director of racial equity and health policy at the Kaiser Family Foundation.
At the start of July, the vaccination rate was about 15 percent lower for Black people than for white people in the US, and the rate for Hispanic people was about 3 percent lower. Asian Americans have maintained an even higher vaccination rate than white Americans, well above 70 percent of all adults. Recently, the gaps have begun to narrow, but disparities still remain, especially at the state level. As the chart below shows, Black people make up 12 percent of the US population but only account for 9 percent of people who have received at least one dose of the vaccine.
Income is another dividing line. Lower-income brackets appear to have a higher share of unvaccinated people than higher-income brackets. The costs of medical care, or the perceived costs, may explain why. People without health insurance may worry about getting a bill, even though Covid-19 vaccines in the US are supposed to be free. There have been instances of people being erroneously billed for their vaccines, and even people with insurance may be skeptical that a medical appointment could come at no cost.
This chart shows the number of people in each income bracket who have not been vaccinated, according to the US Census Bureau’s household pulse survey. It highlights that people with lower incomes make up a larger share of the unvaccinated than those at higher incomes, but the survey also had a significant number of respondents who did not report their income at all.
There is also an age divide, with younger people being less likely to be vaccinated than older adults. That’s partly due to how vaccines were rolled out, with older adults prioritized for access, as they are at the highest risk for severe Covid-19. However, a vaccination lag remains among teenagers and young adults. (The largest unvaccinated age bracket is children under age 12, who are not yet eligible to receive Covid-19 vaccines.)
But to get vaccination rates up, one has to go beyond finding out who has yet to be immunized and figure out exactly why. Is Covid-19 vaccination stalled by a lack of access, or are people deliberately saying no?
What would it take to continue increasing Covid-19 vaccination rates?
Vaccination is a critical element of the public health response to Covid-19, but in the US, getting a shot is seen as a personal decision. To understand these choices, it’s important to distinguish between apathy, hesitancy, refusal, and access issues, since these reasons affect what tactics are most effective at getting more people vaccinated.
Margot Savoy, chair of the family and community medicine department at Temple University, explained that her interactions with patients revealed three kinds of concerns about Covid-19 vaccines: anxiety about safety and side effects, religious beliefs against vaccines, and perceptions of personal risk from Covid-19.
Among those who are hesitant or currently refusing vaccination, many can be convinced, but it does take finesse and engaging with their values. “There is a tendency to dismiss the concerns and questions as if they are not valid and important,” Savoy said in an email. “That is a mistake.”
Some of the people who are concerned about vaccines are also worried about the risks from Covid-19 and are taking the threat seriously, wearing masks and social distancing, Savoy added.
Others perceive Covid-19 to be far less of a threat, in part because the pandemic hasn’t struck every part of the country in the same way. Wyoming, for instance, has vaccinated just over one-third of its population, but the state also dodged some of the worst impacts of the pandemic and began to relax sooner than most.
“We’ve had relatively low levels of COVID-19 illnesses statewide for a while now, which affects threat perception,” said Kim Deti, a spokesperson for the Wyoming Department of Health, in an email. “With schools open all through the past school year and most businesses open, it has likely been harder for some people to see the personal need for vaccination.”
Nonetheless, certain vaccination gaps have begun to narrow with time. For example, as more people see the vaccines in action, racial gaps are shrinking. “Early on during vaccine distribution, we had much larger shares of Black and Hispanic adults that were in this wait-and-see group,” said Ashley Kirzinger, associate director for public opinion and survey research at the Kaiser Family Foundation. “They had legitimate questions and concerns about the vaccine and they didn’t want to be the first in line.”
It stands to reason that more people in these communities can be persuaded with information about the safety and efficacy of Covid-19 vaccines.
Improving logistics is another crucial part of increasing vaccination rates. Particularly in the early stages of the vaccine rollout, doses were distributed through mass vaccination sites and major medical facilities. That served to vaccinate lots of people quickly, but this approach required people to schedule appointments, secure transportation, and carve out a time slot in their day to get their shots.
Lower-income people often work jobs that make it difficult to schedule time off for shots or recovery from side effects. They also face barriers like securing transportation to clinics, particularly in rural areas.
Closing income gaps means lowering barriers to access. Free transportation, paid time off, and financial incentives can all help, along with better messaging about the costs of vaccines. Ride-hailing companies like Uber and Lyft are offering free rides to vaccination sites, and some companies are providing free child care during appointments and during recuperation, though these services aren’t available everywhere. “Employers offering time off matters significantly,” Kirzinger said.
Using smaller community health facilities, mobile clinics, and even door-to-door campaigns are boosting vaccination rates, particularly among low-income people. Given the racial wealth disparities in the US, such approaches can also help close racial gaps. And bringing vaccines directly to people boosts vaccination rates among those who aren’t motivated one way or the other, especially for young adults and teenagers. Still, progress is slow, and this work can get expensive for local health departments.
Meanwhile, incentives seem to be effective at driving up vaccination rates among the unmotivated or unconcerned. In the US, states have offered a variety of rewards — lotteries, cash, beer, marijuana, gift cards — to boost their vaccine coverage. New York City is now offering $100 to anyone who receives their first dose at a city-run site.
Incentives WORK. I alone spoke to 7 people who told me they decided to come because they could get a grocery gift card or (I kid you not) a free empanada— Dr. Hannah Tello, Ph.D (@MsHannahT_PhD) July 24, 2021
One new emerging concern is that some of the variants of the virus that causes Covid-19 seem to be better able to evade immunity from vaccines and may lead to breakthrough infections. That is fueling perceptions among some unvaccinated people, and even vaccinated people, that the vaccines are ineffective, even though they remain potent. It adds another tricky element for the vaccination campaign, and it shows that public health officials can’t be complacent in making the case for Covid-19 vaccines.
There are vast numbers of people who are outright opposed to vaccines
The most challenging group to vaccinate, and the largest, are those ideologically opposed to Covid-19 vaccines. A July poll by the Associated Press and NORC Center for Public Affairs Research found that among unvaccinated people, 35 percent said they probably would not get vaccinated, while 45 percent said they definitely would not. And refusal is closely tied to political views.
“The group that really hasn’t changed over time are those in that ‘definitely not’ or ‘only if required’ groups,” said Kirzinger. “They’re largely white — there are loads of white evangelical Christians, they live in rural areas, they lean Republican, and they haven’t changed their minds.”
The reasons people give for refusing vaccines vary: They don’t think Covid-19 is a big deal, they believe conspiracy theories about vaccines, they think the side effects and risks outweigh the benefits, they resent being told what to do. The varying reasons make it harder to come up with a broad-based appeal to get vaccinated.
Pressure tactics and vaccine requirements may end up being counterproductive, fueling more resistance. “I do think there could also be a backlash against mandates,” Kirzinger said.
On the other hand, historically, mandates have drastically increased vaccination rates. School vaccine requirements and other state-level rules, for example, have ensured that by the age of 2, 90 percent of US children are immunized against chickenpox, 92 percent against polio, and 90 percent against measles, mumps, and rubella.
Among the politically motivated, there’s some evidence that political leaders can change the minds of constituents who share their political views. A recent study reported that among unvaccinated Republicans, 7 percent more people said they intended to get vaccinated after hearing an endorsement from prominent Republicans, including former President Donald Trump.
But many of these attitudes have been hardened since the early days of the pandemic. As Vox’s German Lopez has explained, the partisan divide extends to all aspects of the pandemic, not just vaccines. Trump previously downplayed the severity of Covid-19 and undermined state efforts to control the disease. It may be too late to fix that: The divide in vaccination rates between Republicans and Democrats is poised to grow further.
At the same time, the delta variant and the renewed spread of Covid-19 are reversing positive trends across the whole country, with 46 states seeing increases in new cases. Predictably, transmission is highest in areas with low vaccination rates, with the unvaccinated still comprising almost all hospitalizations and deaths from Covid-19. That’s causing a snap back to mask mandates in some areas, even for people who are immunized.
The minority of Americans who aren’t getting vaccinated are affecting the whole country. As such, it behooves everyone to work toward making Covid-19 vaccines as cheap, easy, nonpartisan, and popular as possible.