In 1999, the U.S. Centers for Disease Control and Prevention (CDC) named childhood vaccination as one of the top 10 public health achievements of the 20th century, highlighting dramatic declines in deaths across a range of vaccine-preventable diseases. That progress has continued into the 21st century, with more than 90 percent of children fully vaccinated against conditions such as polio, measles, mumps, rubella, Hepatitis B and chickenpox.
Adult vaccination, however, is a far different story. Each year in the United States, between 50,000-90,000 adults die from vaccine-preventable conditions. Adult vaccination rates for a range of conditions are suboptimal, and the consequences in terms of lives lost and healthcare costs are severe.
We can change this trajectory by taking a lesson from the pandemic: Recommended vaccines should be available free for everyone, particularly for those who would not otherwise be able to pay. CDC's Vaccines for Children program (VFC) is built on this premise, and the results have been remarkable. CDC has requested funding from Congress to stand up a Vaccines for Adults program modeled after VFC. Congress should agree to this request, as such a program would be a tremendous public health achievement.
VFC was launched in 1994 in the aftermath of another public health crisis: an epidemic of measles that resulted in more than 55,000 cases, 11,000 hospitalizations, and at least 120 deaths between 1989-1991. That epidemic was driven primarily by a lack of vaccination among children of color in low-income communities — many of whom lacked health insurance — so VFC was designed intentionally to eliminate cost barriers to vaccination.
Under the program, CDC purchases recommended children's vaccines and distributes them to state and local health agencies. The vaccines are then sent to participating health providers and made available at no cost to children who are either uninsured, underinsured (insured, but the cost of vaccines is not covered), Medicaid-eligible, or American Indian/Alaska Native.
As a pediatrician and the former commissioner of the Chicago public health department, I have experienced firsthand how VFC has become one of our nation's most effective public health programs. Each year, approximately 75 million vaccines are distributed to healthcare providers participating in VFC. This has revolutionized children's health: CDC estimates that — beginning with children born in 1994 when the program was created, through 2021 — childhood vaccination will prevent 472 million illnesses and more than 1 million deaths while saving $2.2 trillion in total societal costs. Research shows that VFC has not just played a leading role in increasing childhood vaccination rates overall, but has also helped to reduce or even in some cases eliminate persistent racial and ethnic disparities.
In recent years, several states have taken the initiative by standing up their own Vaccines for Adults Programs modeled after VFC — including Florida, California, New York, Washington, and Virginia — but a national program is sorely needed. At least three-quarters of adults do not receive at least one recommended vaccine; research shows that immunization rates tend to be lower for vaccines for which adults have to pay out-of-pocket.
Per CDC, only 30 percent of adults ages 19-64 at significant risk of severe pneumococcal disease (e.g., bloodstream infections and meningitis) have received a pneumococcal vaccine, while only 40 percent of adults 60 and over have received a Zoster (shingles) vaccine. In a typical year, about half of adults do not get vaccinated against the flu. Racial and ethnic disparities within several adult vaccination categories persist. And the resulting healthcare costs are staggering: Four vaccine-preventable conditions alone result in at least $26.5 billion in healthcare costs annually.
We have made some recent progress toward removing cost as a barrier to vaccination. Major federal investments guaranteed free COVID-19 vaccines for all eligible people in the United States; nearly 80 percent of adults have completed their primary series, and studies estimate that millions of lives have been saved as a result. Starting in 2023, thanks to the Inflation Reduction Act, recommended vaccines will be free for adults covered under both Medicare Part D and Medicaid.
But there are threats to this progress. Congress' ongoing refusal to provide additional COVID-19 vaccine funding means that when those vaccines transition to the commercial marketplace — likely to happen early in 2023 — they will no longer be free for everybody.
Indeed, Pfizer has already announced that it expects to charge up to $130 for COVID-19 vaccine doses next year. CDC's vaccine advisory committee's recent recommendation to add COVID-19 vaccines to VFC will help soften the cost blow for America's 3.9 million uninsured children, but without a corresponding program for adults, the nearly 24 million U.S. adults without health insurance may be priced out of that market. That will make it even harder to increase uptake of the updated, bivalent COVID-19 booster, which has lagged behind previous COVID-19 vaccine campaigns.
Cost is not the only barrier to vaccination; there are a number of additional steps we need to take to improve access and build trust. These steps include guaranteeing paid family and medical leave and making childcare more affordable, so that people can take time off from work to make vaccine appointments without risking a paycheck or even a job; maintaining provisions of the COVID-19 Public Health Emergency that significantly expand pharmacists' ability to administer vaccines; continuing to bring vaccines directly to communities that lack healthcare providers and staying vigilant in combating the recent explosion of mis- and disinformation surrounding vaccines.
Eliminating the cost barrier for adults, as we have successfully done for children, would be a game-changer for public health. In a country as wealthy as ours, a person's income or health insurance status should never determine whether a vaccine is administered or withheld. A Vaccines for Adults Program would put us well on our way to making adult vaccination a top public health achievement of the 21st century.
Julie Morita, MD is executive vice president of the Robert Wood Johnson Foundation and a member of CDC's Advisory Committee to the Director. Twitter: @DrJulieMorita.
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