All U.S. Adults Can Get the COVID Vaccine. Now What?

Photo: Will Newton/The Washington Post via Getty Images

Adults over the age of 16 in all 50 states, Washington, D.C., and Puerto Rico are now eligible to get vaccinated against the coronavirus. That doesn’t mean all will, or will be able to — at least right away — but full eligibility marks a significant new phase in the country’s mass-vaccination effort (as well as what is hopefully the beginning of the end of any confusion among Americans regarding whether or not they can sign up for a shot). The important milestone also arrives as the U.S. vaccine rollout passes a literal halfway point: According to the CDC, 50.4 percent of Americans over the age of 18 have now received at least one shot of a COVID vaccine, or 40 percent of the total U.S. population. One in four adults have now been fully vaccinated, including 65 percent of people 65 or older. Below is a look at some of the shifts, challenges, and remaining questions as the U.S. vaccination effort enters its next — and hopefully final — stage.

The need to increase demand

At the end of last week, COVID-19 cases were rising in at least 21 states, and the country’s seven-day average of new daily cases had ticked up for the fifth consecutive week. Overall, however, the national case numbers have mostly remained flat for weeks. One top COVID expert theorized Sunday that vaccinations have thus far blunted what would have likely been another nationwide wave of cases fueled by the spread of the most contagious B.1.1.7 coronavirus variant first detected in the United Kingdom:

Mass vaccination remains the only way to end the pandemic in the U.S. — and while some states may reach full vaccination of all willing adults by June, others might not be able to reach that point until the end of the year. In addition, many states seem to have reached or surpassed a vaccine-demand tipping point, where the people who are doggedly seeking COVID vaccines are now outnumbered by those who aren’t. Many Americans remain hesitant or unwilling to get a shot, vaccination gaps between racial and ethnic groups persist, and the pace of vaccination in urban and suburban areas is far ahead of most rural areas.

On the other hand, according the Kaiser Family Foundation’s research, confidence in, and willingness to receive, the COVID vaccines has continued to rise in the U.S., particularly as more and more Americans see their friends and family get the shot. However, the KFF Vaccine Monitor report noted last week, “with a small but persistent group opposed to getting the vaccine and many others still on the fence, the U.S. may soon hit a point where vaccine supply exceeds demand, a situation that is already the case in certain communities.” It also remains unclear what impact federal regulators’ sudden pause of the Johnson & Johnson COVID vaccine over an extremely rare potential side effect will have on vaccine confidence.

KFF also pointed out, as others have, that the debate around vaccine hesitancy is often needlessly oversimplified:

While some media narratives have focused on which groups are most “vaccine hesitant,” our research finds that no group is monolithic in their vaccine attitudes, and in every demographic segment there are large shares of people who are ready to get the vaccine, others who are in “wait and see” mode, and some who are more resistant. Even though certain demographics (for example, Republicans) have a higher share than other groups saying they don’t intend to get vaccinated and others (for example, Black adults) have a higher share saying they want to “wait and see,” we’ve found that majorities across all demographic groups are at least somewhat open to getting the vaccine.

And vaccine confidence has risen among all groups over the past several months. Educational attainment is another factor, and here is what KFF has found regarding the persistent political divide regarding the intention to get vaccinated:

Vaccination intentions have also divided along party lines since December, reflecting the broader partisan dialogue about the pandemic over the past year. About eight in ten Democrats (79%) are eager to get the vaccine or say they have done so already, compared to nearly six in ten independents (57%) and just under half of Republicans (46%). About three in ten Republicans (29%) say they will “definitely not” get vaccinated, a share that has not changed substantially over time.

In addition, 28% of White Evangelical Christians say they will definitely not get the vaccine, reflecting the fact that two-thirds (66%) of this group either identifies as Republican or leans towards the Republican party. One in five rural residents also say they will definitely not get vaccinated, about twice the share as in urban areas, a gap largely explained by the concentration of Republicans and White Evangelical Christians who live there.

Americans who are still waiting and seeing are primarily concerned about vaccine side effects and whether or not they will have to miss work because of them. The KFF found that the wait-and-see crowd’s other concerns “reflect a lack of access to accurate information; for example, many are concerned that they might get COVID-19 from the vaccine (which is not possible) or that they will have to pay out-of-pocket costs to get vaccinated (when in fact, vaccination is free).” Logistical concerns also persist, like “issues with vaccine access, including needing to take time off work to get vaccinated, issues with transportation, or concern about not being able to get the vaccine from a trusted place.”

Convincing these Americans to get off the vaccine fence will require “a combination of information, outreach, and policies to both bolster confidence in COVID-19 vaccines and make vaccination accessible across communities,” the KFF suggests.

Moving beyond vaccination by appointment

With all adults now eligible for vaccination, if the vaccine supply steadily increases like the Biden administration says it will, Americans actively seeking vaccines should be able to schedule their appointments on-demand. Opening up access would also require eliminating the need for scheduling appointments altogether, and that’s already been happening.

More and more vaccine administration sites have begun allowing walk-in appointments and efforts to effectively deliver the vaccine are also ramping up in many states. Mobile vaccine clinics are already being deployed across the country to bring doses to harder to reach populations. Those efforts will likely become more and more prominent in the coming weeks and months as national, state, and local public health authorities, often in partnership with community groups and organizations, continue to work to lower the barriers to vaccination. Many of the existing mobile efforts were relying on the one-dose Johnson & Johnson vaccine, however, and have been disrupted by the ongoing pause.

Other creative solutions to get-out-the-dose

Louisiana, which like many other states, has found itself with more shots than arms to put them in — and where surveys suggest at least 40 percent of residents remain hesitant about getting vaccinated —  is already trying a variety of new approaches to reach the unvaccinated, the Associated Press noted last week:

Brass bands playing at a 24-hour drive-thru coronavirus vaccine event. Doses delivered to commercial fishermen minutes from the docks. Pop-up immunization clinics at a Buddhist temple, homeless shelters, truck stops and casinos, with shots available at night or on weekends. And now, door-to-door outreach getting underway in neighborhoods where few people have gotten vaccinated. … Civic organizations and faith-based groups working with the state have started using get-out-the-vote tactics, knocking on doors and making phone calls, to pitch the vaccine.

And it’s not just happening in the home of the Big Easy:

Ohio’s health agency asked vaccine providers to develop sites near bus stops and to consider offering mobile immunization services. In Connecticut, the health department launched an effort to call residents directly to schedule appointments. Mississippi is working with local organizations to bring vaccinations directly to homebound elderly people. Alabama’s health agency surveyed vaccine reluctance to determine how it should craft messaging to appeal to the hesitant.

Another novel approach: Alaska plans to pilot a vaccine tourism program which would offer a first dose of a COVID vaccine to out-of-state visitors in the airport after they arrive.

Proof of vaccination, and why it might matter

With so many Americans getting vaccinated, another emerging issue is how they can prove that and what official benefits they earn by doing so. The list of places and scenarios where proof of COVID vaccination is required continues to grow. Many colleges, for instance, have already announced that they will require proof of COVID vaccination for students this fall (as most already do for other vaccinations). Workplaces might try to, as well, though it is currently illegal for employers to require vaccination if, as is currently the case, the vaccines have only been granted emergency use authorization by the FDA.

At present, a CDC proof-of-vaccination card is the only documentation Americans receive when they get vaccinated. The somewhat fragile paper card, which does not seem to be easy to replace if lost or damaged, is not a legal document, but it’s still valuable enough that a market for counterfeit cards has reportedly emerged.

Vaccine passports issued by states or private companies provide another option, though as our Recode colleague Rebecca Heilweil recently explained, it’s a complicated and contentious one:

The term “vaccine passport” generally refers to a smartphone app that can quickly confirm that someone has received a Covid-19 vaccine, so the phone’s owner can do things like enter a venue or board a plane. The debate over vaccine passports, however, often confuses these apps with the broader issue of how vaccination records are handled. Some Republicans have likened the concept to invasive government surveillance and even banned vaccine passports in some states, while vaccine passport proponents have argued proof of inoculation could help businesses recover and push people’s lives closer to normal.

White House officials have said there will be no vaccination passport offered or mandated by the federal government. Instead, different private and state-run initiatives have popped up offering hundreds of vaccine-related apps and services people can choose to use. …

Whether these so-called vaccine passports will become a large part of reopening the American economy remains to be seen.

Third doses are on the way, but it’s not clear how much we’ll need them yet

Both Pfizer and Moderna have said will make a third-dose booster shot for their COVID vaccines available this fall. “There will be likely a need for a third dose, somewhere between six and 12 months. And then from there, there will be an annual revaccination. But all of that needs to be confirmed,” Pfizer CEO Albert Bourla said earlier this month. Last week, Moderna CEO Stephane Bancel said that the company hoped to combine the flu vaccine it has been developing with a COVID booster so that in future years, people will be able to receive a two-in-one shot. Both companies have reported that their current vaccines appear to provide protection against the coronavirus for at least six months.

David Kessler, the chief science officer on the Biden administration’s COVID response team, told members of Congress last week that Americans should expect to receive booster shots, and that the administration is supporting drugmakers’s efforts to develop them, suggesting the additional doses might be needed to guard against coronavirus variants, which appear to make the vaccines “work harder” — though the durability of the vaccines’ antibody response seems strong thus far. (The administration is also investing $1.7 billion of the COVID relief package to expand efforts to track variants.)

So the bottom line: the pharmaceutical companies are definitely going to offer them, but it remains unclear whether COVID booster shots will actually be necessary — let alone necessary to mandate — because it remains unclear exactly how long the protection provided by the current U.S.-authorized COVID vaccines will last, and how much variants will really impact that in the near or distant future. Right now, neither the variants nor booster shots are something that fully vaccinated people should be worried about. Kessler told Congress the issue remains something the government is thinking about “for planning purposes only.”

All U.S. Adults Can Get the COVID Vaccine. Now What?