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Excerpted From: GAO Reports, ¶ 68,472 Federal Efforts to Provide Vaccines to Racial and Ethnic Groups, Medicare & Medicaid Guide P 68472 (C.C.H.), (February 07, 2022) (7 Footnotes/Appendix/Reference) (Full Document)

 

GAORepots

Why GAO Did This Study

COVID-19 continues to have devastating effects on public health, serious economic repercussions, and has disproportionately affected some racial and ethnic groups. Ensuring all racial and ethnic groups have fair access to the COVID-19 vaccine is critical to reducing severe COVID-19 health outcomes and saving lives.

The CARES Act includes a provision for GAO to report on its ongoing oversight efforts related to the COVID-19 pandemic. This report describes, among other things, the actions CDC, HRSA, and FEMA have taken through their programs to provide COVID-19 vaccines to underserved and historically marginalized racial and ethnic groups, and the extent to which these programs vaccinated various racial and ethnic groups.

GAO analyzed CDC, HRSA, and FEMA vaccine administration data through September 2021; interviewed agency officials and reviewed agency documentation on COVID-19 vaccine programs and published literature on vaccine administration; interviewed health officials from four selected states and representatives from six selected stakeholder groups based on several criteria, such as states' racial and ethnic population distributions; and compared the agencies' vaccine administration data to 2020 U.S. Census Bureau population counts.

GAO provided a draft of this report to the Department of Health and Human Services (HHS), including CDC and HRSA, and FEMA. HHS and FEMA provided technical comments, which GAO incorporated as appropriate.

 

What GAO Found

In February 2021, the Centers for Disease Control and Prevention (CDC), the Health Resources and Services Administration (HRSA), and the Federal Emergency Management Agency (FEMA) each launched COVID-19 vaccine programs to supplement state and jurisdictional vaccination efforts. Through these three programs, the agencies took steps to provide COVID-19 vaccines to underserved and historically marginalized racial and ethnic groups, such as by using population data on race and ethnicity when selecting vaccination sites.

CDC, HRSA, and FEMA data—although limited in completeness—suggest that the agencies' COVID-19 vaccine programs vaccinated varying shares of racial and ethnic groups. GAO's analysis of data from CDC's retail pharmacy program, the largest of the programs, suggests that, among those with identified race and ethnicity, 43 percent of people vaccinated through the program were from racial and ethnic groups other than non-Hispanic White, as of September 4, 2021. (See figure.)

Percentage of People Vaccinated against COVID-19 through CDC's Retail Pharmacy Program by Race and Ethnicity, as of September 4, 2021

CDC exceeded its goal to administer at least 40 percent—the approximate percent of the U.S. population comprised of racial and ethnic groups other than non-Hispanic White—of COVID-19 vaccines through its retail pharmacy program to persons from these groups. However, comparisons between program vaccination data and U.S. population percentages suggest that some racial and ethnic groups, such as non-Hispanic Black persons, represented a smaller share of persons vaccinated through each of the three federal vaccine programs relative to their population size. For example, non-Hispanic Black persons make up roughly 12 percent of the U.S. population, but account for about 9 percent of persons vaccinated through CDC's retail pharmacy program with identified race and ethnicity, as of September 4, 2021. These findings should be interpreted with caution due to the rate of missing race and ethnicity program data, which may account for some, or even all, of the differences in comparisons.

[. . .]

Coronavirus Disease 2019 (COVID-19) continues to have devastating effects on public health and serious economic repercussions. Such effects have been uneven, disproportionately affecting certain racial and ethnic groups, highlighting health disparities—preventable differences in the burden of disease—in the United States. Data from the Centers for Disease Control and Prevention (CDC) suggest that some racial and ethnic groups have experienced worse health outcomes related to COVID-19. For example, between March 2020 and January 2022, available CDC data indicated that Hispanic or Latino persons and non-Hispanic Black persons were hospitalized due to COVID-19 at a rate 2.4 and 2.5 times more than non-Hispanic White persons, respectively, after adjusting for age.

Available data on persons vaccinated against COVID-19 also suggest some racial and ethnic disparities in vaccination rates. Nationwide, about 67 percent of the U.S population eligible for vaccination (those 5 years and older)—about 208 million individuals—had been fully vaccinated as of January 9, 2022, according to CDC. However, vaccination rates vary, including for certain racial and ethnic groups. For example, although 22.9 percent of data made available by CDC on fully vaccinated persons were missing race and ethnicity information, CDC data show that across the total U.S. population, 46 percent of non-Hispanic White persons were fully vaccinated against COVID-19, compared with 38 percent of non-Hispanic Black persons as of January 9, 2022.

Given the identified disparities and the importance of COVID-19 vaccines in preventing more severe outcomes such as hospitalizations and deaths, ensuring vaccine equity—when all people have fair access to COVID-19 vaccinations—is critical to saving lives and reducing severe COVID-19 health outcomes for all Americans. Additionally, ensuring vaccine equity continues to be critical as variants emerge, children become eligible for COVID-19 vaccines, and those already vaccinated may need booster shots to sustain sufficient immunity against the virus.

The January 2021 National Strategy for the COVID-19 Response and Pandemic Preparedness and related executive orders call for the federal government to help ensure equity in the response to COVID-19. To help ensure vaccine equity, in February 2021, the CDC, the Health Resources and Services Administration (HRSA), and the Federal Emergency Management Agency (FEMA) each established a program in part to provide COVID-19 vaccines to underserved and historically marginalized racial and ethnic groups, among other groups. These federal programs are in addition to the vaccines the federal government made available to the 50 states and other jurisdictions to further distribute to health care providers in their jurisdictions.

The CARES Act includes a provision for us to monitor and oversee the authorities and funding provided to address the COVID-19 pandemic and the effect of the pandemic on the health, economy, and public and private institutions of the United States. This report, which is part of our body of work related to the CARES Act, describes:

1. actions CDC, HRSA, and FEMA have taken through their COVID-19 vaccine programs to provide vaccines to underserved and historically marginalized racial and ethnic groups;

2. the extent to which CDC, HRSA, and FEMA's programs have vaccinated various racial and ethnic groups; and

3. monitoring by CDC, HRSA, and FEMA on the extent to which their programs have vaccinated underserved and historically marginalized racial and ethnic groups.

To conduct this work, we focused our review on three of the agencies' COVID-19 vaccine programs:

• CDC's Federal Retail Pharmacy Program for COVID-19 Vaccination (retail pharmacy program),

• HRSA's Health Center COVID-19 Vaccine Program (health center vaccine program), and

• FEMA's Community Vaccination Center Pilot Site and Mobile Vaccination Program (vaccination center pilot program).

To describe the actions CDC, HRSA, and FEMA have taken to provide COVID-19 vaccines to underserved and historically marginalized racial and ethnic groups as well as efforts by the agencies to monitor program vaccination rates by race and ethnicity, we reviewed CDC, HRSA, and FEMA guidance and documents, such as monitoring reports and surveys used to collect information on the administration of COVID-19 vaccine doses. We interviewed or received written responses from CDC, HRSA, and FEMA officials about their COVID-19 vaccine programs' efforts to vaccinate various racial and ethnic groups, how they monitored race and ethnicity data, and how, if at all, they used these data to inform program efforts. We also interviewed health officials from four selected states and representatives from six selected stakeholder groups. We selected these states and groups based on several criteria, such as states' racial and ethnic population distributions and groups involved in COVID-19 vaccine administration or representation of a racial or ethnic group. Lastly, we reviewed selected literature published between 2007 and 2021 to summarize examples of factors that have been identified as potentially affecting COVID-19 vaccine administration for various racial and ethnic groups and actions that could advance equity in vaccine administration.

To determine the extent to which CDC, HRSA, and FEMA's COVID-19 vaccine programs have vaccinated various racial and ethnic groups, we obtained and analyzed aggregated data on vaccines administered through each program by race and ethnicity beginning in February 2021. For context, we compared each agency's vaccine administration data to population data from the U.S. Census Bureau. Specifically, for CDC and HRSA, we analyzed data on the number of persons fully vaccinated through the agencies' vaccine administration programs, by race and ethnicity, along with data on the share of the general U.S. population the racial and ethnic groups represent. For FEMA, we analyzed data on vaccine doses administered through the agency's vaccine administration program by race and ethnicity, along with data on the size of these racial and ethnic groups across the 39 counties with FEMA pilot sites. We compared FEMA vaccination data to population data only from the counties with FEMA pilot sites because, relative to the CDC and HRSA data, there were fewer FEMA pilot sites, and these sites were located in areas with population demographics that were less similar to the aggregate U.S. population. We analyzed FEMA vaccination data cumulatively by race and ethnicity from the beginning of program administration through June 20, 2021, when FEMA's program ended. Additionally, we analyzed the FEMA vaccination data cumulatively by race and ethnicity and by FEMA site type: hubs (large stationary vaccination sites) and spokes (smaller sites that also include mobile vaccination units). The population data we used reflect the population of all ages. As of the date of our analysis of program data, only persons aged 12 and older were eligible for vaccination.

To assess the reliability of the CDC, HRSA and FEMA data sources, we interviewed agency officials and reviewed related agency documentation. We also checked the data for obvious errors, and took steps to ensure consistency in race and ethnicity categories across data sources. Race and ethnicity information were missing for 22.9 percent of CDC's national data on people vaccinated, 26.1 percent of CDC's retail pharmacy vaccine program data, 13.6 percent of HRSA's health center vaccine program data, and 18.6 percent of FEMA's vaccination center pilot program data. According to CDC, some groups may have a higher likelihood of having missing race and ethnicity data, and the percentage of unknown race and ethnicity data may account for some, or even all, of the differences between shares of vaccinations and of the population by race and ethnicity. Therefore, results of our analyses should be interpreted with caution. To assess the reliability of Census Bureau population data, we reviewed documentation related to the relevant data sources and reviewed the data elements for obvious errors, inconsistencies, or missing data. On the basis of these steps, we determined that the data with known race and ethnicity and population data were sufficiently reliable for the purposes of our reporting objectives. See appendix I for more information on our scope and methodology.

We conducted this performance audit from March 2021 to February 2022 in accordance with generally accepted government auditing standards. Those standards require that we plan and perform the audit to obtain sufficient, appropriate evidence to provide a reasonable basis for our findings and conclusions based on our audit objectives. We believe that the evidence obtained provides a reasonable basis for our findings and conclusions based on our audit objectives


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