Rollout of Covid vaccines is bumpy, but not unexpected, experts say

The latest rollout of Covid-19 vaccines has been messy, with people facing more challenges getting one of the updated shots than they may have experienced since the frantic start of the very first vaccination campaign in late 2020 and the first half of 2021.

The issues have come as a surprise to people whose appointments have been canceled for lack of vaccine doses, who couldn’t get an appointment at their nearest pharmacy, or who learned with dismay that the place where they got previous Covid shots is considered out-of-network by an insurance company refusing to pay for what is now a pretty expensive jab.

But to people who are involved with organizing vaccine delivery efforts, or who study them, what’s happened in the two weeks since the Food and Drug Administration and the Centers for Disease Control and Prevention greenlit the updated vaccines is not shocking. The transition from a single-payer program to a system where a variety of private and public insurers are covering the cost of vaccine doses was bound to make for a bumpy ride, they say.

“I think we got spoiled in terms of vaccine access,” said John Brownstein, chief innovation officer at Boston Children’s Hospital, who led development of the Vaccines.gov website, where people can find locations that are administering Covid and influenza vaccines. “When the government is not footing the bill, it’s harder.”

In fact, this is what vaccine rollouts typically looked like, in the pre-Covid era, Michelle Fiscus, chief medical officer for the Association of Immunization Managers, told STAT.

“I think through the initial pandemic rollout, everyone kind of got into this feeling that vaccines become available instantaneously. When you’ve got generals and the military and all of the resources of the U.S. government behind things, then that can happen. You pre-order vaccine, then [CDC’s expert vaccine panel] approves it and boom! The next day there’s a clinic open somewhere. And the reality of it is that’s not how vaccines are really rolled out in real life,” Fiscus said.

“General Perna is no longer in charge.”

(Gen. Gustave Perna, former commanding general of the U.S. Army Materiel Command, was chief operating officer of Operation Warp Speed, the program launched by the Trump administration to fast-track development, production, and distribution of Covid vaccine in the United States.)

Since the first Covid vaccine was authorized by the FDA in December 2020, multiple rounds of vaccinations have been delivered through the federal government. Older adults and people who have immunocompromising medical conditions may have had six or seven shots already, paid for by the federal government.

But with the end of the Covid public health emergency in the spring, the Covid shot market has transitioned to the private market.

Though prices have jumped dramatically as a consequence, under provisions of the Affordable Care Act private insurers have to pay the full cost of vaccine doses. Adults who don’t have private insurance are also eligible for free Covid shots, through Medicare, Medicaid (as of Oct. 1), or through a new program for un- or under-insured adults that will run through the end of 2024, the Bridge Access Program, operated by the CDC. Children who live in households without insurance coverage can get Covid shots through CDC’s Vaccines for Children program.

But though everyone is entitled to a free Covid shot, the shots aren’t free for every person at every location. People looking for a vaccine through the Bridge program, for example, may have to search to find a provider participating in the program. People with private insurance may find they need to get their shot through their primary care physician, or through one pharmacy chain, but not another.

“Any health plan that isn’t grandfathered from the ACA has to, under federal law, provide the vaccine at no cost. But that doesn’t mean that they have to allow any provider anywhere to provide the vaccine at no cost,” Fiscus said, adding that people may have to do some homework in order to avail themselves of a free shot. “It just adds some layers of complexity.”

Meanwhile, the big pharmacy chains may have adequate supplies of vaccine doses, but doctors’ offices or independent pharmacies may be on lower rungs of the delivery ladder because they are buying smaller numbers of doses. They may be forced to wait longer to get vaccines as a consequence.

“We don’t have any indication that there’s a shortage at the level of the manufacturers,” Fiscus said. “I think what you’re seeing is just sort of normal distribution — that it doesn’t all happen overnight. … Those drugstores and medical offices are going to see it coming in, it’s just not going to be instantaneous.”

Brownstein said strong demand for Covid shots may have caught planners and purchasers by surprise; until now, each vaccination round has seen lower uptake than the round before it. But the number of people seeking vaccination appointments through Vaccines.gov since the release of the new vaccines is pretty much on par with what was seen last fall, he said — perhaps because there’s a lot of Covid transmission happening right now.

“I think that’s probably surprising to a lot of people,” he said. “A bit less, but not so far off from last year’s rush.”

Likewise, just about as many locations — nearly 19,000 — are offering Covid vaccines this fall as last fall, Brownstein said.

Some insurers have been slow to start paying for Covid shots, creating more challenges. That has led to a situation where people are occasionally told — despite the fact that they have insurance and the insurance must cover the cost of the vaccine — that for the moment their insurer is not yet covering the cost of a shot. If they want it now, they must pay.

There’s a process in the insurance industry known as “turning on the codes” — programing a company’s billing system to recognize and accept claims for Covid shots — that each insurer must go through, Fiscus explained. Some companies are quicker to do it than others.

“It’s not surprising to us that you hear in the first couple of weeks of a rollout — and this one’s no different — that such-and-such insurance is denying the coverage of this vaccine,” Fiscus said.

She advised waiting. “Really, what you need to do is not pay out of pocket, but just wait a week or two, and those insurance companies should get all of their ducks in a row and get things lined up so that they’ll pay for it.”

The Department of Health and Human Services knows this has been a problem, even though it has been working with insurers and pharmacists for over a year to try to ensure a smooth transition to private market delivery of Covid vaccine. On hearing of problems people have been encountering, the Centers for Medicare and Medicare Services recently began to reach out to insurers to remind them that they are obliged to cover the cost of Covid shots for their enrollees.

“Our message is simple: If you are being turned away for no coverage, please call your insurance for details about in-network coverage to receive the updated Covid-19 vaccine,” an HHS spokesperson said via email.

Saad Omer, dean of the Peter O’Donnell Jr. School of Public Health at the University of Texas Southwestern, agrees with Fiscus and Brownstein that the glitches in this rollout aren’t a surprise. He’s hoping people understand that while this is the way vaccine rollouts used to be, they don’t necessarily have to be this way going forward.

“Absolutely true that what is happening is ‘normal’ for a new vaccine. But I don’t think normal is good enough. We can do better,” Saad said in an interview.

For instance, he thinks there should be a centralized source of information on what the different insurers consider in-network and out-of-network — a single website any interested individual can search to find out where they, with their insurance policy, can get a jab for free.

Omer understands the frustration people are experiencing with the current situation. They’ve seen it doesn’t have to be this way.

“It’s like someone gets upgraded to business class and their normal [ticket] is economy. As a country we’ve seen that we can travel in comfort,” Omer said. “I think it’s reasonable for the American public to say: ‘We want to do this properly.’”