The 4 Main Fault Lines That Divide the Vaccinated and the Unvaccinated

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.

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So who isn’t getting a vaccine, and why? And can they be persuaded to get their shots?

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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.

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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.”

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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.

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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.

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