As COVID-19 vaccine distribution continues and expands to larger segments of the population, it is important to consider how to prevent disparities and ensure equitable access to the vaccine. Ensuring all individuals have access to the vaccine and achieving a high vaccination rate across communities will be necessary to mitigate the disproportionate impacts of the pandemic for underserved populations, prevent widening disparities going forward, and achieve broad population immunity. The nearly 22 million noncitizen immigrants living in the U.S. today face increased risks and challenges associated with the pandemic. Many noncitizen immigrants work in essential jobs that are likely to be included in initial priority groups for COVID-19 vaccination, but they face a variety of potential barriers to obtaining the vaccine. As such, targeted efforts to reach noncitizen immigrants as part of vaccination efforts will be central for preventing disparities in vaccination. This brief provides an overview of key issues to consider for reaching noncitizen immigrants as part of COVID-19 vaccination efforts.
Vaccination Plans and Immigrants
Immigrants make up a significant share of workers in certain categories that are likely to be included in priority groups for vaccination. The Centers for Disease Control and Prevention’s (CDC) Advisory Committee on Immunization Practices (ACIP) is making federal recommendations for vaccine allocation. ACIP has issued initial recommendations to prioritize certain groups to receive access to the vaccine. The first group recommended for Phase 1a of vaccination included health care personnel and residents and staff of long-term care facilities. It subsequently recommended that Phase 1b should include people aged 75 or older and (non-health care) frontline essential workers, and Phase 1c include people aged 65-74 years old, people aged 16-64 years with high-risk medical conditions, and essential workers not included in Phase 1b. States have the discretion to determine their own prioritization and distribution plans and, while some states are following the ACIP recommendations, others are making alternative prioritization decisions. Overall, there are nearly 13 million noncitizen immigrant workers who make up 8% of the workforce. They account for a significant share of workers in categories that are likely to be classified as essential and prioritized for vaccination. For example, they make up 5% of health care workers who have direct patient contact and 8% of those workers in long-term care settings, who are included in the initial Phase 1a priority group for vaccination. They also account for over one in five (22%) of all food production workers, including over a third of crop production workers.
Potential Barriers to Vaccination among Immigrants
Noncitizen immigrants face a range of potential access-related barriers to obtaining a COVID-19 vaccination. Noncitizen immigrants are more likely than citizens to be uninsured (Figure 1) and, as a result, are less likely to have a usual source of care as well as more likely to delay or go without it and to have concerns about its costs. The federal government has provided resources to make the COVID-19 vaccine available at no cost for people who are uninsured regardless of immigration status. However, people who are uninsured may be more likely to have concerns about the potential costs associated with obtaining the vaccine. Noncitizen immigrants may also face challenges accessing the vaccine due to limited transportation options, lack of flexibility in work and childcare demands, and/or language and literacy challenges.
Although anticipated side effects of the COVID-19 vaccine are generally mild, noncitizen immigrants may have heightened concerns about potential side effects. Across the broad population, worries about side effects and safety are a major reason people express hesitancy about getting a vaccine. Although data are not currently available to gauge concerns about vaccine-related side effects among immigrant populations, they may be particularly concerned due to a variety of reasons. Noncitizen immigrants are more likely to be employed in low-wage jobs that are less likely to offer paid sick leave, so they may have heightened concerns that side effects could interfere with their ability to work and result in lost wages. They may also have elevated concerns about health care costs associated with any potential side effects since they are more likely to be uninsured.
Noncitizen immigrants may not know if they are eligible to receive the vaccine and/or worry that obtaining it may have negative immigration-related consequences. Immigrant families may not know if they are eligible for the vaccine, especially since they face restrictions on eligibility for health coverage programs and federal COVID-19 relief. They may also fear that obtaining the vaccine could negatively affect their or a family member’s immigration status. Immigrant families have experienced growing levels of fear and uncertainty over the past few years, during which the federal government has implemented a range of policies to curb immigration, enhance immigration enforcement, and limit the use of public assistance among immigrant families. Research shows that, amid this policy climate, immigrant families have become increasingly reluctant to access programs and services for themselves and/or their children, including health coverage and health care. These fears may also contribute to a reluctance to access the vaccine.
Data collection and sharing related to COVID-19 vaccinations may further raise fears among immigrants. Providers and vaccination sites will collect certain information from individuals receiving the vaccine to monitor uptake, ensure dose matching and appropriate timing for the second dose, and assess vaccine effectiveness and safety. All states have existing state immunization registries or databases to track this data. In addition, the CDC is requiring states to submit COVID-19 vaccination data to support federal monitoring, including certain personally identifiable data, such as name, address, state of birth, and a unique recipient ID. As outlined in the data use and sharing agreement, the Department of Health and Human Services and CDC agree to maintain the confidentiality of identifiable or potentially identifiable data and will only use the data in “furtherance of the public health response to COVID-19.” An appendix to the data use agreement specifies that data may not be used for any civil or criminal prosecution or enforcement, including, but not limited to, immigration enforcement. The data use and sharing agreement further notes that jurisdictions that are unable (due to legal or regulatory restrictions) to submit identifiable data to CDC will be provided with the alternative option for submitting data. Media reports suggest some states are still working through details of their data use and sharing agreements. Beyond these specifications related to data sharing, U.S. Citizen and Immigration Services has clarified that it will not consider testing, treatment, or preventive care, including vaccines, related to COVID-19 as part of a public charge inadmissibility determination. Despite these limits on how the data may be used, the collection of personal data and sharing of it with the federal government will likely make some immigrant families more reluctant to access the vaccine.
Addressing Barriers to Vaccination for Immigrants
Minimizing access barriers, providing targeted outreach and education, and alleviating fears about potential negative immigration-related impacts will be important for preventing gaps in vaccination among immigrant families:
- Ensuring vaccination sites are available in locations that can be easily accessed through multiple modes (e.g., drive-up or walk-up) during a variety of hours (including evening and weekends) that accommodate different work schedules may help reduce access-related barriers. In addition, including providers that serve large numbers of immigrant families as vaccine administration sites may facilitate access and reduce potential language access barriers.
- Targeted outreach and education efforts can help individuals understand that they are eligible to obtain the vaccine and that it is available at no cost. Prior experience with public health messaging and outreach and enrollment efforts under the Affordable Care Act (ACA) point to the importance of providing outreach and information through trusted messengers within the community and making culturally appropriate materials available in multiple languages. Even with these actions, some individuals may remain fearful or reluctant to access the vaccine, particularly if they are concerned that side effects could result in lost work and/or health care costs.
- Minimizing the collection of personally identifiable information, clearly explaining how it will be used, and clarifying that it cannot be used for immigration-related purposes can help reduce fears about accessing the vaccine. While the federal government has indicated that COVID-19 vaccination data cannot be used for immigration enforcement and receipt of the vaccine will not be considered as part of public charge determinations, communicating this information directly to families through trusted messengers will be key for alleviating immigration-related fears.
As of early January 2021, some states have specified plans or actions to specifically address potential barriers to vaccination among immigrant families. A couple of states have indicated prioritizing immigrants as part of vaccination efforts. For example, the state health director in Arizona referred to the undocumented population as a high priority for vaccination, Virginia includes people living in migrant labor camps in Phase 1b of its vaccination plan, and New Jersey includes migrant workers as a high-risk population in Phase 1c. A few states have taken steps to clarify that immigrants are eligible for the vaccine and to reduce fears about potential negative immigration-related impacts. For example, in Connecticut, Governor Lamont noted that receipt of a COVID-19 vaccine is confidential and the information would not be shared with other agencies including Immigration and Customs Enforcement. In Frequently Asked Questions documents, Illinois notes that all individuals, including undocumented immigrants, are eligible for the vaccine and Utah clarifies that personal information is confidential and immigration status will not affect ability to get the vaccine. In early December 2020, New York’s Governor Cuomo sent a letter to the Secretary of Health and Humans Services highlighting concerns the requirements for states to share certain data on vaccinations with the federal government could dissuade undocumented immigrants from seeking vaccinations. Several states, including Arizona, Oregon, and Washington, indicated plans to develop targeted messaging and outreach to immigrant communities. Oregon and Washington also explicitly mentioned including immigrant and refugee communities in planning and advisory work to inform vaccine dissemination. In contrast to these efforts, state officials in Nebraska made remarks suggesting that undocumented immigrants may be excluded or prioritized behind citizens for vaccination.
In sum, the COVID-19 pandemic presents increased risks and challenges for noncitizen immigrants. Many noncitizen immigrants work in essential jobs that are likely to be included in initial priority groups for COVID-19 vaccination, but they face a variety of potential barriers to obtaining the vaccine, including access-related barriers, confusion about eligibility and potential costs, concerns about health and economic impacts of side effects, and immigration-related fears. Given these barriers, efforts to minimize access barriers and targeted outreach and information will be important for facilitating access to vaccination for immigrant families. To date, few states have specified plans or actions to address potential barriers facing immigrant families specifically. Looking ahead, assessing immigrant access to the vaccine and willingness to obtain it will be important for mitigating the impacts of COVID-19 on immigrant communities, preventing widening health disparities for immigrants in the future, and avoiding gaps in vaccination that could leave communities at risk for the continued spread of COVID-19 infections.