A cooperative project placing UC-Davis and its adjoining city inside a single, coordinated health bubble ­has delivered superior results.

This article was published on Wednesday, March 9, 2022 in Kaiser Health News.

By Mark Kreidler

Once a week, Lori Janich drives down the street from her office and partakes in an ongoing success story. Phone in hand to confirm her appointment, she strolls into the massive Activities and Recreation Center on the University of California-Davis campus, reaches a COVID-19 testing station, swirls water in her mouth, spits into a tube, and leaves. Within a day, she receives her test result.

Janich doesn't live in Davis, but because her job as a licensed dental hygienist brings her there, everything about the COVID testing process is free for her. The same goes for all UC-Davis students, faculty members, and staffers; Davis city residents; local workers; and visitors — almost anyone whose life brings them into town. Davis has a population of about 70,000, with an additional 15,000 people living on campus, yet through a joint city-university effort, it has administered more than 740,000 tests.

"It's always worked out for me," Janich said. "I strongly recommend it to anyone qualified to use it."

More than a year and a half in, this experiment — a cooperative project placing a university and its adjoining city inside a single, coordinated health bubble ­— has delivered superior results. Both town and gown have consistently experienced COVID infection and test positivity rates markedly lower than those recorded in the surrounding region and statewide, according to reviews of state and local data.

The program, Healthy Davis Together, includes free saliva-based testing, vaccination, masks, and isolation or quarantine housing if needed. As part of the effort, UC researchers are regularly testing city wastewater for signs of SARS-CoV-2, the virus that causes COVID, and workers from the program routinely screen children in the local school district. A 200-plus army of UC-Davis undergraduate "health ambassadors" raise awareness in the community, with help from a public relations firm. Even during the omicron surge, the program ramped up in time to prevent runaway infection rates.

So why haven't lots of other campus-town combinations tried it?

"Initially, I thought, 'Of course, other people are going to do this,' but it turns out — at least to our knowledge — that there's not another community in the country that did," said Brad Pollock, chair of Public Health Sciences at UC-Davis and the program's leader. Numerous campuses contacted by KHN, in California and outside the state, had no comment about the Davis program.

"Is this model exportable, or is there something so unique about Davis? I think the answer is 'yes' and 'yes,'" Pollock said.

From the project's inception, UC-Davis researchers and administrators have aimed to learn what happens when a university stops trying to seal itself off from the community in which it's embedded and instead extends its health goals to that entire community.

"There is strong data that while universities are somewhat different epidemiologically than their communities, they are intertwined," said Dr. Sarah Van Orman, who directs student health at the University of Southern California and is past president of the American College Health Association. "There are many other college towns where the university is central to community life and this type of closed bubble makes sense."

UC-Davis researchers say the model has worked. Davis' cumulative COVID infection rate is lower than all but a handful of California's 58 counties and is roughly half the statewide average. (Researchers are still compiling figures for hospitalizations.) In January 2021, when California was experiencing a 17% test positivity rate for COVID, Davis' weekly average came in just above 1%, according to data provided by Healthy Davis Together. And this past January, as omicron pushed state positivity rates above 20%, Davis' weekly average never got above 5%.

"When this all began, we were told that Davis would be one of the unhealthiest cities to be in, because our students come from all over the country and all over the world," Pollock said. "Instead, we're one of the healthiest."

Despite the program's success, KHN was hard-pressed to find any similar community — a small U.S. city chiefly identified by its association with a college or university — that has followed suit.

In some cases, the roadblocks may be administrative; in others, political. Certainly, the cost of such a wide-scale program can be prohibitive. UC-Davis officials estimate that it will wind up spending $40 million to $50 million, and the city expects to have contributed $1.5 million by the program's anticipated end in June.

"The Davis experience is a real outlier," said John Packham, associate dean at the University of Nevada-Reno School of Medicine, who works on statewide health initiatives. "I'm not aware of any place in the U.S. that has that combination of positive factors: plenty of dollars, fidelity to evidence and science-based public health practice, social solidarity, isolation, and public/private commitment."

The project began in summer 2020 as COVID case rates began to take off. Dr. Tom Nesbitt, a senior official at UC Davis Health system, suggested to Pollock that a university-city cooperative might be possible, and Pollock sketched an outline during a weekend at his home in Sacramento. "The scheme was just a big circle with Davis in the middle, and on the periphery were all these things we'd need to do," Pollock said.

An effective testing system was paramount, and it was delivered by Richard Michelmore, a university plant geneticist who repurposed a $400,000 machine set up to detect DNA variations in crop plants like lettuce. Michelmore engineered it to process large numbers of saliva-based COVID tests instead, and it has cranked out as many as 10,000 tests a day.

The university covered costs with philanthropic donations; money from the federal Coronavirus Aid, Relief, and Economic Security Act; and state and federal grants. But it has gained the money back in other ways, Pollock said. "We were losing a lot of money by students not being on campus," Pollock said. "We lost housing revenue immediately."

Pollock and his associates are doing modeling to assess the savings in lives, hospitalizations, and economic activity. Davis has had slightly more than 7,900 COVID cases since the pandemic began, with 26 deaths. "I think the results [of the program] are very robust," Pollock said.

The city's willingness to partner with the university is central to those results. When university officials approached Davis City Manager Mike Webb with the idea of trying to safeguard both entities within a single program, "my immediate response was, 'We're in,'" Webb said. "We all knew it was critical."

The city had no budget for the project, so its initial contribution was in kind: It supplied city staff hours, opened city buildings as testing venues, and deployed its communications specialists to help spread the word. In January, city leaders approved $750,000 in American Rescue Plan Act money to keep the program going, and Webb asked for another $750,000 to see it through to the end of this school year.

Across the country, the relationship between campus and city or town is often strained. Davis' own history is fractious, with previous university administrations sparring with city leaders over issues like providing adequate housing for the rapidly growing student population. But Gary May's arrival in 2017 as UC-Davis chancellor has led to more cooperation and coordination, according to several city administrators and local businesses leaders.

The results are visible. On a warm February afternoon, the Davis campus was abuzz with activity. Matthew Nissan, a sophomore math major who is up to date on his vaccinations, said he takes a COVID test at the Activities and Recreation Center once every two weeks, as required by the school. Unvaccinated students and employees, who account for 2% of the campus population, must be tested at least every four days.

"No problem doing it," Nissan said. "I spent my freshman year in remote learning. When I finally got to campus last fall, it was like, 'OK, this is college.'"

Around town, meanwhile, the project is hard to miss. Signs posted on almost every block remind residents to get tested and observe masking rules. People who live in the city receive regular updates about testing hours and sites. The project has expanded to include the rest of Yolo County, with testing and vaccination outreach to agricultural workers in the region's rural stretches.

Pollock said he and his team are capturing all the information they can and sharing their experiences with colleagues on other campuses, pending publication of their work in a peer-reviewed journal. Although the Davis model appears to be rare, experts said, it may yet spread.

Mark Kreidler: @MarkKreidler

As Newsom nears the end of his first term, his ambitious ideas — such as requiring California to make its own insulin and forging drug partnerships across state lines — have failed to get off the ground.

This story was published on Friday, March 4, 2022 in Kaiser Health News.

By Angela Hart and Rachel Bluth and Samantha Young

SACRAMENTO, Calif. — When Gov. Gavin Newsom took office in 2019, he promised to lower prescription drug costs for all Californians.

But now, as Newsom nears the end of his first term, his ambitious ideas — such as requiring California to make its own insulin and forging drug partnerships across state lines — have failed to get off the ground or haven't produced the hefty savings he promised.

"There are powerful forces arrayed against us — not just politicians in Washington, but drug companies that gouge Californians with sky-high prices," Newsom said on his inauguration day in January 2019. "Here in California, we have the power to stand up to them, and we will."

A few months later, he vowed California would save "hundreds of millions of dollars right away — potentially billions" — by using the state's massive purchasing power to negotiate lower drug prices for California's counties, its businesses, and other states. But so far only a few counties are participating in the program, and savings have fallen far short. Another program, which debuted Jan. 1, is intended to save the state hundreds of millions of dollars a year by consolidating drug purchasing for the 14 million low-income Californians enrolled in Medicaid, but how those savings will materialize isn't clear.

Newsom's third initiative requires the state to manufacture generic drugs, but it hasn't gotten off the ground.

Drug spending by public and private health insurers grew 5% in California during Newsom's first year in office, according to the most recent state data available — and costs are expected to continue rising in California and across the country because of increases in both pharmaceutical prices and prescription drug use.

Yet Newsom, a Democrat who is running for reelection in November, argues that California's initiatives are leading the nation and that realizing cost savings can take years.

Newsom's office declined to answer questions about the cost savings shortfalls, but his administration provided written responses to some KHN queries.

Leveraging the Power of Government

When Newsom announced that California would contract with its counties, its businesses, and other states to buy drugs in bulk — and expand existing bulk purchasing agreements across state agencies — he said the initiative would save "hundreds of millions," if not billions.

Three years later, the state has seen some modest savings — but nothing near what Newsom predicted.

Although it seemed as though Newsom was announcing a new program to partner with California's counties, its businesses, and other states, he was building on state drug discount agreements that predated his administration.

"The state was already doing it," said Jane Horvath, a consultant who advises state policymakers on 'healthcare costs. "They've sort of opened it up to counties to participate."

California for years has negotiated with drug manufacturers to get discounts on prescription drugs for state-run hospitals, jails, and other entities that buy and dispense drugs. Newsom's 2019 executive order expanded those agreements to allow other entities to benefit, akin to giving them a coupon code that is applied at checkout. Though Newsom initially said two other states were interested in joining the program, none have.

So far, three populous counties — Los Angeles, Orange, and Sacramento — have joined. County officials and the Newsom administration say the state's pricing agreements have saved money, but how much is unclear — they have given different figures and time frames.

The state Department of General Services, which oversees the Statewide Pharmaceutical Program, said the three counties saved about $500,000 from January 2021 to September 2021. But Sacramento County in February reported saving nearly $700,000 on drugs for its jails "in a little over a year."

How many state agencies have banded together to buy cheaper drugs is also unclear. The Newsom administration said the California State University system joined the program and saved $476,000 over five months. The governor's office also said the state saved $3 million over five months on mental health medications under an August 2021 bulk purchasing arrangement.

Other states have been banding together for years to get discounts.

Oregon Health Authority pharmacy director Trevor Douglass runs a drug purchasing consortium with Washington that has saved both states at least $142 million since 2016. Nevada plans to join the consortium, and Douglass said he is in talks with Delaware and Wisconsin — but hasn't heard from California.

"I would be happy to hear from California tomorrow," Douglass said. "I would have been happy to hear from them yesterday."

Overhauling Medicaid Drug Purchasing

Starting in January, a single company started administering prescription drugs for all of California's Medicaid patients, most of whom previously got their medications through about two dozen managed-care plans.

But the state contractor, Magellan Health, was woefully understaffed and unprepared when the transfer occurred Jan. 1, and thousands of patients were left without critical medications. The state and Magellan have worked to address some of the shortfalls, but some physicians say problems persist. 

Newsom's administration projects the state will save $414 million in the 2022-23 budget year, mostly by securing rebates from drug companies now forced to deal with the nation's most populous state at the negotiating table. The state expects to double those savings the following budget year.

However, it's too soon to tell whether Newsom's experiment will succeed. Health insurance plans are skeptical, citing industry-backed studies that show high prescription drug costs in the few states that run their own programs.

"We think the assumptions, the savings, are exaggerated," said John Baackes, CEO of L.A. Care Health Plan, the largest publicly operated health plan in the country. "That would be a polite way to say it."

Newsom isn't alone in pushing his state away from managed care as a cost-saving measure.

In July, Ohio will begin using a single health contractor for its Medicaid program, which the state estimates will save the Buckeye State $186 million in fiscal year 2022-23. New York is planning to make the switch in April 2023.

In Missouri, Josh Moore, the state's Medicaid pharmacy director, said there's no question that the state's move in 2009 to buy drugs for Medicaid enrollees has saved taxpayers millions of dollars through rebates alone. Today, he said, the state collects 99% of drug rebates offered by drug companies to state and federal governments, compared with the 90% to 95% that states typically claim through managed-care plans, which don't always catch or follow up on billing errors.

"Small percentages make large numbers whenever we talk about the kind of money that we're talking about in Medicaid pharmacy systems," Moore said.

Diving Into the Generic Drug Market

In 2020, Newsom's proposal to create a California generic drug brand, CalRx, became law and required the state to manufacture the drugs or partner with drug manufacturers.

The law calls on the state to "enter into partnerships" to produce or distribute generic prescription drugs and at least one form of insulin. The Newsom administration is in discussions with drug manufacturers and has made some progress, but no contracts have been inked, according to prepared responses from Rodger Butler, a spokesperson for the state Health and Human Services Agency.

Vishaal Pegany, assistant secretary for the Health and Human Services Agency, told lawmakers at a hearing in January that the state is focusing on developing insulin and other generic drugs that would serve a large population, as well as drugs that are high-cost or in short supply. But the state isn't sharing details about which other drugs California might produce, the names of the drug companies it's negotiating with, or how long producing the first CalRx drugs might take.

The state had previously been in talks with Utah-based nonprofit drug company Civica Rx, but Senior Vice President Allan Coukell declined to say whether the company is still working with the state.

State Sen. Richard Pan (D-Sacramento), who authored the 2020 generic drug bill, said California must also eventually develop the ability to manufacture its own generic drugs. "You can't just stand up a factory overnight and we have a learning curve, so right now we have to find a generic manufacturer that wants to play ball with California," Pan said. "But I hope in the long run we will stand up our own manufacturing capacity so we're not constrained by a company willing to work with us."

Phillip Reese, an assistant professor of journalism at California State University-Sacramento, contributed to this article.

This story was produced by KHN, which publishes California Healthline, an editorially independent service of the California 'healthcare Foundation.

Angela Hart: ahart@kff.org, @ahartreports

Rachel Bluth: rbluth@kff.org, @RachelHBluth

With J&J seemingly destined to be a benchwarmer among COVID vaccines in the U.S., it often has been left out of public discourse and guidance on COVID.

This article was published on Tuesday, March 1, 2022 in Kaiser Health News.

By Bernard J. Wolfson

Yes, we are all exhausted by the COVID pandemic. Flummoxed by the constantly shifting science and guidelines. Worried about a succession of scary new variants, each with its own name, like hurricanes.

But a sizable minority — nearly 17 million U.S. residents, including me — has its own special quandary. Our initial vaccine was Johnson & Johnson, which was just one shot, and that has many of us confused. Are we fully vaccinated, even with a booster, or should we get a third shot to catch up with the 92 million vaccinees who got two doses of Pfizer or Moderna early on and have since been boosted? Since J&J has largely disappeared from the public eye, actionable information is in scarce supply — not to mention that the guidance is constantly shifting, for everybody.

On April 4, 2021, I dutifully traveled across Los Angeles to line up for my J&J shot at a mass vaccination site. Like many of my J&J brethren, I was following the advice of public health officials to take the first available vaccine.

At the time, J&J was kind of a cool newcomer among COVID-19 vaccines. The protection it provided against illness, though apparently less than that afforded by the so-called messenger RNA (mRNA) vaccines from Pfizer and Moderna, seemed sufficient to ward off serious illness.

And while those vaccines required two shots, J&J was billed as "one and done" — a big advantage for people with needle phobia and for transient populations, including farmworkers, people living in homelessness, and inmates in county jails. Its easy storage requirements, compared with the deep freeze needed to handle the Pfizer and Moderna vaccines, also made it a good choice for remote rural populations.

But just days after I got my shot, the reputation of J&J entered what would prove to be a disastrous tailspin, with news of the vaccine's link to a rare but potentially deadly blood clotting disorder. That prompted federal health officials to hit the pause button on it, only to clear it 10 days later and then reverse course in December by recommending the Moderna and Pfizer vaccines over J&J's, mainly because of studies that intensified the blood clot concern.

In the interim, J&J was plagued by production snafus and concerns about its vaccine's efficacy. Research showed a disproportionate share of breakthrough infections among J&J vaccinees during a COVID surge on Cape Cod last summer. State data from California covering most of 2021 paints a similar picture, not only for infections but also for hospitalizations and deaths.

With J&J seemingly destined to be a benchwarmer among COVID vaccines in the U.S., it often has been left out of public discourse and guidance on COVID.

"Very little J&J vaccine is currently being used, which is part of the reason that people don't talk about it very much anymore," says Dr. William Schaffner, a professor of infectious diseases at Vanderbilt University Medical Center in Nashville, Tennessee.

When the Biden administration first recommended boosters in August, it initially excluded J&J vaccinees, citing a lag in the data.

No wonder the citizens of J&J Nation have been feeling a bit like neglected stepchildren.

"I wish I had chosen something that more people had received so I could get more information," says Leah Justman, a 39-year-old resident of Los Angeles, who preferred the J&J shot last April because she was breastfeeding her newborn baby at the time, was nervous about the new mRNA technology, and thought J&J was "more similar to getting a regular vaccine."

Now, she says, she feels as if there's a bit of a stigma attached to being a J&Jer: "When I go to restaurants or show that I'm vaccinated, people are like, 'Oh my God, you got J&J.' It's almost like a joke, where people think, 'Thank God I didn't get it.'"

In December, Justman got the half-dose Moderna booster recommended by the Centers for Disease Control and Prevention. That leaves her behind the curve compared with Moderna and Pfizer recipients who received two full doses initially and a booster later on. She worries about how long she will be protected and what her next move should be.

There appears to be a growing consensus in scientific circles that one shot of J&J was never enough and that it could account for the lower efficacy compared with the mRNA vaccines.

"A lot of us believe it should have been a two-dose vaccine all along," says Bradley Pollock, associate dean for public health sciences at the UC Davis School of Medicine. In coming months, he says, "it is entirely possible that they're going to say a three-dose schedule is full vaccination."

That got me thinking about whether I am fully vaccinated. Factoring in the half-dose Moderna booster I received in late October, I'm still behind those who've had three Pfizer or Moderna shots.

I've spoken to several J&J vaccinees who, thinking similar thoughts, sought a second booster even though the current federal guideline for J&J vaccinees calls for just one mRNA booster, two months or more after the initial vaccination.

I recently went online to book an appointment for a second Moderna booster. On my first try, I got a message from the pharmacy saying I wasn't eligible. A second pharmacy allowed me to book a slot, but I canceled at the last minute after receiving dissuasive emails (albeit mild ones) from two of my expert sources.

"It's not as quantitative as you're making it out to be," wrote Dr. George Rutherford, a professor of epidemiology at UCSF. The J&J and mRNA vaccines work differently, he said, "so it's not like one J&J plus one Moderna equals 1.5 Pfizer doses. I don't think it will make you sick, but I'd just sit tight. Omicron is going away."

New research suggests that as few as two COVID shots could be enough to protect most people from serious illness and death for many months, or even years.

If you are among the nearly 17 million J&J people and have had a booster, consider standing pat like I finally did. But if you haven't had a booster yet, do so ASAP. It seems clear, or at least as clear as anything can be where COVID is concerned, that if you are vaccinated and boosted, your risk of developing severe illness is very low.

New federal guidance allows for a second booster if your immune system is compromised by, for example, cancer treatment, HIV, or an organ transplant. If you're not immunocompromised but are worried about weak protection, you can try to persuade a pharmacist or the staffers at a vaccination site to give you another shot. It won't be easy, but it's possible. Or talk to your doctor, who may be willing to prescribe one.

Now that I've spent most of this column pointing out the problems with the J&J vaccine, it's only fair that I say a few positive things about it.

First, even though it appears to be less effective than the Pfizer and Moderna shots, the J&J vaccine still provides a high degree of protection against serious illness and is vastly preferable to no vaccine. J&J, which is cheaper than the mRNA vaccines and easier to transport, also has a critical role to play in low-income countries with large rural populations and poor transportation infrastructure.

Even in the United States, where use of the J&J shot has declined sharply, it's helpful to have the vaccine in stock. It's a good alternative for those who are anxious about the mRNA shots and would otherwise not get vaccinated.

And it's always possible that demand for it could return. The mRNA vaccines carry a risk of heart inflammation for young men, a side effect that appears to be short term in most cases. But if future studies show it can lead to permanent damage or even death, "that would make the J&J vaccine potentially at least as attractive, if not more attractive," says Dr. Walter Orenstein, a professor of epidemiology at Emory University in Atlanta.

The vaccines are still new, many clinical trials have yet to yield unambiguous results, and every new variant throws doubt on data collected when a different strain was dominant.

"It may turn out to be true that three doses or two doses and a variant-focused booster are going to turn out to be best. We don't know yet," says Dr. Gregory Poland, director and founder of the Mayo Clinic's Vaccine Research Group in Rochester, Minnesota. "And the way things have been going, we will barely be getting the answers to those questions, and more time will have passed, and a new variant will arrive."

This story was produced by KHN, which publishes California Healthline, an editorially independent service of the California Healthcare Foundation.

Bernard J. Wolfson: bwolfson@kff.org, @bjwolfson

There is no nationwide compilation of how many Medicaid enrollees have been vaccinated.

This article was published on Monday, February 28, 2022 in Kaiser Health News.

By Phil Galewitz

Medicaid enrollees continue to get vaccinated against COVID at far lower rates than the general population despite vigorous outreach efforts by government officials and private organizations to get low-income people inoculated, according to data from several states.

That leaves many Medicaid enrollees — who tend to be sicker than those with private insurance — at higher risk for severe illness, hospitalization, or death from the virus.

Nationally, more than 215 million Americans — including 75% of adults and 57% of children ages 12 to 17 — are fully vaccinated, according to the Centers for Disease Control and Prevention. Among children 5 to 11 years old, who have only been eligible for a shot since early November, about 25% have been fully vaccinated. A vaccine has not yet been authorized for children younger than 5.

There is no nationwide compilation of how many Medicaid enrollees have been vaccinated.

But in Utah — one of a handful of states that publish that data — fewer than half of adult Medicaid enrollees are fully vaccinated.

Disparities exist in every age and racial/ethnic group that the state publishes data on. For example, about 40% of Black Medicaid enrollees are vaccinated, compared with 56% of Black people overall. Among Hispanics, 38% of Medicaid enrollees are vaccinated, compared with 51% of the overall Hispanic population. (Hispanic people can be of any race or combination of races.) Among children 12 to 18, about 35% of Medicaid enrollees are vaccinated, compared with 57% overall.

Officials at Molina Healthcare, which is one of Utah's four Medicaid managed-care plans and has about 90,000 members, said overcoming resistance to the COVID vaccine has been difficult. One of the biggest hurdles is getting in touch with members. Molina officials told a Utah Medicaid advisory board in January that they can't reach 40% of their members because they don't have correct addresses or phone numbers.

"It's worrying," said Brian Roach, division services manager at the Utah Department of Health, which oversees the federal-state health insurance program for low-income residents. "We still see little increases every month, but it is not enough to close the gap," he added. "There has been no silver bullet to solve this issue."

Roach said he is not surprised Medicaid health plans have difficulty reaching members. "The Medicaid population is pretty transient, and people change jobs and move," he said.

Under federal rules implemented for the COVID public health emergency, states can't remove people from the Medicaid rolls if their income changes, so enrollees have generally not had to check in with the state to renew their eligibility. As a result, states might not have updated contact information.

Personal contact with someone trusted by the enrollee is crucial to persuading members to get vaccinated. Harley Jones, a senior manager at Project Hope, a global humanitarian relief group, said unvaccinated people often need to hear from someone they know, such as a clinic nurse, to persuade them to get the shots. Since last summer, the nonprofit has been using a federal grant to help free health clinics in Texas boost vaccination rates.

"It's been a year since the mass vaccination clinics, and this is a slow slog," he said. "What works is finding the trusted voice for people who is from their community, knows the culture, and that one-on-one can take hours or a month to pay off."

The federal government has authorized nearly $400 million for vaccination outreach efforts to underserved communities.

Utah's difficulty getting Medicaid enrollees vaccinated is mirrored in other states.

In Ohio, 54% of adult Medicaid enrollees are at least partly vaccinated, compared with 73% of adults in the general state population.

Washington state has vaccinated 43% of its Medicaid enrollees 5 and older, compared with 76% of all state residents in that age group.

In Virginia, 41% of Medicaid enrollees 5 and older are vaccinated, compared with 76% of state residents in that age group.

In California, about 54% of Medicaid members 5 and older are at least partly vaccinated, compared with 81% of state residents in that age group.

Dr. Christopher Chen, medical director for the Washington Medicaid program, said that since Medicaid enrollees are more likely to be in poorer health, they are more likely to benefit from the vaccine to prevent complications from COVID. "It's definitely something to be concerned about," he said.

Washington, he noted, increased pay to doctors and pharmacists to vaccinate Medicaid enrollees and agreed to pay doctors to counsel patients about the vaccine. The state also gave its Medicaid health plans access to data showing which of their members had not been immunized so they could reach out to those people.

The University of Alabama received a $1 million federal grant last July to increase vaccination rates in an 18-county rural region in the southern part of the state where African Americans make up the majority of the population. Under the plan, community health workers canvass the region to inform residents about the benefit of the vaccine. The initiative also provides a $15 incentive payment for getting a shot.

Since last summer, many of the counties have seen vaccination rates double. But because the rates were so low to begin with, most of the area still has fewer than half of residents vaccinated.

Dr. Hee Yun Lee, who oversees the grant and is associate dean for research at the University of Alabama School of Social Work, said many people lack easy access to shots because they don't have cars and mistrust of vaccines runs strong.

Another obstacle has been skepticism from some pastors, who told congregations not to fear COVID, Lee said. They also incorrectly told congregants that the disease can't afflict them while they attend church, she said. A gathering of more than 300 people in a church recently led to an outbreak.

"There are a lot of misconceptions about the virus here," she said.

Phil Galewitz: pgalewitz@kff.org, @philgalewitz