Why States With the Lowest Median Incomes Have the Lowest Vaccination Rates: Money Investigation

Before COVID-19 vaccines were available, poor people in America were much more likely than the wealthy to get sick and die from the virus. Now that vaccines are here, a Money analysis found that residents of low-income states are much less likely to be getting vaccinated.

This is the case even though vaccine shots are free and have been promoted from coast to coast for months, and even as hospitalizations spike in many of these same low-income states due to the spread of the highly contagious Delta variant.

Why are the groups that seem particularly vulnerable to the virus often the ones who aren't getting the vaccine? Money took a deep look at publicly available health and U.S. Census Bureau data and talked to public health experts about the complicated mix of personal beliefs and structural barriers that have stood in the way — and what might be done to overcome them.

Vaccination rates and income

There are plenty of reasons people give for not getting the shot. In multiple surveys, the most popular explanations have centered on fears about possible side effects. Many unvaccinated Americans also say that the pandemic has been exaggerated by the media. Still others are passing on the vaccine because they believe in unfounded conspiracy theories, like the one that the U.S. is using the vaccine to plant microchips in the population.

Yet for some people, it's less of a choice. Many lower-income Americans face complications and barriers, ranging from minimal public transit to the absence of childcare and paid sick leave, that make it far more difficult to even be in a position to make the decision to get vaccinated.

What's readily apparent in the data is a link between income levels and vaccination rates. It's by no means a direct cause-and-effect relationship, but a very strong correlation nonetheless.

If you look at states' median household incomes and their vaccination rates side by side, you'll quickly see some patterns. The states with higher incomes almost always have higher vaccination rates, while the poorer states are at the lower end of the spectrum for COVID-19 vaccinations.

More specifically, the five states with the lowest median household incomes (Alabama, Louisiana, Arkansas, West Virginia and Mississippi) are in the bottom seven nationally in terms of residents who are fully vaccinated. The fully vaccinated rates for these five states were 39% or below at the end of August, compared to 52% nationwide. (The percentages cover each state's entire population, including children under the age of 12 who are still ineligible for vaccines.)

Mississippi ranks dead last for median income and number of COVID-19 vaccine doses administered as a portion of the population, according to the CDC.

Meanwhile, of the 20 states with the highest median household incomes — we're including Washington, D.C., in this mix — 16 are also in the top 20 for vaccination rates. On the flip side, 14 out of the 20 states with the lowest median household incomes have vaccination rates in the bottom 20 nationally.

The statistics are not particularly surprising to public health experts. "We know that income is a social determiner of health," says Dr. Georges Benjamin, executive director of the American Public Health Association (APHA). "Wealth actually correlates with health."

Vaccination rates track overall state health rankings, which take into account factors including obesity rates, low birth weights, high maternal mortality, access to care and food insecurity. APHA publishes an annual America's Health Rankings report, and Dr. Benjamin points out the states routinely topping the list rank among the highest for vaccination rates right now. Likewise, the states that come in the bottom of these rankings generally have stubbornly low vaccination rates at the moment.

It makes sense that states that traditionally fall short in terms of the overall health of the population are struggling to get people vaccinated. What's more, it's hardly just about income. It's about state funding and the access and availability of services too. The cluster of poorer states in the Southeast with the lowest vaccination rates generally spend a lot less on health initiatives.

"The states with low [vaccination] rates are the same ones that have invested less in ensuring access to care and public health services, including those with largely rural populations," says Keshia Pollack Porter, Phd, a health policy and management professor at the Johns Hopkins Bloomberg School of Public Health. These same states "are less likely to have paid sick leave" and more likely to "have policies that make it harder to require vaccines or other preventive measures like mask mandates, which contributes to the differences in infection, hospitalization and death rates."

Yet some states with median incomes in the middle or lower end of the spectrum manage to do a very good job with the health of residents — and these states, unsurprisingly, have above-average vaccination rates right now.

Two states that jump out in particular are Vermont and New Mexico. They both have median household incomes below the national median (New Mexico is actually the sixth poorest state by this measure), yet their vaccination rates are in the top 10. Tiny Vermont has the highest vaccination rate in the U.S., with 67% of the population fully vaccinated and 75% receiving at least one dose, compared to national rates of 52% and 61%, respectively.

Experts say these states are having success getting more people vaccinated because they have good health infrastructure systems and longstanding policies in place that promote health. Perhaps most importantly, there has been a strong, almost universal push by local political leaders and organizations to encourage vaccinations in these states.

"You see some major differences in terms of commitment to get people vaccinated" in different states, says Dr. Benjamin of APHA. He says New Mexico is "being held up as an exemplar" not just in making vaccinations available, but also having systems in place to educate people about vaccines' effectiveness and deal with misinformation.

"Leadership plays a critically important role in all aspects of the pandemic," says Julia Raifman, an assistant professor of health law, policy and management at Boston University's School of Public Health. "Leaders prioritizing vaccine delivery and equity can help people access vaccines at work and in their neighborhoods."

Vaccines and race, education and politics

It's hard to isolate the exact impact of income, race and education on vaccination rates, or on health in general, because these factors overlap. But all must be part of the discussion.

Pollack Porter of Johns Hopkins says that structural racism should shoulder a lot of the blame in certain communities when it comes to vaccine hesitancy and low vaccination rates in general. "These states with the lowest median incomes also have most people of color who are in jobs that do not provide flexible work schedules, who lack childcare, who don’t have paid sick leave and are worried about unpaid time off due to vaccine side effects," she says.

Dr. Benjamin ticks off several of the reasons why it's harder for lower-income Americans to get vaccinated, including "if you don't have a car and live five miles from the pharmacy, if you're not computer literate, if you do shift work during the hours vaccines are offered, if you work two jobs."

"People who are experiencing food insecurity and who report being at risk of eviction are also less likely to be vaccinated," says Boston University's Raifman. In other words, it's hard to find the time or even figure out if you want to get the vaccine when you're worried about food on the table or a roof over your head.

Education factors in as well. "Income is correlated with education, so we should not be surprised to also see lower vaccination rates among people with lower education levels," says Pollack Porter.

The latest Census Household Pulse Survey shows that 70% of American adults with less than a high school diploma say they are vaccinated, compared to 92% for adults with college bachelor's degrees or higher.

As for the racial breakdown, Black American adults in this survey are least likely to say they're vaccinated — 76%, versus 83% for whites. (This survey is based on adults only, which is why percentages are higher than studies covering everyone, including younger people not eligible for vaccines.)

Of course, it's not just low-income people of color who aren't being vaccinated. In one survey conducted for the Economist in July, less-educated white people — those with less than a college degree — were 10 percentage points more likely to say they would not be vaccinated than whites with college degrees. Another recent poll, from the Kaiser Family Foundation, found that "younger adults (18-29 years old), Republicans, rural residents, and the uninsured still report lower rates of vaccine uptake than other demographic groups." These same groups are generally more likely to say they will "definitely not" get the vaccine as well.

The political divide in America may reveal an even stronger correlation with vaccination rates than basic income levels. Almost all of the traditionally red states have lower vaccination rates, including some with relatively high incomes like Wyoming and Idaho.

Of the 20 states with the lowest vaccination rates, 18 gave their electoral college votes to Donald Trump in the 2020 election. (Georgia and Nevada are the exceptions.) And all of the 25 states that favored Trump in 2020 currently have fully vaccinated rates below the national average.

How to increase vaccination rates

Some of the hurdles that stop people from getting vaccinated, or make it prohibitively difficult, are hard to address in a hurry. Few states seem willing to pressure businesses into offering paid sick or spend big money on convenient and affordable public transportation to boost vaccination rates. Some companies and state and local governments are mandating vaccines for employees, but these orders seem more likely to arise and be politically palatable in areas where vaccination rates are already high.

Experts say there are some other steps that can be taken, without enormous costs or red tape. "Having vaccination centers be open on evenings and holidays is very important," says Dr. Benjamin. Offering vaccines in more work settings and convenient neighborhood spots will help too.

With expanded hours and locations, all of those people with super long workdays, or who have trouble arranging childcare or transportation, or simply have unpredictable schedules, would see more opportunities to get vaccinated.

And while there's no short-term measure that could suddenly change stalwart holdouts' minds, those who are mildly skeptical or hesitant might be convinced that vaccines are a good idea. Experts say there's plenty of room for improvement in terms of state and national leaders communicating clearly about the importance and safety of vaccines.

This is particularly critical in today's age, given the mass of half-baked theories and unequivocal misinformation spread on social media and cable news. Nearly one-third of Americans in a Rasmussen poll this summer said they believe public health officials are lying about the safety of vaccines. Another survey, from from Pew Research Center, shows that nearly half of Americans get some (30%) or a lot (18%) of their information about vaccines from social media.

"To some people, the disease isn't real," says Dr. Benjamin. "There are people who are terribly confused about who is at risk, and people who believe the vaccines are not effective."

Clearer, unambiguous messaging would not result in a 100% vaccination rate anywhere, especially not in places where views are entrenched that the vaccines are unnecessary or perhaps even dangerous. But it would help move the needle, so to speak, in terms of coaxing more unvaccinated Americans to finally get the shot.

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