Covid killed 170,000 in nursing homes. Most residents still haven’t gotten the latest shot.

“Americans look to you as the highest public health official in the land; it would speak volumes if, in addition to other actions, you appealed directly to residents and their family members,” Katie Smith Sloan, president of industry group LeadingAge, wrote in a Dec. 22 letter to Becerra.

More than 170,000 nursing home residents have died since Covid arrived four years ago. But after the all-hands-on-deck effort to vaccinate elderly people in 2020 and 2021, America’s most vulnerable citizens are now largely on their own.

Sloan gave Becerra a to-do list to help the homes: allow them to make small vaccine orders that fit slackening demand, enlist hospitals in the vaccination campaign, permit the industry to bill Medicare more for administering the shots, and come up with a message that works.

A day later, at the second meeting, Becerra didn’t offer new aid, but did reiterate the federal rules requiring homes to offer vaccines.

“We’ve chased down all these to-do items for three years running — I don’t think they’ve had the impact,” one senior administration official, granted anonymity to discuss the administration’s response, said of the nursing homes’ demands. The person said the agency would examine the latest requests and continue to work with the industry, but was skeptical it would radically change the outcome even if the administration acceded to them.

“I don’t think this letter with the items in it, even if we checked off every box, would all of a sudden, magically change the vaccination rate,” the official said.

‘We know they can do it’

Nursing home residents, because of their age and underlying conditions, are particularly vulnerable to Covid-19.

When the first Covid shots arrived in nursing homes late in 2020 in government-run clinics, almost every resident chose vaccination — a massive relief, given the outsize death toll in the homes to that point.

“[The administration] had the major pharmacies that were on board. They brought the clinics to the nursing homes and by and large, the residents received their vaccines,” David Grabowski, professor of health care policy at Harvard Medical School, recalled.

But that success has faded along with the broader vaccination campaign.

There’s no clear answer why, but two shifts have likely contributed, according to industry and government leaders.

First, interest in vaccination has declined as they proved unable to halt transmission, as have disagreements over who needs an annual shot — even as there’s consensus among experts that elderly people do.

Second, the administration stopped buying and managing distribution of the shots starting with the rollout of the updated vaccine last September.

The move coincided with the administration’s decision to end the public health emergency, which justified the move to shift responsibility to insurers, pharmacies, doctors’ offices and the other private health care organizations that manage other vaccinations.

For nursing homes, that means they have to source the shots and manage how they’re given, creating logistical and reimbursement challenges.

Though government and industry leaders agree that a number of other factors could also be at play, the result is clear: Only 38 percent of nursing home residents have gotten the most recent shot — a significant drop from the initial vaccination campaign.

There’s a wide variation among states. Both North and South Dakota report more than 60 percent of nursing home residents are vaccinated whereas only 20.1 percent of Arizona nursing home residents are.

And Covid continues to claim lives in the homes — nearly 600 residents died in the first two weeks of 2024. As of Jan. 14, more than 14,700 Covid-19 cases were confirmed among nursing home residents since the start of winter — a much lower rate of cases than in previous years.

People in the administration point to discrepancies across states as reason to believe providers could do more.

At some homes, most residents are vaccinated, at others almost no one, leading Becerra to remind nursing home executives that they are legally required to at least offer shots to their residents.

“We know they can do it,” the administration official said. “Better is possible.”

And the administration can point to facilities, such as those in the Dakotas, that have vaccinated most of their residents.

“It’s absolutely about that trust,” said Dr. Jeremy Cauwels, who oversees the Good Samaritan Society, South Dakota-based Sanford Health’s long-term care provider.

He said yearslong relationships with patients were powerful enough to overcome vaccine skepticism. In some Sanford-owned facilities, he said uptake is over 90 percent.

‘Bully pulpit’

Sloan acknowledged that some homes are doing a better job than others in vaccinating residents — more than half of residents at LeadingAge facilities have had the latest shot — indicating that the facilities can help boost trust.

But she also said she has noticed the administration doing less to persuade Americans to get vaccinated than it did in the past.

“One of the things that we talked to the secretary about was really the role that HHS in particular can play in using its bully pulpit as the primary public health communicator in the country,” Sloan said. “That, to me, is a huge, huge role.”

Centers for Disease Control and Prevention Director Mandy Cohen told POLITICO in October that getting nursing home residents vaccinated was a top priority for her agency given the risk they face.

“Leading up to this virus season, and throughout the fall, CDC worked with other federal agencies, state and local health departments, and health care partners to address vaccine access issues and encourage uptake. We expect to see improvement,” an agency spokesperson wrote in an email.

But some in the administration also said that it’s appropriate that the shift from a government-run distribution system to one managed by the private sector should also mean a shift away from the government’s pandemic role promoting vaccination.

“There was some thought that maybe it might be better if the messaging came from the manufacturers and from private entities,” the senior official said, believing that the hard sell from the administration was merely reinforcing vaccine skepticism in some communities.