There is a common misconception that RSV primarily affects children. While it’s true that RSV is one of the leading causes of hospitalization among infants and young children, older adults, especially those who have underlying medical conditions, are also at risk. Every year, as many as 160,000 Americans ages 65 and older require hospitalization because of RSV. Around 6,000 to 10,000 seniors die from this virus.
The Centers for Disease Control and Prevention just published new data illustrating how severe RSV can be for seniors. Researchers examined older adults hospitalized in 20 states for RSV, covid-19 and influenza. They found that while RSV-associated hospitalizations were less frequent than those for the other two viruses, clinical outcomes were worse. Patients hospitalized for RSV had higher need for intensive care and higher rates of requiring oxygen and other respiratory support.
Thankfully, federal health officials have approved two highly effective vaccines. One is 85 percent effective against RSV-associated lung disease that’s severe enough to require medical attention; the other is 88 percent.
These numbers surpass the efficacy of the influenza and coronavirus vaccines. A 2017 review found that the flu vaccine reduced hospitalization among older adults by an average of 40 percent. The bivalent coronavirus vaccine decreases the risk of hospitalization by 65 percent in the seven to 59 days following the shot, though that protection tapers off quickly. Its effectiveness dropped to 48 percent by two to four months and was just 22 percent by four to six months.
Protection by the RSV vaccine is also more durable; a single shot should retain high levels of efficacy well into next year. Yet despite these sound rationales for getting the shot, doing so is challenging for many Americans.
One major reason is that unlike the flu and coronavirus vaccines, which are included under Medicare Part B, the RSV vaccine is covered under Medicare Part D. Part B pays for medical services, while Part D pays for prescription drugs.
This has two implications: First, vaccines under Part B are fully covered by Medicare, which means all Medicare enrollees can receive flu and coronavirus vaccines free of charge. Those with Part D prescription benefits shouldn’t have to pay for the RSV vaccine, either, thanks to a provision in the Inflation Reduction Act.
But the roughly 16 million seniors who do not have Part D will have to pay out-of-pocket. The RSV vaccine carries a price tag between $180 and $295 a shot, which is prohibitive for many people.
Second, while doctors’ offices are routinely reimbursed for services under Part B, most are not equipped to bill claims to Part D. That means they can offer the flu and coronavirus vaccines in their clinics, but they must refer patients to pharmacies for the RSV shots. A “one-stop shop” is always preferable, especially for people with mobility difficulties and limited transportation.
Patients without Medicare between ages 60 and 64 also face barriers. Those without insurance will have to bear the cost themselves or try to find discounted shots from health departments and subsidized clinics. Those with insurance might have to do the same. Private insurers are supposed to cover vaccines recommended by the CDC, but in this case, the CDC’s guidance was nuanced. Instead of explicitly recommending that people receive the RSV shot, as it does for the flu and coronavirus vaccines, it said that they “may” receive it, in consultation with their health-care providers.
Richard H. Hughes IV, a vaccine policy expert and partner at Epstein, Becker & Green, told me that “some insurers have used this language as a way out” by claiming that “may” does not equate a full-throated recommendation. This is a deliberate perversion of CDC’s intention, which was to empower patients to choose what’s best for their individual situations. Instead, that decision is now driven by whether they can pay.
Two policy changes can resolve these issues. Congress can move coverage of all vaccines to Part B. Many advocates have pushed for this change, which would ensure that other vaccines under Part D, such as those for shingles, are covered as well. The federal government can also close the insurer loophole so that all vaccines, recommended outright or through shared decision-making, are offered free of charge.
It’s essential that adult vaccinations are fully covered for everyone, as they are for kids. More than 3 in 4 adults are missing at least one recommended vaccine. The United States spends more than $26 billion each year treating vaccine-preventable diseases in older individuals. By comparison, a national adult vaccine program would cost $12 billion. That’s quite a bargain — and it would save lives.
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