Forecasting the Cost of Exclusion: COVID-19 Vaccine Access and Health Plan Implications

Understanding how decisions like the new COVID-19 vaccine access limits will affect population health and subsequent health plan utilization, claims, and costs can be difficult. One way to look at this is through the lens of vaccine effectiveness (VE), how much a vaccine lowers the risk of the outcome (e.g., getting sick) in a trial setting. For the 2024–2025 COVID-19 vaccine, VE was 33% against COVID-19-associated emergency department (ED) or urgent care (UC) visits among adults aged ≥18 years, compared with not receiving a vaccine dose—indicating that the 2024–2025 vaccination provided additional protection and significantly reduced COVID-19-related ED/UC utilization (Link-Gelles et al., 2025). With the FDA’s new guidance limiting COVID-19 vaccine approval to seniors and high-risk individuals—excluding many younger and lower-risk populations (Prasad & Makary, 2025; Roubein & Sun, 2025)—it is reasonable to conclude that populations aged ≥6 months who had access to the vaccine in 2024 but will not in 2025 may experience increased COVID-19-related ED/UC utilization.

Prasad, V., & Makary, M. A. (2025, May 20). An evidence-based approach to COVID-19 vaccination. The New England Journal of Medicine. https://www.nejm.org/doi/full/10.1056/NEJMsb2506929

Link-Gelles, R., Chickery, S., Webber, A., et al. (2025). Interim estimates of 2024–2025 COVID-19 vaccine effectiveness among adults aged ≥18 years — VISION and IVY Networks, September 2024–January 2025. MMWR Morbidity and Mortality Weekly Report, 74, 73–82. http://dx.doi.org/10.15585/mmwr.mm7406a1

Roubein, R., & Sun, L. H. (2025, May 20). The FDA to limit COVID shot approval to 65+, those with medical conditions. The Washington Post. https://www.washingtonpost.com/health/2025/05/20/covid-vaccine-elderly-high-risk-fda/