The August 2022 passage of the Inflation Reduction Act (IRA) represented a watershed moment for U.S. policy across a host of critical issues, including reducing the cost of health care; addressing climate change and air pollution; and making the tax system more fair. The IRA will save families thousands of dollars, reduce the deficit, and create jobs. Along with these celebrated outcomes, the law also has important public health benefits. These come at a critical time, as the United States confronts infectious diseases preventable by safe and effective vaccines—such as COVID-19, monkeypox, and polio—and the health consequences of climate change are continuing to mount.
The IRA contains several timely provisions to address ongoing critical public health concerns and build a healthier future for all. Although significantly more action is required to protect public health in the United States, the IRA takes a step in the right direction by improving access to adult vaccines and reducing health-endangering air pollution from fossil fuels—all while addressing persistent health disparities that place a disproportionate burden on communities of color.
With the COVID-19 pandemic reaching a new phase, the United States has an opportunity to apply lessons learned from the pandemic and improve the health and quality of life for all Americans. Public health interventions will be a critical tool for reaching that goal. Investments in public health touch every part of life for Americans, improving the overall health of society while advancing equity, economic prosperity, and climate resiliency.
Improving adult access to vaccines
Vaccination is one of the most cost-effective public health investments, after clean water. Vaccination reduces disease and death while also lowering net health care spending. The IRA eliminates cost-sharing for adult vaccines covered under Medicare Part D and expands coverage of adult vaccines under Medicaid and the Children’s Health Insurance Program (CHIP). This will boost vaccine uptake and protect public health—especially for communities of color who face the same cost barriers as white communities—but also experience issues such as pharmacy shortages, language barriers, and reduced ability to schedule and keep vaccination appointments.
Even after the passage of the Affordable Care Act (ACA) in 2010, vaccine coverage under the Medicare and Medicaid programs has been varied and confusing. The ACA exempted Medicare from covering with zero cost-sharing all the vaccines recommended by the Advisory Committee on Immunization Practices (ACIP). Thus, only a handful of vaccines, including the COVID-19 vaccine, have been authorized by Congress for full coverage under Medicare Part B. Other vaccines are covered by Part D prescription drug plans and may require out-of-pocket spending—a barrier that has led to major disparities in vaccination rates between Part B and Part D drugs. For example, the life-saving shingles vaccine is covered under Part D, and those who have not yet met their deductible can owe more than $170 out of pocket per dose. As compared with vaccines covered by Part B, the shingles vaccine has a lower percentage of older adults who report receiving it, and, at 30 percent, it has the largest uptake gap between the highest and lowest income groups.
Although Medicaid-eligible children can receive ACIP-recommended vaccines at no cost through the Vaccines for Children Program, Medicaid does not universally cover ACIP-recommended vaccines without cost-sharing for adults. Only Medicaid-covered adults eligible through the ACA expansion pay no out-of-pocket costs when receiving vaccines, which leaves coverage for all other adults in Medicaid (38 percent of all enrollees, or more than 32 million people) up to the states. As of 2020, 25 states did not cover all ACIP-recommended vaccines, and 15 states place a cost-sharing requirement on adult vaccines. Unsurprisingly, Medicaid-enrolled adults have lower vaccination rates than those with private insurance for nearly all vaccines. For example, between 2015 and 2018, the influenza vaccination rate for pregnant women enrolled in Medicaid was only 36.5 percent, a full 21 percent less than the 57.5 percent vaccination rate for pregnant women with private insurance.
All of that is set to change, however, with the enactment of the IRA. Starting in 2023, Medicare Part D plans will be prohibited from applying a deductible, coinsurance, or other cost-sharing requirement for vaccines recommended by ACIP, and Medicaid will be mandated to cover ACIP-recommended vaccines for all adult enrollees. Although out-of-pocket costs are not the only barrier to vaccine uptake, these changes to coverage are likely to improve vaccination rates. Studies of the impact of vaccine cost-sharing on uptake among Medicare and Medicaid populations have consistently shown that costs impose an additional barrier to vaccination for patients, and removing this barrier could improve vaccination rates. The impact of these changes could be substantial, as, in 2020, 18 percent of insured Americans were covered by Medicare and another 18 percent were covered by Medicaid. These changes will be especially important for communities of color, who make up 25 percent of Medicare enrollees and 62 percent of Medicaid enrollees.
Addressing the health impacts of climate change and air pollution
Climate change has been called the “greatest threat to global public health.” By limiting greenhouse gas emissions—which contribute to climate change and harm the physical and mental health of Americans—and more specifically, reducing harmful particulate emissions, the IRA will save thousands of lives and address environmental health disparities.
Greenhouse gas emission-driven climate change endangers public health in several ways, including driving up deaths from extreme heat and intensifying natural disasters—such as wildfires and floods—that introduce air pollution and spread waterborne diseases. Climate change poses a threat to all Americans, and communities of color feel the impacts acutely. Extreme weather events, such as hurricanes, have historically led to more severe consequences for Black survivors, and people of color are more likely to live in areas that increase their exposure to extreme heat, flooding, and other severe weather risks.
Particulate emissions also pose a threat to public health. Particulate matter is emitted into the air by a variety of sources, but many are associated with climate change, including agricultural production, industrial processes, and fires. Multiple studies have shown that particulate matter is linked to hospitalization and emergency department visits, serious health conditions, and both adult and infant mortality. While particulate matter threatens the health of all Americans, a history of environmental racism and racial segregation has led to a disproportionate number of Black, Latino, and Indigenous communities being exposed to dangerous levels of air pollution.
To address these growing crises, the IRA includes provisions that target greenhouse gas emissions and reduce air pollution. At a national level, the IRA will bolster Environmental Protection Agency (EPA) rules limiting greenhouse gas and methane emissions; drive investment in renewable energy projects; and support the auto industry in moving toward an electric-car future. According to Energy Innovation models, these measures will reduce greenhouse gas emissions 37 percent to 41 percent below 2005 levels—allowing the United States to achieve its nationally determined contribution and avoid the worst ramifications of climate change. Additionally, the IRA is projected to cut air pollution at such a level that 3,700 to 3,900 deaths, 99,000 to 100,000 asthma attacks, and 405,000 to 417,000 sick days will be avoided by 2030.
At an individual level, the law creates up-front tax and long-term saving incentives to benefit families as they electrify their homes and vehicles, thus improving their indoor air quality. For example, low- and moderate-income homes can receive benefits to install energy-efficient home appliances, including rebates to cover up to 100 percent of the cost of replacing polluting appliances. Though research on the health benefits of electric household appliances and cars is still nascent, studies have shown that enhanced energy efficiency upgrades reduce indoor air contaminants and improve symptoms of asthma and other respiratory health issues, while electric vehicles can reduce health care costs from cardiopulmonary disease and improve quality and length of life.
Critically, the IRA is the first law passed during the Biden administration that expressly contains environmental justice (EJ) requirements, codifying into law EJ goals and initiatives previously established by executive order. For example, the law establishes block grants to fund community-based organizations and improve neighborhood accessibility by tearing down community-dividing highways and reestablishes the Black Lung Excise Tax, which will ensure polluters pay for the harms they inflict on communities. The IRA also provides funding across a host of federal agencies to improve their community outreach activities and evaluate the environmental impact of their decisions. Across these and other programs, the IRA will direct billions of dollars to communities of color and low-income communities with EJ concerns.
In addition to other benefits, the IRA will make progress toward protecting public health. By closing gaps in the health care system that prohibit people from seeking preventative care; taking aim at the root causes of public health crises, such as climate change and air pollution; and addressing health disparities for communities of color and low-income communities, the IRA will move the United States toward a healthier future for all.
The author would like to thank Jill Rosenthal, Emily Gee, Will Beaudouin, Trevor Higgins, Rachel Chang, and Mara Rudman for their review and helpful feedback.