Más de tres cuartas partes de los adultos en Estados Unidos no se vacunaron contra covid la temporada pasada y expertos en salud advierten que esa cifra podría aumentar este año debido a las nuevas recomendaciones del gobierno federal.

Al principio, la vacuna contra covid fue popular. En los primeros meses de 2022, alrededor del 75% de los estadounidenses había recibido al menos una dosis de las primeras versiones de la vacuna, según datos de los Centros para el Control y Prevención de Enfermedades (CDC).

Durante la temporada 2024-2025, en cambio, solo cerca del 23% de los adultos se vacunó contra covid, muy por debajo del 47% que recibió la vacuna contra la gripe.

Las tasas de vacunación contra la gripe, el sarampión y el tétanos también están bajando.

Sin embargo, el covid sigue siendo un riesgo grave y potencialmente mortal. El  año pasado fue la causa principal de muerte registrada en aproximadamente 31.400 certificados de defunción. En comparación, la gripe causó alrededor de 6.500 muertes y la neumonía —una complicación común de la gripe— provocó otras 41.600, según los CDC.

Mientras millones de personas deciden si vacunarse o no esta temporada, investigadores de salud pública temen que las tasas de vacunación caigan aún más, especialmente entre latinos, afroamericanos y personas menores de 30 años, quienes tienen tasas más bajas de inmunización y corren más riesgo de sufrir complicaciones como el covid de largo plazo.

Bajo la administración Trump y con el secretario de Salud y Servicios Humanos Robert F. Kennedy Jr., el gobierno federal restringió sus recomendaciones sobre la vacuna contra el covid, lo que ha generado un mosaico de reglas para el acceso a vacunas en farmacias. En los estados gobernados por republicanos, muchas veces existen más barreras para recibir una dosis.

“Hay mucha desinformación circulando sobre el covid”, dijo Alein Haro-Ramos, profesora asistente de salud, sociedad y comportamiento en la University of California-Irvine. “La desconfianza hacia la vacuna va a aumentar”.

En agosto, la Administración de Drogas y Alimentos (FDA) limitó la aprobación de las vacunas contra covid a personas de 65 años o más y a adultos y niños con al menos una condición médica subyacente que los ponga en alto riesgo de sufrir complicaciones graves.

Un mes después, el Comité Asesor sobre Prácticas de Inmunización de los CDC votó por recomendar una “decisión clínica compartida”, dando marcha atrás respecto de la indicación general de vacunar a todos los adultos. El comité aconsejó a los médicos que explicaran a los adultos menores de 65 años y a los niños que los beneficios de la vacuna son mayores para las personas con afecciones médicas preexistentes.

Esta orientación ha sido rechazada por expertos en enfermedades infecciosas, quienes sostienen que la mayoría de los adultos y niños debería recibir tanto la vacuna contra la gripe como la del covid, ya que ambas son seguras, efectivas y previenen enfermedades graves.

Varias organizaciones médicas independientes, como la American Academy of Family Physicians y la American Academy of Pediatrics, han reiterado su apoyo a una adopción amplia de la vacuna contra el covid.

Más de una veintena de estados han tomado medidas para garantizar que la mayoría de las personas pueda vacunarse contra el covid en farmacias sin necesidad de receta médica, y muchos de ellos basan sus políticas en las recomendaciones de organizaciones científicas.

Además, en muchos de estos estados las aseguradoras están obligadas a cubrir las vacunas sin costo, según un análisis de KFF. En otros estados, en su mayoría gobernados por republicanos, las farmacias podrían requerir receta para aplicar la vacuna.

Entre las razones más comunes para rechazar la vacuna contra el covid están el miedo a los efectos secundarios, preocupaciones sobre consecuencias a largo plazo, dudas sobre su eficacia y desconfianza hacia las farmacéuticas y las autoridades, según una revisión de múltiples estudios publicada en 2024 en la revista Vaccines.

Los datos de los CDC muestran que la desconfianza hacia la vacuna contra el covid durante la temporada 2024-2025 fue mayor entre latinos, afroamericanos, hombres, personas sin seguro médico y personas que viven en estados de tendencia republicana.

Los adultos latinos mostraron una disposición significativamente menor a vacunarse que la mayoría de los otros grupos raciales y étnicos: la tasa de vacunación rondó el 15%.

En parte, esta situación  podría deberse a la edad: una gran proporción de la población latina es joven. Pero las políticas públicas también podrían influir. Por ejemplo, el primer gobierno de Trump vinculó Medicaid a la regla de “carga pública”, una norma que permitía negar la residencia o una visa a inmigrantes que dependieran de programas financiados con fondos públicos. Algunos latinos podrían seguir temiendo inscribirse en servicios sociales, incluso después de que la administración Biden revocó esa norma.

Haro-Ramos fue coautora de un estudio, publicado en 2024, que encontró que muchos latinos dudaban en vacunarse por miedo a que eso afectara su situación migratoria, y que haber sufrido discriminación en el sistema de salud —como negación o retrasos en la atención— aumentaba esa desconfianza.

“¿Confías en el sistema de salud en general? ¿Quieres dar tu información: tu nombre, tu dirección?”, preguntó Haro-Ramos. “La confianza es clave”.

Según Haro-Ramos, el problema probablemente ha empeorado desde que se publicó su estudio. Este verano, la administración Trump reveló que entregaría a Immigration and Customs Enforcement (ICE) los datos personales de las personas inscritas en Medicaid. Muchos latinos están cancelando citas médicas para evitar posibles encuentros con agentes migratorios.

“La gente está evitando salir de sus casas a toda costa”, afirmó.

Janani Rajbhandari-Thapa, profesora asociada en la University of Georgia, College of Public Health, fue coautora recientemente de un estudio sobre la vacunación contra el covid entre casi 1.500 afroamericanos, que viven en el sur de Georgia. El estudio determinó que, al buscar recomendaciones sobre si vacunarse, los participantes tendían a prestar más atención a sus proveedores de salud que a líderes religiosos o compañeros de trabajo.

Más del 90% de los participantes había recibido al menos una dosis de la vacuna, pero quienes no se habían vacunado eran más propensos a creer en afirmaciones falsas, como que la vacuna causa abortos espontáneos, que permanece mucho tiempo en el cuerpo o incluso que contiene un microchip.

“Son los médicos quienes pueden explicar que esas ideas sobre la vacuna son mitos”, afirmó Rajbhandari-Thapa.

Aunque las tasas de hospitalización y muerte por covid han bajado considerablemente desde los peores momentos de la pandemia, las complicaciones fatales siguen siendo más comunes entre personas mayores. El año pasado, aproximadamente el 89% de las muertes por covid en EE.UU. fueron entre personas de 65 años o más, en comparación con el 81% de las muertes por gripe y neumonía.

A medida que la pandemia queda atrás, muchos jóvenes han desarrollado una sensación de invulnerabilidad. Solo el 11% de los estadounidenses entre 18 y 29 años se vacunó durante el período 2024-2025, la tasa más baja entre los grupos de edad adulta. Eso contrasta con el 70% de adultos jóvenes que habían recibido al menos una dosis de la vacuna inicial contra el covid hacia noviembre de 2023.

Aunque muchas personas se contagian de covid incluso después de vacunarse, porque la protección contra la infección disminuye rápidamente, algunas malinterpretan el objetivo de la vacuna, explicó Otto Yang, especialista en enfermedades infecciosas de UCLA Health.

“Piensan: ‘Bueno, me dio covid a pesar de la vacuna, así que no funcionó’”, dijo Yang. “Y lo que no ven es que la vacuna evitó que se enfermaran de gravedad, que es lo más importante”.

Yang agregó que la vacuna también puede ayudar a prevenir el covid prolongado, un problema que puede afectar a personas de cualquier edad. Un estudio reciente de la Northwestern University halló que los adultos jóvenes sufren síntomas más intensos de covid prolongado que los adultos mayores.

En última instancia, dijo Yang, no tiene sentido aplicarse la vacuna contra la gripe y no la del covid, ya que ambas son seguras, efectivas y previenen enfermedades graves. Está claro, añadió, que las personas con sistemas inmunológicos comprometidos y aquellas en mayor riesgo deberían vacunarse contra el covid. La decisión “es un poco menos clara” para los demás, “pero probablemente la mayoría de los adultos debería vacunarse, al igual que se recomienda con la vacuna contra la gripe, así como para la mayoría de los niños”.

Phillip Reese es especialista en periodismo de datos y profesor asociado de periodismo en la Universidad Estatal de California en Sacramento.

Liz Dunnebacke isn’t dying, but for a recent end-of-life care workshop in New Orleans, she pretended to be.

Dunnebacke lay still atop a folding table that was dressed as a bed, complaining that her legs hurt. Registered nurse Ana Kanellos, rolling up two small white towels, demonstrated how to elevate her ankles to ease the pain.

“ Mom’s legs are always swollen? Raise ’em up,” Kanellos said.

About 20 New Orleans residents listened intently, eager to learn more about how to care for loved ones at home when they’re nearing the end of their lives. Attendee Alix Vargas said she used to be terrified of dying. But about three years ago, a close cousin’s death led her to attend group writing workshops, helping her embrace her grief and conquer her fear.

“ I’m feeling very called towards this work,” she said. “It’s definitely knowledge that I wanted to obtain and expand my mind in that way. And this is also something that we’re all going to encounter in our lives.”

The workshop made her think about a neighbor whose mother has dementia.

“ I was immediately thinking, ‘OK, there’s someone in my immediate orbit that is experiencing this,’” Vargas recalled. ‘“Here’s a practical way to put the mutual aid in use.’”

Demand for home health care, including at-home hospice care, has skyrocketed since the onset of the covid pandemic, as has the number of family caregivers. An estimated 63 million people in the U.S. — nearly a quarter of all American adults — provided care over the previous year to another person with a medical condition or disability, usually another adult, according to a 2024 survey by AARP and the National Alliance for Caregiving. In the past 10 years, about 20 million more people have served as caregivers.

With nearly 1 in 5 Americans expected to be 65 or older by 2030, health care experts predict the demand for at-home caregivers will continue to rise. Online resources for end-of-life care are widely available, but hands-on training to prepare people to become caregivers is not, and it can be expensive. Yet untrained family members-turned-caregivers are taking on nursing and medical tasks.

Donald Trump promised more support for caregivers during his 2024 campaign, including a pledge to create new tax credits for those caring for family members. He endorsed a bill reintroduced in Congress this year that would allow family caregivers to receive tax credits of up to $5,000, but the legislation hasn’t moved forward.

Meanwhile, the Medicaid cuts expected from Republicans’ One Big Beautiful Bill Act, which President Trump signed in July, could prompt states looking to offset their added expenses to reconsider participating in optional state Medicaid programs, such as the one that helps pay for at-home hospice care. That would threaten to make dying at home even more unaffordable for low-income families, said advocates and researchers.

Advocates like Osha Towers are trying to help caregivers navigate the uncertainty. Towers leads LGBTQ+ engagement at Compassion & Choices, a national organization that focuses on improving end-of-life care, preparation, and education.

“It is certainly very scary, but what we know we can do right now is be able to just show up for all individuals to make sure that they know what they need to be prepared for,” Towers said.

In New Orleans, a nonprofit called Wake, which focuses on supporting family caregivers providing end-of-life and death care, is one of the organizations trying to help fill the knowledge gap. Wake put on the free, three-day September workshop where Dunnebacke, the group’s founder, pretended to be a dying patient. Such workshops are aimed at preparing attendees for what to expect when loved ones are dying and how to care for them, even without costly professional help. Full-time at-home care is rare.

“You don’t have to have any special training to do this work,” Dunnebacke said. “You just need some skills and some supports to make that happen.”

In some ways, the evolution of end-of-life care in the U.S. over the past century has come full circle. It was only starting in the 1960s that people shifted from dying at home to dying in hospitals, nursing homes, and hospice facilities.

Such institutions can provide immediate advanced medical support and palliative care for patients, but they often lack the human connection that home care provides, said Laurie Dietrich, Wake’s programs manager.

Now, more people want to die in their homes, among family, but with the support and technology that comes with modern medical facilities.

In the past decade, death doulas — who support the nonmedical and emotional needs of the dying and their loved ones — have grown in popularity to help guide people through the dying process, helping to fill that gap. Douglas Simpson, executive director of the International End of Life Doula Association, said his organization recognizes the lack of resources for death care, so it is training doulas to be community educators. He hopes doulas can be especially useful in rural communities and lead conversations about dying.

“Making people more open, more comfortable about talking about death and considering their mortality,” Simpson said.

Death doula training varies depending on the organizer, but Simpson’s group focuses on teaching attendees about the dying process, how to maintain the autonomy of the dying person, and how to be aware of how they show up to a job and take care of themselves while caring for others.

Some people who attended Wake’s workshop had also attended some form of death doula training in the past. After Nicole Washington’s mother was killed in 2023, she considered becoming a death doula. But she thought the doula training, which can cost $800 to $3,000, was clinical and impersonal, as opposed to Wake’s community-based approach.

“I feel very energized, very uplifted,” Washington said. “It’s also really nice to be in a space with people who are familiar with death and grief.”

Ochsner Health’s Susan Nelson, who has worked as a geriatrician for 25 years, said there is a need for more specialized programs to train and prepare caregivers, like Wake’s.

“Learning caregiving skills is probably, unfortunately, more trial by fire,” Nelson said.

Compassion & Choices is another organization trying to educate caregivers. Towers said the group’s training ranges from advanced planning to acting as a health care proxy to caring for the dying.

“We’ve gone to a place in our country where we’re so removed from end-of-life care in a way that we didn’t used to be,” Towers said.

She said the movement to care for people at home and give them community support has roots in the AIDS epidemic, when some doctors refused to care for AIDS patients. Friends, especially in the lesbian community, started coordinating food delivery, visits, bedside vigils, and even touch circles, where patients could receive comforting forms of touch such as hand-holding to ease pain and feelings of isolation.

“I like to look at it as a blueprint for what we can get back to doing now, which is again just prioritizing community care,” Towers said.

This article was produced in collaboration with Verite News. Verite News reporter Christiana Botic contributed to this report.

Elisabeth Yoder’s son, Darragh, was 15 months old in August when he developed what at first looked to his parents like hand, foot, and mouth disease. The common viral infection generally clears up in less than a week, but Darragh’s condition worsened over several days. His skin turned bright red. Blisters gave way to skin peeling off his face.

An online search of his symptoms suggested he had staphylococcal scalded skin syndrome, a serious bacterial infection. Yoder drove the toddler from their home in the small town of Mechanicsburg, Ohio, to the Mercy Health hospital in nearby Urbana.

Staff in the emergency room there quickly confirmed that Darragh had scalded skin syndrome and said he needed to be taken by a private company’s ambulance to Dayton Children’s, a hospital about 40 miles away.

“I asked them: ‘Can I take him? Can I drive him?’” Yoder said. “And they were like, ‘Oh, absolutely not.’”

So, Yoder and her son got into the ambulance, with Darragh strapped in his car seat. The ambulance driver didn’t turn on the siren or drive particularly fast, Yoder said. The trip took about 40 minutes, she said. “It was fairly straightforward transportation from Point A to Point B.”

Yoder had heard that ambulance rides can be pricey. But she didn’t know how much her son’s ride would cost.

Darragh was hospitalized for three days and recovered from the illness.

Then the bill came.

The Medical Procedure

During the ride, the ambulance crew monitored Darragh’s vitals and an intravenous line, inserted at the hospital, carrying fluids and antibiotics, but he received no other medical treatment, Yoder said.

The Final Bill

$9,250, which included a “base rate” charge of $6,600 for a “specialty care transport” and a mileage fee of $2,340, calculated at $60 for each of the ride’s 39 miles. It also included $250 for use of an intravenous infusion pump and $60 for monitoring Darragh’s blood oxygen.

The Problem: No Insurance, Few Protections

The children’s hospital charged only about $3,000 more for the toddler’s three-day stay than the ambulance company charged for the ride, Yoder said.

Darragh’s family doesn’t have health insurance, leaving them on the hook for the full charges. Their income is a bit too high for them to qualify for Medicaid, the public health program that covers low-income residents, or for the Ohio Children’s Health Insurance Program, which covers moderate-income kids.

The Yoders belong to a Christian health care sharing ministry, with members paying into a fund that helps reimburse them for medical bills.

Unlike health insurance, such arrangements do not offer members negotiated rates with ambulance companies or other medical providers. And there are no state or federal billing protections that would help an uninsured patient in Ohio with a ground ambulance bill.

The federal No Surprises Act protects those with insurance from large bills for air ambulance transportation provided outside their insurers’ network agreements. But ground ambulance services aren’t covered by the law — and even if they were, that wouldn’t have helped the Yoders, since they didn’t have insurance.

Patricia Kelmar, the senior director of health care campaigns for PIRG, a national advocacy group, said ambulance charges vary widely. She said she’s seen per-mile charges ranging from less than $30 to more than $80, as well as base rates that differ dramatically.

Some patients, such as those with traumatic injuries, need ambulances with highly trained staff and advanced medical equipment, Kelmar said, so it makes sense that those rides would be more expensive. But patients rarely are told what the ride will cost until they receive a bill.

Jennifer Robinson, a spokesperson for Mercy Health, said she couldn’t comment on a specific patient’s case but said the staff follows established medical standards. “When a patient requires a higher level of treatment, ambulance transfer between facilities is best practice to ensure appropriate care,” she said in an email to KFF Health News.

Kimberly Godden, a vice president for the ambulance company, Superior Ambulance Service, said a doctor at the first hospital requested a high-level transport for the patient, requiring specially trained staff.

“Our priority is always to ensure patients receive the highest-quality care when they need it most, and we respond to every call regardless of a patient’s ability to pay,” Godden said in an email. “Superior had the team and resources available to quickly and safely move the patient to the higher level of care they needed within the time frame set by the ordering physician.”

Godden said the company would offer a “charity care” rate to Yoder if the family qualified for it.

The Resolution

Yoder said she repeatedly discussed the bill with ambulance company representatives, including the option for charity care. They told Yoder the best deal they could offer was to reduce the total by about 40%, to $5,600, if the family paid it in a lump sum, she said.

After months of discussion, the family wound up agreeing to that deal, Yoder said. They put the charge on a new credit card, which gave them 17 months to pay it off with no interest.

They have agreed to payment plans with the two hospitals, which offered charity care discounts that dropped the bills to a total of about $6,800.

The Yoders expect the sharing ministry to reimburse them for about 75% of the payments they’re making to the hospitals and the ambulance service.

The Takeaway

Patients and their families should feel comfortable asking hospital staffers whether a recommended ambulance company is in their insurance network and how much the ride to another location will cost, said Kelmar, a national expert on such bills. “Shouldn’t the hospital know that?” she said. “I don’t think it’s that heavy of a lift.”

Kelmar said she doesn’t want to discourage people from taking an ambulance if a doctor says it’s necessary. Once consumers receive a bill for the service, she said, they often can negotiate the price down. It can help to look up what the ambulance service accepts as payment from government programs. Those rates are often much lower than the full-price charges patients see on a bill.

If the family had been covered by Ohio’s Medicaid program, the ambulance service would have been paid much less than it charged the Yoders. The public health program pays ambulance services a $413 base rate for “specialty care transports,” plus $5.05 per mile. Those rates would have added up to $609.95 for the transportation part of Darragh’s ambulance ride.

Yoder said she wishes she had driven Darragh straight to the children’s hospital. If she had skipped the local ER, she said, they would have arrived at the bigger hospital sooner and she would have saved thousands of dollars.

But she didn’t feel as if she had a choice about putting her son in the ambulance, she said. The doctor told her it was necessary, and the hospital staff had already inserted an intravenous line. “I wasn’t going to pull out his IV line and just leave,” she said.

Yoder said she remains uninsured because she hasn’t seen any private insurance options that suit her family’s circumstances. No matter who pays the ambulance bill, she thinks the charges were much too high. She understands that patients can often negotiate discounts, she said, “but you shouldn’t have to work so hard for it.”

Bill of the Month is a crowdsourced investigation by KFF Health News and The Washington Post’s Well+Being that dissects and explains medical bills. Since 2018, this series has helped many patients and readers get their medical bills reduced, and it has been cited in statehouses, at the U.S. Capitol, and at the White House. Do you have a confusing or outrageous medical bill you want to share? Tell us about it!