Impact of healthcare capacity disparities on the COVID-19 vaccination coverage in the United States: A cross-sectional study

Diego F. Cuadros, Juan D. Gutierrez, Claudia M. Moreno, Santiago Escobar, F. De Wolfe Miller, Godfrey Musuka, Ryosuke Omori, Phillip Coule, Neil J. MacKinnon

Research output: Contribution to journalArticlepeer-review


Background: The impact of the COVID-19 vaccination campaign in the US has been hampered by a substantial geographical heterogeneity of the vaccination coverage. Several studies have proposed vaccination hesitancy as a key driver of the vaccination uptake disparities. However, the impact of other important structural determinants such as local disparities in healthcare capacity is virtually unknown. Methods: In this cross-sectional study, we conducted causal inference and geospatial analyses to assess the impact of healthcare capacity on the vaccination coverage disparity in the US. We evaluated the causal relationship between the healthcare system capacity of 2417 US counties and their COVID-19 vaccination rate. We also conducted geospatial analyses using spatial scan statistics to identify areas with low vaccination rates. Findings: We found a causal effect of the constraints in the healthcare capacity of a county and its low-vaccination uptake. Counties with higher constraints in their healthcare capacity were more probable to have COVID-19 vaccination rates ≤50, with 35% higher constraints in low-vaccinated areas (vaccination rates ≤ 50) compared to high-vaccinated areas (vaccination rates > 50). We also found that COVID-19 vaccination in the US exhibits a distinct spatial structure with defined “vaccination coldspots”. Interpretation: We found that the healthcare capacity of a county is an important determinant of low vaccine uptake. Our study highlights that even in high-income nations, internal disparities in healthcare capacity play an important role in the health outcomes of the nation. Therefore, strengthening the funding and infrastructure of the healthcare system, particularly in rural underserved areas, should be intensified to help vulnerable communities. Funding: None.

Original languageEnglish (US)
Article number100409
JournalThe Lancet Regional Health - Americas
StatePublished - Feb 2023


  • COVID-19
  • Healthcare capacity
  • Healthcare underserved communities
  • United States
  • Vaccine uptake

ASJC Scopus subject areas

  • Health Policy
  • Internal Medicine
  • Public Health, Environmental and Occupational Health


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