And they almost all have something in common.

“I’ve only had one patient who was vaccinated, and he was being treated for cancer with chemotherapy,” she said, on the vaccines’ limited effectiveness for cancer patients. “Everyone else hasn’t been vaccinated.”

While taking care of those seriously ill with covid, she asks patients, with sympathy and respect: Why not get vaccinated? A few of them told the internist and hospital researcher that they’re concerned about vaccine safety. But mainly, she said, the responses break down into two groups: One comprises people who have been planning to get vaccinated but didn’t get around to it yet. The second highlights a disturbing deficiency in the pandemic response: those eager to get vaccinated but unable to do so because they are homebound.

“For many of the older people, the people with chronic diseases, it’s been very difficult for them to get out and get the vaccine,” she said. And, since many such patients receive home visits from health care providers, she wonders why the vaccine wasn’t brought to them.

“They’re already connected to a health care organization that’s coming to their home on a regular basis. It seems like that should be a strategy we should be using,” said Horwitz.

Doctors in , and have noted the same trend: The covid wards are filled with unvaccinated people. the Centers for Disease Control and Prevention, 76% of Americans ages 65 and older have been fully vaccinated, and about 87% have had at least one dose. Cities and states have slowly been rolling out programs to reach some of Americans, but the programs tend to have modest goals and target only a fraction of the people who likely need outreach.

To boost the financial incentives for vaccinating people in their homes, Medicare it will be reimbursing shots delivered this way at $75 per shot instead of $40 per shot.

New York City in March for reaching the homebound by working with housing agencies, private health care providers, the city’s Department for the Aging and teams of nurses from the Fire Department. By the second week in June, the program had reached 11,000 people, according to a City Hall spokesperson.

Horwitz and others say the city’s program for reaching these people appears to be working, but not as quickly and efficiently as possible.

For instance, the Visiting Nurse Service of New York, one of the area’s largest home care providers, has a contract with the city to vaccinate people in Queens. Anyone homebound in Queens is eligible, whether they’re a VNS client or not. But if you’re in Brooklyn, Manhattan, Staten Island or the Bronx and get home care from VNS, it won’t help you get vaccinated. You then must go through the central bureaucracy and get assigned to one of the other providers contracted to work in your area.

“The city and the providers we use are the primary entity for homebound vaccinations in the city,” said Avery Cohen, a spokesperson for the administration of Mayor Bill de Blasio. “This is a time-consuming and intricate operation, and we’re doing our best to reach as many people as quickly as we can.”

A spokesperson for the Visiting Nurse Service said that over the past 10 weeks its teams of nurses had administered 2,600 doses and vaccinated 1,700 Queens residents. The contract runs through the beginning of July.

About 75% of city residents 65 and up are partially or fully vaccinated, according to the about 10 points lower than the national average. It’s difficult to say how many of the remaining 25% are homebound, but advocates say it’s surely many times larger than the 23,000 people the city is targeting in its homebound vaccination effort.

Defining and counting the “homebound” is problematic. Laird Gallagher, from the Center for an Urban Future, said there are 141,000 people 60 and older who live alone and report ambulatory difficulty in New York City. Susan Dooha, with the Center for Independence of the Disabled, using a broader standard for disability, estimates there are 422,000 city residents age 65 and up who are either fully homebound or significantly impaired, including 262,000 who are at least 75.

She said the city should cast a broader net in defining the homebound and then create a network of public and private care providers to meet the vaccination needs of this population. Some who remain unvaccinated despite a desire to get a shot may tend to some needs on their own. But they may be cognitively impaired and lack the organizational wherewithal to find a shot, Horwitz said.

After raising the issue for much of the past six months, Dooha was glad the mayor announced a program but was immediately dismayed by its boundaries. “I kept asking, What are the criteria?’” she recalled. “Under the [Americans with Disabilities Act], if you need a home visit — you don’t have to be absolutely homebound by a disability — you deserve an accommodation.”

Manhattan Borough President Gale Brewer, who sits on a panel overseeing the vaccine rollout in Manhattan, said she has not been able to get a straight answer from the city about how it defines “homebound” and then decides who gets targeted for home visits for vaccines.

“There’s been a lot of back-and-forth and confusion,” Brewer said. “It’s like, ‘Am I homebound if I go downstairs to get my mail, but don’t go out?’ The real issue is transparency, and we don’t know what the rules are, and we don’t have any data.”

Dr. Zenobia Brown, a physician and executive with Northwell Health, the state’s largest hospital network, anticipates a difficult slog getting the remaining New Yorkers vaccinated.

“What we find is that there’s not a single barrier, or even a simple set of barriers,” Brown said. “We’re to the point where this is hand-to-hand combat, to understand what the individual barriers are and then create solutions for them.”

For instance, the parents of a 22-year-old man with autism wanted to get their son vaccinated, but due to very fixed routines could make him available only at limited times. Another patient, in his 90s, didn’t want to trouble anyone to come to his sixth-floor walk-up apartment.

Robert Janz, 88, and his wife, Jennifer Kotter, 68, weren’t shy about seeking help. As soon as city plans were announced to serve the homebound, Kotter tried to get an appointment for her husband, an who’s bedridden due to what she describes as a “series of small medical failures,” including back injuries from falling.

It took months before she could book her husband’s vaccination — even though caregivers already come frequently to their fourth-floor walk-up apartment in Manhattan. One of them gave Kotter a phone number to call, which led to another phone number and then another, until she finally succeeded. On June 1, a nurse and an EMT arrived together and gave Janz the Johnson & Johnson single-injection vaccine.

Kotter has come to expect such delays as a caregiver. “When you’re caring for a patient, you have to be patient,” she said.

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“I’d be getting a house with 10 people, with a pool, and we’d be going crazy in Miami,” said Sile Ogundeyin, 22, a senior economics major at Columbia University, who was sitting on the steps of the library with his friends.

“I was supposed to be in London for study abroad this semester, so I probably would’ve gone someplace close to there for spring break — maybe in southern Europe,” said New York University sophomore Aliyah Verdiner, 20, a business major from Brooklyn. “That would’ve been a lot of fun, but I guess not this year.”

Some students, however, are being more adventurous. Rumors on campus abound about students who are exploiting loopholes and getting vaccinated against covid in order to party and go on spring break.

“She’s going skiing in Vermont with a bunch of friends,” Aliza Abusch-Magder said of her roommate, whom she declined to name. “She’s very excited to be going to parties and — how do I say this? — making up for lost time in quarantine.”

Abusch-Magder said her roommate was “calling on something in her medical history that doesn’t actually affect her day-to-day, to qualify for the vaccine.” Other young people shared similar reports, such as of peers getting vaccinated who had asthma in their past but not their present.

“I just don’t think it’s ethical,” said Abusch-Magder, a first-year English major from Atlanta. But she also expressed doubt that such behavior is widespread at Columbia.

“I think here it’s an outlier, and I think at some schools it’s standard,” she said, echoing what she’d heard from high school friends on other campuses. “There’s a very high standard of ethics here, and there’s a lot of discourse on it.”

It’s impossible to know how often college students are getting vaccinated. Rumors about it happening illegitimately are widespread, but most of the stories appear to be secondhand. And many aren’t so nefarious on closer examination, because some vaccinated students are actually eligible; they work in labs or health care settings, or they have underlying health issues that put them at high risk for severe covid.

“I put in my height. I put in my weight. And it said I was obese,” said Shira Michaeli, who was sitting on the Columbia library steps, “attending” an online lecture on human rights on her laptop. Obesity qualifies you for early vaccination in at least 29 states.

Michaeli is a bit ambivalent, because she feels healthy, and she’s comfortable with her body weight, which she believes is not really a “comorbidity.” But she said she has had breathing problems ever since suffering a bad case of covid last year. And she also plans to be a camp counselor this summer. So she feels she qualifies for the vaccine on a few counts, even if her body mass index is what officially qualifies her.

“I think, for a while, I was really insecure about it, and then I thought, ‘Listen, for most of my life [my weight] has been bad for me. Clothing hasn’t been my size. People haven’t been … ” Michaeli’s voice trailed off. “But for once in my life, it’ll benefit me, instead of hurting me.”

The 19-year-old Bronx native was scheduled to receive her first shot the next day, so she was several weeks away from being fully vaccinated. She said it wouldn’t have mattered for spring break, anyway, because she had planned to stay close to her dorm, working on papers, perhaps sleeping in a little more than usual, and getting coffee with friends.

“I’m excited to get vaccinated, but I don’t think it’s going to give me any freedom other people don’t have,” Michaeli said. “I think I’ll be a little less anxious, but I don’t think it’s going to change any of my behavior. I think there are plenty of people being unsafe, so I don’t have any wiggle room to be unsafe.”

Down in Greenwich Village, at NYU, there’s very little tension among the vaccine haves and have-nots when it comes to spring break — because there isn’t much of a spring break. It’s a single day, added to create a long weekend in March.

But that doesn’t keep Simran Hajarnavis from dreaming.

“If there wasn’t covid, and there was a real spring break, I’d probably try to plan something with my friends,” she said, turning to one of them and asking: “Want to go to Hawaii?”

Sitting in Washington Square Park, Hajarnavis and her girlfriends said they’re not too worried about being vaccinated right away, as long as they get their shots in time to study abroad in their upcoming junior year.

A few yards away, Aishani Ramireddy said she has already gotten her vaccine, but she’s not doing anything differently from any other student.

“It’s definitely weird,” she said. Ramireddy’s mother is a physician in Los Angeles. She said that, when she was home, she got the vaccine at the end of the day, at her mother’s office, because there were unused doses that would have been thrown out. Still, she feels conflicted about it.

“It just felt like such a privilege to even have that as an option,” Ramireddy said.

Another NYU student, Anna Domahidi, from Chicago, also had an option to get a vaccine, but declined. She doesn’t hold it against her friend Ramireddy, but she does question another friend, who she said talked up his childhood asthma to qualify for a shot. Domahidi still thinks he crossed an ethical line, even though he lives with a parent who’s immunocompromised: “That’s, like, a little better in my mind, but I don’t know.”

This story comes from KHN’s health reporting partnership with .

Â鶹ŮÓÅ Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at Â鶹ŮÓÅ—an independent source of health policy research, polling, and journalism. Learn more about .

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This story can be republished for free (details).