December 17, 2021 2:20 PM EST

For the last month, Dr. John Waits and his staff have asked the parents of any kid who walks into the clinic the same question: will the child have the COVID-19 vaccine?

“Instantly you see the body language and you get a sense of where we’re going,” says Waits, a family medicine physician and CEO of Cahaba Medical Care in Alabama. The conversations don’t usually end in a “heck no,” he says, but they don’t often end in an immediate vaccination, either. Across Cahaba’s network of 17 health clinics and several visits to local schools, Waits and his team have vaccinated about 150 children since Nov. 2, the day the Centers for Disease Control and Prevention (CDC) recommended the COVID-19 vaccine for kids ages 5 to 11.

“One of the challenges of the pandemic that’s made it so hard for public health is that people just want to get back to their doctor and hear their doctor talk about it, and then kind of think about it,” Waits says. “That’s not the speed we need to continue to flatten the curve.”

Another challenge: Unless a patient actually receives the vaccine, Waits and his staff usually don’t get paid for the time spent counseling them about it. All that unpaid time makes for tough finances—especially for community health centers, like Cahaba, which often operate on thin margins and treat underserved populations, and which public health experts say are crucial to getting more Americans vaccinated.

Already the effort to vaccinate children has been an uphill battle. After an initial spike of interest in the first ten days that young children were eligible for the COVID-19 vaccine, progress has slowed significantly. More than a month later, just 1 in 5 children have gotten their first shot, and significant disparities have developed among states: some report that a quarter of kids are vaccinated; others are under 10%.

With Omicron taking off in the U.S. and cases surging amid holiday gatherings, President Joe Biden has been encouraging Americans to get vaccinated as soon as possible. “​​We are looking at a winter of severe illness and death—if you’re unvaccinated—for themselves, their families, and the hospitals they’ll soon overwhelm,” he said on Dec. 16.

In an effort to facilitate more vaccinations, the Biden Administration announced earlier this month that it will now require Medicaid, the public insurance program for low-income Americans, to pay health care providers for simply talking with families about kids’ vaccinations. While states still have to implement the new policy, Medicaid provides health insurance for more than 40% of children across the country, so the impact could be significant.

“This policy really just underscores the importance of vaccination education, how critical that is as a piece of what gets people to making that decision to go ahead and get vaccinated and how critical it is to combating mis- and disinformation,” says Dr. Cameron Webb, senior adviser for equity on the White House COVID-19 Response Team.

Doctors fighting an uphill battle

In some ways, vaccinating children en masse should be easy. Primary care and family medicine doctors, as well as pediatricians, give vaccines all the time. But the politics and urgency of administering the COVID-19 to kids makes it infinitely more difficult—and requires doctors to engage in fraught conversations before almost every shot.

When the Food and Drug Administration (FDA) authorized the Pfizer vaccine for kids ages 5 to 11, the agency announced that the shot was safe and effective for children. The common side effects were fatigue, headache and fever. But Americans were ambivalent. While 63% of parents say they are confident the COVID-19 vaccines are safe for adults, just 52% say they’re confident for kids ages 12 to 17, and just 43% say they are confident it’s safe for kids ages 5 to 11, according to a Kaiser Family Foundation survey published Dec. 9. About a third of parents with kids between 5 to 11 in the survey say they want to wait and see before giving their child the vaccine.

Read More: To Get Kids Vaccinated Against COVID-19, Health Officials Will Need to Reach Hesitant Parents

Pediatricians remain the most trusted source of information for Covid-19 vaccines. Overall, 77% of parents said they trust their child’s pediatrician or health care provider a great deal or a fair amount, and that trust remained high across party, race and ethnicity. Providers know this and they want to use their power of persuasion on each family. But they often have limited time and are also trying to help patients catch up on medical care they missed during the pandemic, ask about any chronic disease issues or figure out why a patient is sick now, and ensure parents know about regular annual vaccines their children still need.

“You make an audible on the line of scrimmage every visit. If somebody has got a lot of genuine questions and the conversation is going well, you steal an extra three or four minutes for the conversation, and you take it out of the next visit,” Waits says. If a parent seems to really shut down, he might move on more quickly and revisit the issue another time.

Dr. Ron Yee, chief medical officer of the National Association of Community Health Centers, says taking the time to patiently answer parents’ questions is perhaps especially key when serving low-income people like those on Medicaid, or populations that might have cultural, language or educational barriers that doctors need to navigate. “Being able to have that extra time to spend with the patients and specifically the parents—of course, they’re going to be the ones who are being educated—that is really critical,” he says.

A long time coming

Provider associations have been pushing for reimbursement for counseling about vaccines since long before the pandemic. But when discussions about the COVID-19 vaccine began to take more and more time, providers say the urgency for reimbursement increased.

“Vaccine counseling was kind of that low level background noise that we did, you know, three, four times a day. And now we’re doing this, if we see 25 patients a day, I’m probably doing it 15 or 20, plus a couple of phone calls a day,” says Dr. Jesse Hackell, a pediatrician who chairs the Committee on Practice and Ambulatory Medicine for the American Academy of Pediatrics (AAP), which has worked closely with the administration on its vaccine rollout for kids. “With the urgency to get millions of kids vaccinated quickly, the volume of this has just skyrocketed, and it’s no longer the low level of background noise. It’s a real time consuming effort that we have.”

The American Academy of Pediatrics’ president praised the Biden administration’s action on reimbursing doctors for vaccine counseling, and other groups have been enthusiastic about the change too. The American Academy of Family Physicians, the American College of Obstetricians and Gynecologists, the American College of Physicians, the American Osteopathic Association, and the American Psychiatric Association were among those who consulted directly with the Biden Administration on the rule change, says Webb, the COVID-19 equity adviser.

Vacheria Tutson, director of regulatory affairs at the National Association of Community Health Centers, says her organization started meeting with officials at the Centers for Medicare and Medicaid Services (CMS) to discuss reimbursement challenges during the presidential transition period. “This is such a great step in the right direction,” she says.

Challenges remain

Under the new policy, the cost of COVID-19 counseling visits for children who have Medicaid will be covered by 100% federal funding. But because Medicaid is a joint federal-state program, state Medicaid agencies still have to adopt it, and providers still have to learn about it and figure out how to document everything appropriately. Its effectiveness will also depend on which staff members can get paid for doing the counseling and how much staffing health centers can maintain. “The devil is in the details,” Waits says.

CMS held a call with states last week to explain the program, and Webb says the reception was positive. He has also heard from providers who like the change but are already asking about whether the reimbursement can be extended to other populations as well. “This is an important first step from a federal standpoint for us to see the impact here,” Webb says. “We’re always looking to do whatever we can to support providers who have been working so hard through this pandemic and so we’ll keep our eye out.”

The change does not cover patients who don’t have insurance, or those who have private insurance. But private health insurance companies often follow CMS precedent, so some insurers may decide to start covering vaccine counseling for children once Medicaid does so.

In the meantime, community health centers have plenty of financial challenges to balance as they push forward on vaccination. “Health centers are often on very small budgets or margins,” says Yee of the National Association of Community Health Centers. Community health centers want to be providing as many services as possible, and getting paid for more of their work could help.

“If the staff is able to capture that and bill for it, then it helps the health centers. It helps them to maintain their operations, it helps them to retain their staff, and to maintain those enabling services. That includes transportation, translation, enrollment—all those things help education,” he says.

Read More: Biden’s Health Equity Task Force Highlights Progress in Addressing COVID-19 Disparities

Encouragement for more counseling

In Mississippi, where just 6% of children have gotten their first shot, Dr. Wendy Williams has seen this. She serves as the chief medical officer for Coastal Family Health Center, a group of clinics near the gulf coast that treats a diverse population including many Spanish speakers, as well as a large Vietnamese community, migrant workers and those who work on ships docked in the local ports. The Biden administration’s move to pay providers for the time they spend counseling patients could help if it goes smoothly, she says. Her clinics have been struggling to get reimbursed from the federal government for vaccinating uninsured patients throughout the pandemic. So far, she says they have been reimbursed for about 30-40% of those shots, which means the center has fronted the rest of the cost.

As the health center balances its budget, Williams has sometimes had to worry about buying supplies or sending staff out to vaccinate homebound patients or the workers on ships, which can take significant amounts of time compared to the cost. “You would love to go out and do everything for everybody. But you have to make sure that you can pay those people that are going out to do it too,” she says.

This is exactly the kind of issue the administration hopes to help address. After seeing the disparities among communities of color and rural communities in early vaccination months, the White House is also hoping that by targeting Medicaid patients this change can help avoid repeating those for children as part of its equity-focused COVID response.

“We want to make sure that providers know how much we value the counseling and the work that they’re doing,” Webb says. “And at the same time, [we want to] give them that encouragement to continue doing it.”

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Write to Abigail Abrams at abigail.abrams@time.com.

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