The Access Paradox: A Decade of Expanded Influenza Vaccine Access That Did Not Close a Racial Disparity

OBJECTIVES: Despite more than a decade of expanded influenza vaccine access through Medicare, pharmacy-based programs, and community clinics, older African Americans remain vaccinated at markedly lower rates than older White and Asian adults. This study examines why the disparity has persisted and whether U.S. vaccination policy evidence was ever designed to address it. METHODS: A narrative review synthesized surveillance data with peer-reviewed literature (2006-2026) on vaccine confidence and uptake among older African American adults, compared against themes from a 2015 qualitative study, and interpreted through the Theory of Planned Behavior and a multidimensional model of healthcare access. RESULTS: Structural interventions endorsed by the CDC's Community Preventive Services Task Force were never evaluated for their capacity to close race-specific disparities; applied nationally for a decade, they did not. Decomposing access into component dimensions showed policy addressed only affordability and availability, leaving accessibility, accommodation, acceptability, and awareness unmeasured. Self-advocacy, evaluating vaccine information independently rather than deferring to providers, was documented in 2006, 2016, and 2025 alike. CONCLUSIONS: This "Access Paradox", persistent disparity despite expanded, evidence-based structural access, reflects a gap in the evidence base itself, not only a gap in trust. Closing it requires testing trust-centered, culturally responsive approaches with the rigor historically reserved for structural interventions. PUBLIC HEALTH IMPLICATIONS: Provider relationships, culturally responsive communication, and community engagement should complement, not replace, structural access, and self-advocacy should be treated as an asset rather than an obstacle. Structural expansion alone should not be assumed sufficient until interventions are evaluated for equity impact.