Xavier Becerra, the secretary of health and human services, hinted on Tuesday that the Biden administration may need to ask Congress for more money to fight the coronavirus pandemic, depending on the scope and severity of a potential new wave of infections fueled by the Omicron variant.During a round-table discussion with reporters that focused heavily on testing, Mr. Becerra noted that while the administration has some flexibility to move money around, of the $50 billion Congress has allocated for testing, about $10 billion is left. President Biden has made expanded testing a centerpiece of the winter pandemic strategy he announced last week.“Are we going to have more than $10 billion worth of needs and costs on Covid, especially in regards to testing?” Mr. Becerra said. “There’s a strong chance we will, depending on where Omicron takes us.” He added that his department’s experts were trying to make projections to determine whether additional funding would be necessary — before the need becomes urgent.“The president said we’ve got to stay ahead of this, so we don’t want to be asking Congress for money after we know we need it,” he said.With the pandemic heading into its third year, and Omicron on the horizon, much of the money that Congress has allocated for coronavirus response has been spent. The $2 trillion CARES Act was signed by former President Donald J. Trump in March 2020, and the $1.9 trillion American Rescue Plan was signed by Mr. Biden in March 2021. Both were aimed at boosting the economy, as well as addressing Americans’ health needs during the crisis.The rescue plan included $14 billion to speed up vaccine distribution, and $130 billion to help schools reopen safely, among other coronavirus-related provisions. But the plan, and the CARES Act before it, went into effect before the emergence of the Delta variant this summer, which caused hospitalizations and deaths to spike, adding strain to an already overburdened health care system. The Centers for Disease Control and Prevention has been tracking Omicron cases, which have now turned up in more than 20 states. “Even if most infections are mild, a highly transmissible variant could result in enough cases to overwhelm health systems,” agency officials wrote in a report last week.On Thursday, the Department of Health and Human Services announced it was releasing $9 billion in “provider relief fund” payments to bolster hospitals and other health care providers that have experienced revenue losses because of the pandemic. More than 69,000 providers in all 50 states, plus Washington, D.C., and eight territories, will receive payments.In September, the department announced that it would spend a total of $25.5 billion on the effort. That includes the $9 billion released on Thursday and $8.5 billion released last week to rural health care providers. The remainder of the funds will be disbursed in 2022.In announcing his winter strategy last week, Mr. Biden vowed to fight the pandemic with “science and speed.” He said that people who buy at-home rapid coronavirus tests would soon be eligible for reimbursement from their insurers, and that to ensure access for the uninsured, the federal government would distribute 25 million tests to community health centers and rural clinics.After the announcement, administration officials said people buying the tests would have to request reimbursement, rather than being reimbursed in the pharmacy as when filling prescriptions. Some public health experts and consumer advocates have balked at that. Mr. Becerra said Thursday that his department was still figuring out the particulars. A number of states have been distributing free at-home tests, including Massachusetts, New Hampshire, Maryland, Colorado and Ohio.Other countries have spent more heavily on rapid testing. In Britain, citizens can use a government website to order free rapid tests for home use. Germany invested hundreds of millions of dollars to create a network of 15,000 rapid testing sites. The United States has instead focused public purchasing on vaccines, and efforts to encourage their uptake.On Tuesday, Mr. Becerra pledged, “We are going to make sure that the American people have access to tests and they don’t have to pay out of pocket.”“How that exactly gets done, we work with our team to make it happen,” he added. “We’re hoping that it will be done in a way that is as smooth as possible.”

A bipartisan group led by two former governors is urging President Biden to help an estimated 167,000 children who have lost parents or caregivers.WASHINGTON — Courtney Grund, whose husband died of Covid-19 in August, got an alarming text message last week: Her 16-year-old son was “talking about self-harm,” according to the message, sent by his friend. She quickly signed him up for grief counseling, she said in a tearful interview, using her maiden name to protect his privacy.John Jackson, a disabled veteran on a fixed income, said he had struggled to find help for his 14-year-old daughter, whose mother died in the pandemic. “I can see it in her, where she’s suffering,” he said.Pamela Addison, a reading teacher whose husband died, said she felt fortunate that she could afford therapy — $200 a session out of pocket — for her grieving 3-year-old.Although Congress has allocated trillions of dollars to combat the pandemic, including more than $100 million for existing children’s mental health programs and $122 billion for schools, the Biden administration and lawmakers have not yet created initiatives specifically for the tens of thousands of children who have lost parents and primary caregivers to Covid-19.Behind the scenes, leaders of a bipartisan coalition of experts in education, the economy and health — backed by wealthy philanthropies and headed by two former governors, Dirk Kempthorne of Idaho, a Republican, and Deval Patrick of Massachusetts, a Democrat — have been meeting with White House officials, urging them to do more.On Thursday — just two days after the surgeon general warned that young people were facing “devastating” mental health issues related to the pandemic — that group, the Covid Collaborative, will release a report estimating that more than 167,000 children in the United States have lost parents or in-home caregivers to the disease.The collaborative is asking President Biden to initiate a national campaign to identify these children and, with help from the private sector, take steps to improve their emotional and economic well-being. Its recommendations include offering them mental health care and creating a “Covid Bereaved Children’s Fund,” similar to a fund established after the Sept. 11 attacks, to provide up to $10,000 to families in need.“The president is uniquely positioned to put an official imprimatur on the call in this report to coordinate all resources, public and private, at every level of government and every level of the private sector and philanthropy to help these children,” Mr. Patrick said in an interview.“It’s a tragedy not of their making,” he added, “but they’re our kids. They belong to us, and all we are saying is, ‘Let’s act like it.’”The report, titled “Hidden Pain,” estimates that more than 70 percent of the bereaved children are 13 or younger. It is based on federal data and a modeling study led by Dan Treglia, a social policy researcher at the University of Pennsylvania.Communities of color are disproportionately affected. Dr. Treglia, who is also part of the collaborative, said racial and ethnic disparities in caregiver loss from Covid-19 exceeded the already stark disparities in coronavirus deaths.Parents and young people left behind said the push by the Covid Collaborative was welcome news, if only to force officials in Washington to recognize this new cohort of bereaved children.Ms. Grund picked up her son from school last week after she got the text from his friend; he has not yet returned.He went to his first group therapy session Tuesday evening. In an interview, he said he was having mood swings and suicidal thoughts, and had not wanted to leave his room. He would like to see initiatives that better equip teachers and school officials to help grieving students.Ms. Grund with her son and Georgie, their therapy dog. Her son said he would like to see initiatives that better equip teachers and school officials to help grieving students.Adriana Zehbrauskas for The New York Times“No one knew how to deal with what I was going through, so it was hard for the teachers to communicate to me,” he said, adding that while he could talk to his friends, it had not helped much. “I can share with them, but it’s in one ear and out the other,” he said. “They don’t completely understand and, like, process the whole situation.”A spokeswoman for the Department of Health and Human Services, Kirsten Allen, said the administration “has made a number of investments and launched several initiatives covering a wide range of mental health priorities — including support for children who have lost parents.”She cited the surgeon general’s advisory and the expansion of several existing programs. In May, for example, the department announced it was releasing $14.2 million, allocated by Congress through the American Rescue Plan, to expand access to pediatric mental health care. The rescue plan also provided money for suicide prevention programs and a program to improve care and access to services for “traumatized children.”John Bridgeland, the collaborative’s founder and chief executive officer, said expanding existing programs was not enough. “We need a focused effort to help the unbearable loss of these 167,000 children,” he said.Losing a parent or a caregiver is hard for a child in ordinary times. But experts in grief counseling and school officials say the pandemic has exacted a particular toll.“The death of a parent is something that we deal with all the time — not just with Covid,” said Susan Gezon Morgan, a school nurse in Emmett, Idaho, a small city outside Boise. “But I think the fact that Covid is in the news and so sudden, and oftentimes it’s a young parent, that it seems so much more traumatizing.”In a small community like Emmett, where everyone knows everyone else, Ms. Morgan said, the grief cuts both ways. Grieving children lose their privacy, but they also have a tight-knit community to provide support. In big cities, it is another story.Mr. Jackson, of Reisterstown, Md., just outside Baltimore, is home-schooling his daughter, Akeerah, in part because he fears her peers will be insensitive, encouraging her to “just get over” her loss.When Akeerah’s mother, Cathy Fulcher, died, Mr. Jackson got a note from the Baltimore County school system saying she could delay turning in her grades, but little in the way of guidance. Soon afterward, he said, he started looking for a place for his daughter to get therapy.“One was $250; they didn’t take any type of insurance,” he said. “That was just for us to come in for an evaluation. That’s just not in the budget.”Akeerah Jackson, 14, with her father, John, and a photo of herself with her mother, Cathy Fulcher, who died of Covid-19. A grief support center in Baltimore has helped Akeerah cope with her loss.Alyssa Schukar for The New York TimesEventually he found Roberta’s House, a grief support center for Baltimore families. There, Akeerah said, she has learned how to cope with her grief by drawing and writing in a journal, and she is now a “peer ambassador,” leading sessions for other teens. She has also attended Camp Erin, a free camp for grieving children offered in cities across the country.Both are funded by the New York Life Foundation, which also backs the Covid Collaborative and has created a website, grievingstudents.org, to provide information for educators as part of its “grief-sensitive schools” initiative, which predates the pandemic. The vice president of the foundation, Maria Collins, says many of its programs have waiting lists.“It’s known in this field that the young person is the forgotten griever,” she said, adding that the foundation was open to working with the federal government and would be “eager to provide tangible support, financial and otherwise, for Covid-bereaved children.”The collaborative envisions $2 billion to $3 billion for the bereavement fund, possibly supplemented by money from private foundations. It would help parents struggling with everything from rent payments to their children’s academic performance to finding the right therapy at a reasonable cost.The report builds on similar research: The journal Pediatrics, relying on data through June 30, before the wave of infections caused by the Delta variant, reported in October that more than 120,000 American children had lost parents or caregivers from Covid-19.The researchers who conducted the collaborative’s study found that Black and Hispanic children were roughly two and a half times as likely as whites to be bereaved as a result of the pandemic, while Native American children were nearly four times as likely. Dr. Treglia, whose research focuses on vulnerable populations, said the number of bereaved children grew quickly during the Delta surge in part because it hit so many adults of childbearing age.“There is an extraordinary responsibility to care for those children,” he said. “So many of them were facing economic and other hardships even before the pandemic began, and certainly before they lost a caregiver. Now they are facing their darkest days.”Some parents whose spouses were frontline workers say they would like at least some recognition from Washington that their loved ones died while trying to protect others.Ms. Addison, whose husband was a hospital speech pathologist in Paterson, N.J., runs a support group called Young Widows and Widowers of Covid-19. She estimates that 95 percent of her 900 members have children.“You invite athletes to the White House because they’ve won a championship; why not invite families who lost their loved one because they went into a hospital, they went into a school that wasn’t really safe?” she said. “You see when a military person dies there is this big celebration of their life and the kids know their parent is a hero. Our kids need that.”

The Biden administration will spend billions of dollars on a new plan to combat the pandemic, investing in antiviral pills, rapid tests and manufacturing.WASHINGTON — The Biden administration, under pressure to increase the supply of coronavirus vaccines to poor nations, plans to spend billions of dollars to expand manufacturing capacity, with the goal of producing at least one billion additional doses a year beginning in the second half of 2022.The investment is part of a new plan, announced Wednesday by White House officials, for the government to partner with industry to address immediate vaccine needs in the United States and overseas and to prepare for future pandemics. It comes on top of recent decisions to buy enough of Pfizer’s new Covid-19 pill for about 10 million courses of treatment, and to spend $3 billion on rapid over-the-counter tests, which are needed to detect the virus early enough for the Pfizer drug to work.Taken together, the moves amount to an expansive new effort to control the pandemic at a time when Americans are desperate for normalcy and caseloads are creeping up with winter’s approach.In another development that the White House hopes will reassure the public, the Food and Drug Administration is likely to approve requests from Pfizer-BioNTech and Moderna to offer booster shots to everyone 18 and older.President Biden has pledged to fight the coronavirus pandemic by making the United States the “arsenal of vaccines” for the world. But national self-interest is also at work; as long as vaccination rates remain low in other parts of the world, allowing the virus to spread, dangerous new variants could arise and plunge the United States into crisis once again.The global need is great. Testifying on Capitol Hill on Wednesday, Loyce Pace, the director of global affairs at the Department of Health and Human Services, said that more than half of the world’s five million coronavirus deaths had occurred in low- and middle-income countries, and that vaccination rates in some of them “are in the single digits.”Less than 10 percent of Africa’s population is vaccinated, she said, compared with more than 50 percent in North America and Europe. In many poor nations, including those struggling to combat other diseases like tuberculosis, malaria and H.I.V., even health care workers on the front lines of the pandemic remain unvaccinated.Expanding vaccine manufacturing through public-private alliances is not without risks. Until recently, the federal government had a manufacturing partnership with Emergent BioSolutions, whose Baltimore facility ruined millions of doses of Johnson & Johnson’s coronavirus vaccine earlier this year. The Biden administration severed its relationship with Emergent earlier this month.Administration officials insist this plan will be different. In interviews, Jeff Zients, President Biden’s coronavirus response coordinator, and Dr. David Kessler, who oversees vaccine distribution as the chief science officer for the Covid-19 response, said the intent is to invest in companies with experience making mRNA vaccines, enabling those companies to expand production to meet the government’s needs.That could include building new plants or production lines, and it might require licensing technology from other vaccine manufacturers.“This is about assuring expanded capacity against Covid variants and also preparing for the next pandemic,” Dr. Kessler said in an interview. “The goal, in the case of a future pandemic, a future virus, is to have vaccine capability within six to nine months of identification of that pandemic pathogen, and to have enough vaccines for all Americans.”Dr. Kessler and Mr. Zients conceded the plan is not fully fleshed out; the Biomedical Advanced Research and Development Agency on Wednesday issued a request for ideas from industry. The price tag is unknown; Dr. Kessler estimated it at several billion, with the money coming from the American Rescue Plan, the $1.9 trillion coronavirus relief package Mr. Biden signed into law earlier this year.Mr. Zients said the government was looking to move quickly, and wanted responses from industry within 30 days. The potential partners appear to be limited; only two major vaccine makers — Pfizer and Moderna — are currently using mRNA technology, although those companies employ contract manufacturers to do the work for them.In a statement on Wednesday, Pfizer commended the administration and pledged to “come to the table with how we can best contribute” to the fight against Covid-19. Officials at Moderna did not respond to an email message seeking comment. But Steve Brozak, an investment banker whose company, WBB Securities, specializes in biotechnology, said engaging industry could prove difficult.“Without a specific commitment of money, without a specific time plan, companies may not be interested,” Mr. Brozak said. If the administration wants to ramp up vaccine manufacturing, he added, it will also have to increase production of resins and other vaccine components.Reaction to the plan was mixed, especially among activists who have been pushing the Biden administration to lean on Pfizer and Moderna to share their technology with manufacturers overseas. (The National Institutes of Health is in a patent dispute with Moderna, which received billions in taxpayer funding, over who deserves credit for inventing the central component of the company’s coronavirus vaccine.)“The idea of making a business plan with two companies rather than a public health plan is disturbing to us,” said Dr. Joia Mukherjee, chief medical officer of Partners In Health, a global public health nonprofit. “We believe that Biden has the power, particularly with Moderna because so much of it was taxpayer funded, to demand the sharing of patents and know-how.”Some activists, furious with what they regard as the administration’s slow progress, turned up at the home of Ron Klain, Mr. Biden’s chief of staff, in September and deposited a fake mountain of bones on the sidewalk in protest. Another group protested outside Mr. Zients’s home on Wednesday morning.Addressing criticism that the Biden plan is not focused on building capacity overseas, Dr. Kessler said that domestic manufacturing “is important not only for the U.S. supply, but for global supply.”At the same time, partnering with big drug makers offers no guarantees. Mr. Biden announced earlier this year that he had brokered a deal with Merck & Co., the pharmaceutical giant, to manufacture Johnson & Johnson’s vaccine, including for other countries. Officials hailed the partnership as historic, saying it fit in with the president’s vision of a manufacturing campaign like the one Franklin D. Roosevelt spearheaded to produce supplies for World War II.But the Merck deal has not panned out as expected. Administration officials initially hoped Merck would begin producing the vaccine’s key ingredient by the end of this year, but that will not happen until April, Dr. Kessler said.Congress put a total of $16.05 billion in the American Rescue Plan this year, in two separate tranches, that could be used to procure and manufacture treatments, vaccines and other tools for ending the pandemic.But in an analysis released this summer, the AIDS advocacy group Prep4All found that all told, the administration had spent $145 million — just $12 million of it from the American Rescue Plan — to expand vaccine manufacturing. Most went to retrofitting Merck’s production lines.James Krellenstein, a founder of Prep4All and the author of the study, pointed to the experience with Emergent and Merck to suggest that simply paying industry to build new production lines will not work. His group has called for the government to build its own vaccine manufacturing facility, and to hire a contract manufacturer to run it.“The Biden administration is at two forks in the road right now,” Mr. Krellenstein said. “We have to commend them in the first place for committing to address seriously the manufacturing and supply issues. But we do need the Biden administration to learn a little bit from history.”The advocacy group Public Citizen has called for a $25 billion government investment to make eight billion doses of mRNA in one year, enough to meet global need. Peter Maybarduk, Public Citizen’s access to medicines director, criticized the administration for not doing more to press Moderna and Pfizer to share their technology with manufacturers in developing nations.“Sharing doses is charity, and desperately needed,” he said. “But sharing knowledge is justice.”

The $1.85 trillion social policy bill would provide free private health insurance for more than two million adults locked out of coverage, but only for four years.ALBANY, Ga. — After giving up on their goal of creating a new Medicaid program to cover two million poor adults, Democrats are aiming to provide them with free private coverage as part of the party’s social policy bill. But there is a catch: The benefits would last only four years.Even with that expiration date, the legislation cannot come fast enough for people like Evelyn Davis, who suffered two heart attacks and has high blood pressure and diabetes. A former home health care aide, she lost coverage when she got divorced two years ago. She has chest pains and heart palpitations but said she cannot afford to see a cardiologist.“If I can’t get any medicine, I just get Tylenol PM when I sleep,” Ms. Davis, 63, said, “and just pray to God when I wake up that I won’t be in pain.”She is among an estimated 2.2 million American adults who lack insurance because they live in one of the 12 states where Republicans have refused to expand Medicaid, which is jointly financed by the federal government and states, under the Affordable Care Act. Too poor to qualify for subsidized private insurance through the Obamacare exchanges yet not poor enough for Medicaid, they navigate a byzantine system of charity care — and often skip care altogether.Now these patients may get what many have hoped for since the Affordable Care Act’s passage more than a decade ago — albeit with no guarantee that the new benefits are here to stay. The framework announced last week by President Biden for the $1.85 trillion social policy bill includes the biggest expansion of health care since the Obama-era health law, patching holes in the landmark law that had long seemed impossible to fix.Still, the framework is tenuous. On Monday, Senator Joe Manchin III, Democrat of West Virginia, dashed hopes for a quick Senate vote by refusing to endorse the measure, whose health care provisions had already been pared back under pressure from Mr. Manchin and other centrists to keep the price down.The “public option,” promoted by Mr. Biden during his presidential campaign as a way for people to buy into a Medicare-like plan, was never even considered. Language authorizing the government to negotiate prices with drug companies was scrapped. A plan to give dental, vision and hearing coverage to Medicare recipients has been whittled down to just hearing.And in the end, negotiators dropped the idea of a new Medicaid plan financed entirely by the federal government for people in the 12 holdout states, which would have been complicated to create, in favor of fully subsidized private coverage — but only through 2025.The free plans would be comparable to Medicaid coverage, with minimal fees for doctor visits and enhanced benefits like transportation to medical appointments. All told, an estimated 4.4 million people — including the uninsured and other low-income adults — would be able to take advantage of them.For Democrats, who took back the House in 2018 and this year gained control of the Senate in part by vowing to expand access to affordable heath care, the bill is a political necessity. And perhaps no Democrat needs it more than Senator Raphael Warnock, Georgia’s first Black senator, who won a special election in January on a promise of expanding Medicaid.Mr. Warnock will be on the ballot again in 2022, a year that is widely expected to be grim for his party, and the contest could determine control of the Senate. In Washington, closing the coverage gap remains Mr. Warnock’s signature issue.“I believe that health care is a human right, and if you believe it’s a human right, you don’t believe it’s a human right for 38 states,” Mr. Warnock said in an interview in September.But some Democrats, notably Mr. Manchin, view solving the problem solely with federal dollars as unfair to states that did expand Medicaid and continue to pay 10 percent of the cost; why, they ask, should Republicans be rewarded for resisting? Republicans oppose the social policy plan in its entirety, calling it a “tax and spending spree.”A rural hospital treating Covid-19 patients in Rio Grande City, Texas. The state accounts for more than a third of people in the Medicaid coverage gap.Christopher Lee for The New York TimesThe profile of those who fall in the gap is much the same as the profile of those hardest hit by the coronavirus pandemic: poor people of color. Most are in the South; Texas alone accounts for more than a third of people in the gap, according to the Kaiser Family Foundation.Della Young, 49, a kidney transplant patient with lupus, was doing fine when she lived in New York. As an end-stage renal disease patient, she is covered by Medicare, which paid 80 percent of her medical expenses. Medicaid picked up the rest.But when Ms. Young moved to McDonough, Ga., in 2015, she lost her Medicaid coverage and was unable to pay for drugs to prevent her body from rejecting her donated organ. Her transplant failed in 2016, and she has been waiting for a new kidney ever since, while undergoing dialysis three times a week. She sends the dialysis center a check for $5 a month — a small offering toward a much larger bill.Because out-of-pocket expenses associated with transplants are so high, Emory Transplant Center, where Ms. Young is a patient, advised her to raise money on her own. She started a GoFundMe account, hoping to raise $100,000. She has raised $5,077 so far.“This whole fund-raising thing is crazy,” she said. “Health care should be the same across the board, regardless of what state you live in.”In Albany, a small city about three hours south of Atlanta, patients like Ms. Davis are eager for any help they can get. She and about a dozen other uninsured people shared their stories in the bare-bones waiting room of the Samaritan Clinic, founded 15 years ago by the Rev. Daniel Simmons, the senior pastor of Mount Zion Baptist Church, who said he had followed the will of God.“People were suffering, dying right in our backyard,” he said. “I said, ‘Lord, what do you want me to do?’”Lisa Jones, 59, lost her employer-sponsored insurance when she gave up her job at a chicken processing plant to care for her ailing husband. He put her on his plan, but when he died she fell into the coverage gap.Nicole Craine for The New York TimesStill, the clinic can only do so much. Lisa Jones, 59, lost her employer-sponsored insurance when she gave up her job at a chicken processing plant to care for her ailing husband. He put her on his plan, but when he died she fell into the coverage gap. She gets blood pressure and cholesterol drugs through the clinic, which works with companies that offer free medicines.But when Ms. Jones sought care for Covid-19, she got a bill for $150. “That went to collections because I didn’t have the money to pay it,” she said.Volunteer doctors provide primary care at the clinic, but Nedra Fortson, a nurse practitioner and the clinic’s executive director, said it was difficult to refer patients to specialists because so many refuse to offer free care. Georgia is one of a dozen states that have not expanded Medicaid under the Affordable Care Act. Addressing the coverage gap has been a priority for the state’s two Democratic senators, Raphael Warnock, center, and Jon Ossoff, right. J. Scott Applewhite/Associated PressSome patients, she said, can afford to go to the community health center, which has a low co-payment of $25. “But oftentimes, once they get in to see a provider and they have to run labs, the patient ends up having a bill,” Ms. Fortson said. “And once they can’t pay that bill, they are unable to get appointments, and so they come to us to get help.”The question of Medicaid expansion has percolated through Georgia politics for much of the past decade. The Affordable Care Act intended for states to expand Medicaid to cover adults with incomes up to 138 percent of the federal poverty line — currently about $17,800 a year for an individual. Republican states sued, and in 2012 the Supreme Court upheld the law but made Medicaid expansion optional.Nedra Fortson, a nurse practitioner and the clinic’s executive director, said it was difficult to refer patients to specialists because so many refuse to offer free care.Nicole Craine for The New York TimesIn 2014, Georgia Republicans went one step further. Fearful that a Democrat would win the governorship, they passed a law requiring the legislature to approve any expansion plan. In 2018, Stacey Abrams, the Democratic candidate for governor, hit Republicans hard on health care. The next year, the state sought to partially expand Medicaid, with requirements for recipients to work.The Trump administration approved the plan, which would have covered only a fraction of the state’s uninsured low-income adults, just days before Mr. Trump lost the 2020 election. The Biden administration, opposed to work requirements, has put it on hold.In the meantime, people in the coverage gap are trying to make do — now with new hope that the social policy bill will become law. Ms. Davis, the former home health care aide, pays $90 out of pocket to see a primary care doctor once a year and gets annual mammograms from the county health department, where they are free. Her children help, but she does not like to accept it.The Democrats’ plan to fully subsidize four years of coverage would tide Ms. Davis over until she turns 65 in two years and becomes eligible for Medicare. She sought Social Security disability benefits, hoping to qualify for Medicare that way, but was unsuccessful.“I filed for disability and they denied me,” she said, “and I’m like, ‘Oh Lord, it ain’t so much about the check.’ If I could just get some insurance so I could see my doctors, that’s all I want.” She added, “If I could get four years, it would be great.”

The $1.85 trillion social policy bill would provide free private health insurance for more than two million adults locked out of coverage, but only for four years.ALBANY, Ga. — After giving up on their goal of creating a new Medicaid program to cover two million poor adults, Democrats are aiming to provide them with free private coverage as part of the party’s social policy bill. But there is a catch: The benefits would last only four years.Even with that expiration date, the legislation cannot come fast enough for people like Evelyn Davis, who suffered two heart attacks and has high blood pressure and diabetes. A former home health care aide, she lost coverage when she got divorced two years ago. She has chest pains and heart palpitations but said she cannot afford to see a cardiologist.“If I can’t get any medicine, I just get Tylenol PM when I sleep,” Ms. Davis, 63, said, “and just pray to God when I wake up that I won’t be in pain.”She is among an estimated 2.2 million American adults who lack insurance because they live in one of the 12 states where Republicans have refused to expand Medicaid, which is jointly financed by the federal government and states, under the Affordable Care Act. Too poor to qualify for subsidized private insurance through the Obamacare exchanges yet not poor enough for Medicaid, they navigate a byzantine system of charity care — and often skip care altogether.Now these patients may get what many have hoped for since the Affordable Care Act’s passage more than a decade ago — albeit with no guarantee that the new benefits are here to stay. The framework announced last week by President Biden for the $1.85 trillion social policy bill includes the biggest expansion of health care since the Obama-era health law, patching holes in the landmark law that had long seemed impossible to fix. Still, the framework is tenuous. On Monday, Senator Joe Manchin III, Democrat of West Virginia, dashed hopes for a quick Senate vote by refusing to endorse the measure, whose health care provisions had already been pared back under pressure from Mr. Manchin and other centriststo keep the price down. The “public option,” promoted by Mr. Biden during his presidential campaign as a way for people to buy into a Medicare-like plan, was never even considered. Language authorizing the government to negotiate prices with drug companies was scrapped. A plan to give dental, vision and hearing coverage to Medicare recipients has been whittled down to just hearing.And in the end, negotiators dropped the idea of a new Medicaid plan financed entirely by the federal government for people in the 12 holdout states, which would have been complicated to create, in favor of fully subsidized private coverage — but only through 2025. The free plans would be comparable to Medicaid coverage, with minimal fees for doctor visits and enhanced benefits like transportation to medical appointments. All told, an estimated 4.4 million people — including the uninsured and other low-income adults — would be able to take advantage of them.For Democrats, who took back the House in 2018 and this year gained control of the Senate in part by vowing to expand access to affordable heath care, the bill is a political necessity. And perhaps no Democrat needs it more than Senator Raphael Warnock, Georgia’s first Black senator, who won a special election in January on a promise of expanding Medicaid.Mr. Warnock will be on the ballot again in 2022, a year that is widely expected to be grim for his party, and the contest could determine control of the Senate. In Washington, closing the coverage gap remains Mr. Warnock’s signature issue.“I believe that health care is a human right, and if you believe it’s a human right, you don’t believe it’s a human right for 38 states,” Mr. Warnock said in an interview in September.But some Democrats, notably Mr. Manchin, view solving the problem solely with federal dollars as unfair to states that did expand Medicaid and continue to pay 10 percent of the cost; why, they ask, should Republicans be rewarded for resisting? Republicans oppose the social policy plan in its entirety, calling it a “tax and spending spree.” A rural hospital treating Covid-19 patients in Rio Grande City, Texas. The state accounts for more than a third of people in the Medicaid coverage gap.Christopher Lee for The New York TimesThe profile of those who fall in the gap is much the same as the profile of those hardest hit by the coronavirus pandemic: poor people of color. Most are in the South; Texas alone accounts for more than a third of people in the gap, according to the Kaiser Family Foundation.Della Young, 49, a kidney transplant patient with lupus, was doing fine when she lived in New York. As an end-stage renal disease patient, she is covered by Medicare, which paid 80 percent of her medical expenses. Medicaid picked up the rest.But when Ms. Young moved to McDonough, Ga., in 2015, she lost her Medicaid coverage and was unable to pay for drugs to prevent her body from rejecting her donated organ. Her transplant failed in 2016, and she has been waiting for a new kidney ever since, while undergoing dialysis three times a week. She sends the dialysis center a check for $5 a month — a small offering toward a much larger bill.Because out-of-pocket expenses associated with transplants are so high, Emory Transplant Center, where Ms. Young is a patient, advised her to raise money on her own. She started a GoFundMe account, hoping to raise $100,000. She has raised $5,077 so far.“This whole fund-raising thing is crazy,” she said. “Health care should be the same across the board, regardless of what state you live in.”In Albany, a small city about three hours south of Atlanta, patients like Ms. Davis are eager for any help they can get. She and about a dozen other uninsured people shared their stories in the bare-bones waiting room of the Samaritan Clinic, founded 15 years ago by the Rev. Daniel Simmons, the senior pastor of Mount Zion Baptist Church, who said he had followed the will of God.“People were suffering, dying right in our backyard,” he said. “I said, ‘Lord, what do you want me to do?’ ”Lisa Jones, 59, lost her employer-sponsored insurance when she gave up her job at a chicken processing plant to care for her ailing husband. He put her on his plan, but when he died she fell into the coverage gap.Nicole Craine for The New York TimesStill, the clinic can only do so much. Lisa Jones, 59, lost her employer-sponsored insurance when she gave up her job at a chicken processing plant to care for her ailing husband. He put her on his plan, but when he died she fell into the coverage gap. She gets blood pressure and cholesterol drugs through the clinic, which works with companies that offer free medicines.But when Ms. Jones sought care for Covid-19, she got a bill for $150. “That went to collections because I didn’t have the money to pay it,” she said.Volunteer doctors provide primary care at the clinic, but Nedra Fortson, a nurse practitioner and the clinic’s executive director, said it was difficult to refer patients to specialists because so many refuse to offer free care. Georgia is one of a dozen states that have not expanded Medicaid under the Affordable Care Act. Addressing the coverage gap has been a priority for the state’s two Democratic senators, Raphael Warnock, center, and Jon Ossoff, right. J. Scott Applewhite/Associated PressSome patients, she said, can afford to go to the community health center, which has a low co-payment of $25. “But oftentimes, once they get in to see a provider and they have to run labs, the patient ends up having a bill,” Ms. Fortson said. “And once they can’t pay that bill, they are unable to get appointments, and so they come to us to get help.”The question of Medicaid expansion has percolated through Georgia politics for much of the past decade. The Affordable Care Act intended for states to expand Medicaid to cover adults with incomes up to 138 percent of the federal poverty line — currently about $17,800 a year for an individual. Republican states sued, and in 2012 the Supreme Court upheld the law but made Medicaid expansion optional.Nedra Fortson, a nurse practitioner and the clinic’s executive director, said it was difficult to refer patients to specialists because so many refuse to offer free care.Nicole Craine for The New York TimesIn 2014, Georgia Republicans went one step further. Fearful that a Democrat would win the governorship, they passed a law requiring the legislature to approve any expansion plan. In 2018, Stacey Abrams, the Democratic candidate for governor, hit Republicans hard on health care. The next year, the state sought to partially expand Medicaid, with requirements for recipients to work.The Trump administration approved the plan, which would have covered only a fraction of the state’s uninsured low-income adults, just days before Mr. Trump lost the 2020 election. The Biden administration, opposed to work requirements, has put it on hold.In the meantime, people in the coverage gap are trying to make do — now with new hope that the social policy bill will become law. Ms. Davis, the former home health care aide, pays $90 out of pocket to see a primary care doctor once a year and gets annual mammograms from the county health department, where they are free. Her children help, but she does not like to accept it.The Democrats’ plan to fully subsidize four years of coverage would tide Ms. Davis over until she turns 65 in two years and becomes eligible for Medicare. She sought Social Security disability benefits, hoping to qualify for Medicare that way, but was unsuccessful.“I filed for disability and they denied me,” she said, “and I’m like, ‘Oh Lord, it ain’t so much about the check.’ If I could just get some insurance so I could see my doctors, that’s all I want.” She added, “If I could get four years, it would be great.”

But his plans face a tough road as pressure grows for big pharmaceutical companies to share their vaccine technologies with poorer nations.WASHINGTON — President Biden, declaring the coronavirus an “all-hands-on-deck crisis,” set out ambitious goals on Wednesday for ending the pandemic and urged world leaders, drug companies, philanthropies and nonprofit groups to embrace a target of vaccinating 70 percent of the world by next year.But the course that Mr. Biden charted, at a virtual Covid-19 summit meeting that he convened on the sidelines of the United Nations General Assembly in New York, may be difficult to turn into reality. And pressure is mounting on the president to lean harder on U.S. pharmaceutical manufacturers, which are resisting sharing their Covid-19 technology with poorer countries.The daylong meeting, the largest gathering of heads of state to address the pandemic, was a reflection of Mr. Biden’s determination to re-establish the United States as a leader in global health after President Donald J. Trump severed ties with the World Health Organization last year, at the outset of the coronavirus crisis.Mr. Biden announced a series of actions, including the purchase of an additional 500 million doses of Pfizer’s vaccine at a not-for-profit price to donate overseas and $370 million to administer the shots. Vice President Kamala Harris announced that the United States would donate $250 million to a new global fund that aims to raise $10 billion to prevent future pandemics.“We’re not going to solve this crisis with half-measures or middle-of-the-road ambitions. We need to go big,” the president said in televised remarks. “And we need to do our part: governments, the private sector, civil society leaders, philanthropists.”Still, Mr. Biden’s summit meeting spurred some resentment toward the United States from those who have criticized the administration for hoarding vaccines and not doing enough to help developing nations manufacture their own. Others said the administration was claiming credit for a plan that already existed.“It’s not really new, but the financial power of what they put on the table is new of course,” Dr. Marie-Paule Kieny, a French virologist and former top W.H.O. official, said in an interview. She noted that the organization had already set a target of vaccinating 70 percent of people in low- and middle-income countries by next September.“The U.S. wants to be engaged,” she added, “but they still don’t know exactly how to engage with the new world that has developed while they were away.”Mr. Biden also faces criticism for offering booster doses to fully vaccinated Americans when millions of people around the world, including health care workers, have yet to receive a first dose. In his speech at the United Nations on Wednesday, President Uhuru Kenyatta of Kenya said that such inequities were hindering efforts to rebuild the global economy, which requires confidence and investment.“The surest way to building that confidence is by making vaccines available to the world, in an equitable and accessible manner,” Mr. Kenyatta said. “That, sadly, is currently not the case. The asymmetry in the supply of vaccines reflects a multilateral system that is in urgent need for repair.”In his opening remarks, Mr. Biden cited two especially urgent challenges: vaccinating the world against Covid-19 and solving a global oxygen shortage, which is leading to unnecessary deaths among Covid-19 patients who might survive if oxygen were more available.But as soon as the president finished speaking and the television cameras were turned off, the director general of the World Health Organization, Dr. Tedros Adhanom Ghebreyesus, called on countries and companies to immediately share doses, intellectual property and technical know-how for manufacturing vaccines, according to one person who attended the summit and took notes on the remarks.President Cyril Ramaphosa of South Africa was equally pointed, the person said. Mr. Ramaphosa called the vaccine inequities “unjust and immoral” and reiterated his proposal that developing countries should be able to manufacture their own doses.More than 4.7 million people around the world, and more than 678,000 in the United States, have died of Covid-19 — a “global tragedy,” Mr. Biden said. While three-quarters of Americans have had at least one coronavirus shot, less than 10 percent of the population of poor nations — and less than 4 percent of the African population — has been fully vaccinated.Worldwide, 79 percent of shots that have been administered have been in high- and upper-middle-income countries, according to the Our World in Data project at the University of Oxford. Covax, the W.H.O.-backed international vaccine initiative, is behind schedule in delivering shots to low- and middle-income nations that need them the most.The United States has pledged to donate 1.1 billion doses of Covid-19 vaccines to low- and middle-income nations.Daniel Irungu/EPA, via ShutterstockAt a briefing held by Physicians for Human Rights this week, Dr. Soumya Swaminathan, the chief scientist of the W.H.O., issued a plea for nations to work together to distribute vaccines in a coordinated and equitable way. She also urged countries to share their excess supplies.“A country-by-country approach, a nationalistic approach, is not going to get us out of this pandemic,” she said. “And that’s where we are today.”.css-1xzcza9{list-style-type:disc;padding-inline-start:1em;}.css-3btd0c{font-family:nyt-franklin,helvetica,arial,sans-serif;font-size:1rem;line-height:1.375rem;color:#333;margin-bottom:0.78125rem;}@media (min-width:740px){.css-3btd0c{font-size:1.0625rem;line-height:1.5rem;margin-bottom:0.9375rem;}}.css-3btd0c strong{font-weight:600;}.css-3btd0c em{font-style:italic;}.css-w739ur{margin:0 auto 5px;font-family:nyt-franklin,helvetica,arial,sans-serif;font-weight:700;font-size:1.125rem;line-height:1.3125rem;color:#121212;}#NYT_BELOW_MAIN_CONTENT_REGION .css-w739ur{font-family:nyt-cheltenham,georgia,’times new roman’,times,serif;font-weight:700;font-size:1.375rem;line-height:1.625rem;}@media (min-width:740px){#NYT_BELOW_MAIN_CONTENT_REGION .css-w739ur{font-size:1.6875rem;line-height:1.875rem;}}@media (min-width:740px){.css-w739ur{font-size:1.25rem;line-height:1.4375rem;}}.css-9s9ecg{margin-bottom:15px;}.css-16ed7iq{width:100%;display:-webkit-box;display:-webkit-flex;display:-ms-flexbox;display:flex;-webkit-align-items:center;-webkit-box-align:center;-ms-flex-align:center;align-items:center;-webkit-box-pack:center;-webkit-justify-content:center;-ms-flex-pack:center;justify-content:center;padding:10px 0;background-color:white;}.css-pmm6ed{display:-webkit-box;display:-webkit-flex;display:-ms-flexbox;display:flex;-webkit-align-items:center;-webkit-box-align:center;-ms-flex-align:center;align-items:center;}.css-pmm6ed > :not(:first-child){margin-left:5px;}.css-5gimkt{font-family:nyt-franklin,helvetica,arial,sans-serif;font-size:0.8125rem;font-weight:700;-webkit-letter-spacing:0.03em;-moz-letter-spacing:0.03em;-ms-letter-spacing:0.03em;letter-spacing:0.03em;text-transform:uppercase;color:#333;}.css-5gimkt:after{content:’Collapse’;}.css-rdoyk0{-webkit-transition:all 0.5s ease;transition:all 0.5s ease;-webkit-transform:rotate(180deg);-ms-transform:rotate(180deg);transform:rotate(180deg);}.css-eb027h{max-height:5000px;-webkit-transition:max-height 0.5s ease;transition:max-height 0.5s ease;}.css-6mllg9{-webkit-transition:all 0.5s ease;transition:all 0.5s ease;position:relative;opacity:0;}.css-6mllg9:before{content:”;background-image:linear-gradient(180deg,transparent,#ffffff);background-image:-webkit-linear-gradient(270deg,rgba(255,255,255,0),#ffffff);height:80px;width:100%;position:absolute;bottom:0px;pointer-events:none;}.css-uf1ume{display:-webkit-box;display:-webkit-flex;display:-ms-flexbox;display:flex;-webkit-box-pack:justify;-webkit-justify-content:space-between;-ms-flex-pack:justify;justify-content:space-between;}.css-wxi1cx{display:-webkit-box;display:-webkit-flex;display:-ms-flexbox;display:flex;-webkit-flex-direction:column;-ms-flex-direction:column;flex-direction:column;-webkit-align-self:flex-end;-ms-flex-item-align:end;align-self:flex-end;}.css-12vbvwq{background-color:white;border:1px solid #e2e2e2;width:calc(100% – 40px);max-width:600px;margin:1.5rem auto 1.9rem;padding:15px;box-sizing:border-box;}@media (min-width:740px){.css-12vbvwq{padding:20px;width:100%;}}.css-12vbvwq:focus{outline:1px solid #e2e2e2;}#NYT_BELOW_MAIN_CONTENT_REGION .css-12vbvwq{border:none;padding:10px 0 0;border-top:2px solid #121212;}.css-12vbvwq[data-truncated] .css-rdoyk0{-webkit-transform:rotate(0deg);-ms-transform:rotate(0deg);transform:rotate(0deg);}.css-12vbvwq[data-truncated] .css-eb027h{max-height:300px;overflow:hidden;-webkit-transition:none;transition:none;}.css-12vbvwq[data-truncated] .css-5gimkt:after{content:’See more’;}.css-12vbvwq[data-truncated] .css-6mllg9{opacity:1;}.css-qjk116{margin:0 auto;overflow:hidden;}.css-qjk116 strong{font-weight:700;}.css-qjk116 em{font-style:italic;}.css-qjk116 a{color:#326891;-webkit-text-decoration:underline;text-decoration:underline;text-underline-offset:1px;-webkit-text-decoration-thickness:1px;text-decoration-thickness:1px;-webkit-text-decoration-color:#326891;text-decoration-color:#326891;}.css-qjk116 a:visited{color:#326891;-webkit-text-decoration-color:#326891;text-decoration-color:#326891;}.css-qjk116 a:hover{-webkit-text-decoration:none;text-decoration:none;}Experts estimate that 11 billion doses are necessary to reach widespread global immunity. Before Wednesday, the United States had promised to donate more than 600 million doses. The additional 500 million that Mr. Biden pledged brings the total U.S. commitment to 1.1 billion doses, more than any other country.“Put another way, for every one shot we’ve administered to pay in America, we have now committed to do three shots to the rest of the world,” Mr. Biden said.But activists, global health experts and world leaders say donated doses will not be enough. They are calling for the Biden administration to do more to scale up global manufacturing of vaccines, particularly in Africa, where the need is greatest.“The Covid-19 pandemic reminds us of the importance of diversification of production centers across the world,” President Joko Widodo of Indonesia, which has suffered one of the biggest surges in cases, said in his General Assembly speech. “We know that no one is safe until everyone is.”The landscape for getting shots into arms has become increasingly challenging since Covax was created in April 2020. Some Asian countries have imposed tariffs and other trade restrictions on Covid-19 vaccines, slowing their delivery. India, home to the world’s largest vaccine maker, has banned coronavirus vaccine exports since April, although officials say they will resume next month.In his opening remarks, Mr. Biden called on other wealthy nations to live up to their donation commitments. He also appeared to take a veiled shot at China, which did not participate in the summit, and has for the most part been selling — rather than donating — its vaccine to other countries.“We should unite around the world on a few principles: that we commit to donating, not selling — donating, not selling — doses to low- and lower-income countries, and that the donations come with no political strings attached,” the president said.He also announced a vaccine partnership with the European Union and said the United States was working to scale up production overseas through a partnership with India, Japan and Australia that was “on track to produce at least 1 billion vaccine doses in India to boost the global supply by the end of 2022.”The doses the Biden administration is donating, however, have been trickling out slowly. So far, 157 million have been shipped overseas. Dr. Peter J. Hotez, an infectious disease expert at Texas Children’s Hospital who helped develop a coronavirus vaccine that is being manufactured in India, said the president should have laid out “a frank articulation of the magnitude” of the shortage.“We don’t need it by 2023,” Dr. Hotez said. “We need it now, over the next six to eight months.”Rick Gladstone

Resistance to vaccine mandates, once a fringe position, has entered the Republican mainstream. But the governors fighting President Biden’s Covid-19 vaccine requirements impose mandates of their own.WASHINGTON — Like other Republican governors around the country, Tate Reeves of Mississippi reacted angrily to the coronavirus vaccine mandates President Biden imposed on private businesses. Declaring the move “terrifying,” he wrote on Twitter: “This is still America, and we still believe in freedom from tyrants.”There is a deep inconsistency in that argument. Mississippi has some of the strictest vaccine mandates in the nation, which have not drawn opposition from most of its elected officials. Not only does it require children to be vaccinated against measles, mumps and seven other diseases to attend school, but it goes a step further than most states by barring parents from claiming “religious, philosophical or conscientious” exemptions.Resistance to vaccine mandates was once a fringe position in both parties, more the realm of misinformed celebrities than mainstream political thought. But the fury over Mr. Biden’s mandates shows how a once-extreme stance has moved to the center of the Republican Party. The governors’ opposition reflects the anger and fear about the vaccine among constituents now central to their base, while ignoring longstanding policy and legal precedent in favor of similar vaccination requirements.“Republicans care about getting beyond this pandemic every bit as much as Democrats do,” said Dr. Ashish Jha, the dean of the Brown University School of Public Health. But, he added, “politicians are certainly happy to exploit this issue for political gain, which is why I think the Republican governors are up in arms.”Mr. Biden also imposed vaccine mandates on federal workers and many health care workers. But Republican outrage is really boiling over his plan to require all private-sector businesses with more than 100 employees to mandate vaccines or weekly testing for their work forces.Gov. Greg Abbott of Texas called the president’s move “a power grab.” Gov. Henry McMaster of South Carolina promised to fight Mr. Biden in court, to “the gates of hell.” Gov. Greg Gianforte of Montana called it “unlawful and un-American.” Gov. Kay Ivey of Alabama called the move “outrageous” and “overreaching.”But each of these states — indeed every state in the country — already mandates certain vaccinations for children, and sometimes for adults, including health care workers and patients in certain facilities.President Biden announcing the vaccine mandate at the White House on Thursday. Experts in public health law agree that he is on solid legal footing.Al Drago for The New York TimesMississippi, which has one of the lowest coronavirus vaccination rates in the nation, has consistently led the United States in childhood vaccinations — a point of pride for its health officials and many of its lawmakers. Alabama, similar to Mississippi, also refuses to acknowledge “philosophical, moral or ethical” exemptions to mandatory childhood vaccinations.Experts in public health law agree that Mr. Biden is on solid legal footing, because his actions are grounded in federal workplace safety laws. They say Republican governors who insist that vaccine mandates are an intrusion on personal liberty need a refresher on their own state policies.“That is pure hypocrisy,” Lawrence O. Gostin, a public health law expert at Georgetown University, said of Mr. Reeves’s remarks. “Even religious exemptions are swept away in the state of Mississippi, so how can he say that an order that a president makes to keep workers safe, with authorization by Congress, is an overreach or in any way unconstitutional?”A spokeswoman for Mr. Reeves, Bailey Martin, rejected Mr. Gostin’s assertion. “The only people being hypocritical are President Biden and his administration, who for months have said they would not mandate the vaccine,” she said in an email, adding that Mr. Reeves would use “every tool at his disposal” to block the mandates.Republican suspicion of vaccines was building before the pandemic; when Donald J. Trump was running for president in 2016, he rejected established science by raising the debunked claims that vaccines cause autism. Now, some of the governors argue that given the country’s outsize divisions, and widespread suspicion of Washington, federal intervention would be counterproductive. It would be best, they say, to let state officials continue making the case that the vaccines are safe and effective, and to allow people to make decisions themselves.“I’m trying to overcome resistance, but the president’s actions in a mandate hardens the resistance,” Gov. Asa Hutchinson, Republican of Arkansas, said Sunday on NBC’s “Meet the Press.” School mandates, he said, “have always come at the state level, never at the national level. And so this is an unprecedented assumption of federal mandate authority that really disrupts and divides the country.”Dr. Jha said Mr. Biden had in fact done Republicans a favor.“What the president does is he creates political cover for Republican leaders, who will scream loudly because it’s politically expedient,” he said. “But I think many of them are actually feeling relieved, because now they don’t have to do the hard work of convincing their constituents.”Indeed, when the highly infectious Delta variant began ripping through their communities and overwhelming their hospitals, many elected Republicans — notably Senator Mitch McConnell of Kentucky, the minority leader — started pleading with people to get vaccinated. Most of the Republican governors criticizing Mr. Biden have said much the same.Even as Mr. Reeves blasted Mr. Biden on Twitter, he took care to declare the vaccine itself “lifesaving.” Mr. McMaster held a news conference last month to encourage South Carolinians to take the shots, saying, “Now is a great time to do it while we’re getting ready for the fall.” In Alabama, Ms. Ivey has adopted the same stance as Mr. Biden: “It’s time to start blaming the unvaccinated folks” for the deadly coronavirus surge, she said recently.Three-quarters of American adults have had at least one Covid-19 shot, which suggests growing acceptance of the vaccine. Mr. Biden’s move is aimed at the roughly 80 million Americans who are eligible but remain unvaccinated. Experts call it an unprecedented exercise of presidential authority to encourage vaccination.“It’s really uncharted waters,” said Claire Hannan, the executive director of the Association of Immunization Managers, which represents state immunization officials.Mr. Biden is pointing to childhood vaccine mandates to make his case.“Parents, get your teenagers vaccinated,” he said on Friday during a visit to a middle school in Washington. “You got them vaccinated for all kinds of other things. Measles, mumps, rubella. To go to school and play sports, they have had those vaccinations.”The Supreme Court has twice upheld vaccine mandates, beginning more than a century ago in the 1905 case of Jacobson v. Massachusetts, in which Justice John Marshall Harlan reasoned that a “community has the right to protect itself against an epidemic of disease” — in that case, smallpox — “which threatens the safety of its members.”Even as Gov. Tate Reeves of Mississippi blasted Mr. Biden on Twitter, he took care to declare the vaccine itself “lifesaving.”Rogelio V. Solis/Associated PressBoth cases upheld state or city mandates, and do not apply to Mr. Biden’s actions, according to Mr. Gostin. Because public health powers are reserved to the states under the Constitution, he said, the Supreme Court would almost certainly strike down a national mandate.But Mr. Biden did not impose a national mandate. He took a series of specific, limited actions that legal experts agree are within his purview as president. The mandates he announced — for the federal work force and federal contractors, for employees of health care facilities and Head Start programs that accept federal funding, and for large businesses — are grounded in powers that Congress has granted to the president, including the authority to ensure a safe workplace under the law that established the Occupational Safety and Health Administration.And Mr. Biden gave businesses an out. Employees who do not want to get vaccinated can undergo weekly testing — a fact that his critics fail to note. Mr. Reeves, for instance, asserted that the president had “no authority to require that Americans inject themselves because of their employment at a private business,” without mentioning testing as an option..css-1xzcza9{list-style-type:disc;padding-inline-start:1em;}.css-3btd0c{font-family:nyt-franklin,helvetica,arial,sans-serif;font-size:1rem;line-height:1.375rem;color:#333;margin-bottom:0.78125rem;}@media (min-width:740px){.css-3btd0c{font-size:1.0625rem;line-height:1.5rem;margin-bottom:0.9375rem;}}.css-3btd0c strong{font-weight:600;}.css-3btd0c em{font-style:italic;}.css-w739ur{margin:0 auto 5px;font-family:nyt-franklin,helvetica,arial,sans-serif;font-weight:700;font-size:1.125rem;line-height:1.3125rem;color:#121212;}#NYT_BELOW_MAIN_CONTENT_REGION .css-w739ur{font-family:nyt-cheltenham,georgia,’times new roman’,times,serif;font-weight:700;font-size:1.375rem;line-height:1.625rem;}@media (min-width:740px){#NYT_BELOW_MAIN_CONTENT_REGION .css-w739ur{font-size:1.6875rem;line-height:1.875rem;}}@media (min-width:740px){.css-w739ur{font-size:1.25rem;line-height:1.4375rem;}}.css-9s9ecg{margin-bottom:15px;}.css-16ed7iq{width:100%;display:-webkit-box;display:-webkit-flex;display:-ms-flexbox;display:flex;-webkit-align-items:center;-webkit-box-align:center;-ms-flex-align:center;align-items:center;-webkit-box-pack:center;-webkit-justify-content:center;-ms-flex-pack:center;justify-content:center;padding:10px 0;background-color:white;}.css-pmm6ed{display:-webkit-box;display:-webkit-flex;display:-ms-flexbox;display:flex;-webkit-align-items:center;-webkit-box-align:center;-ms-flex-align:center;align-items:center;}.css-pmm6ed > :not(:first-child){margin-left:5px;}.css-5gimkt{font-family:nyt-franklin,helvetica,arial,sans-serif;font-size:0.8125rem;font-weight:700;-webkit-letter-spacing:0.03em;-moz-letter-spacing:0.03em;-ms-letter-spacing:0.03em;letter-spacing:0.03em;text-transform:uppercase;color:#333;}.css-5gimkt:after{content:’Collapse’;}.css-rdoyk0{-webkit-transition:all 0.5s ease;transition:all 0.5s ease;-webkit-transform:rotate(180deg);-ms-transform:rotate(180deg);transform:rotate(180deg);}.css-eb027h{max-height:5000px;-webkit-transition:max-height 0.5s ease;transition:max-height 0.5s ease;}.css-6mllg9{-webkit-transition:all 0.5s ease;transition:all 0.5s ease;position:relative;opacity:0;}.css-6mllg9:before{content:”;background-image:linear-gradient(180deg,transparent,#ffffff);background-image:-webkit-linear-gradient(270deg,rgba(255,255,255,0),#ffffff);height:80px;width:100%;position:absolute;bottom:0px;pointer-events:none;}.css-uf1ume{display:-webkit-box;display:-webkit-flex;display:-ms-flexbox;display:flex;-webkit-box-pack:justify;-webkit-justify-content:space-between;-ms-flex-pack:justify;justify-content:space-between;}.css-wxi1cx{display:-webkit-box;display:-webkit-flex;display:-ms-flexbox;display:flex;-webkit-flex-direction:column;-ms-flex-direction:column;flex-direction:column;-webkit-align-self:flex-end;-ms-flex-item-align:end;align-self:flex-end;}.css-12vbvwq{background-color:white;border:1px solid #e2e2e2;width:calc(100% – 40px);max-width:600px;margin:1.5rem auto 1.9rem;padding:15px;box-sizing:border-box;}@media (min-width:740px){.css-12vbvwq{padding:20px;width:100%;}}.css-12vbvwq:focus{outline:1px solid #e2e2e2;}#NYT_BELOW_MAIN_CONTENT_REGION .css-12vbvwq{border:none;padding:10px 0 0;border-top:2px solid #121212;}.css-12vbvwq[data-truncated] .css-rdoyk0{-webkit-transform:rotate(0deg);-ms-transform:rotate(0deg);transform:rotate(0deg);}.css-12vbvwq[data-truncated] .css-eb027h{max-height:300px;overflow:hidden;-webkit-transition:none;transition:none;}.css-12vbvwq[data-truncated] .css-5gimkt:after{content:’See more’;}.css-12vbvwq[data-truncated] .css-6mllg9{opacity:1;}.css-qjk116{margin:0 auto;overflow:hidden;}.css-qjk116 strong{font-weight:700;}.css-qjk116 em{font-style:italic;}.css-qjk116 a{color:#326891;-webkit-text-decoration:underline;text-decoration:underline;text-underline-offset:1px;-webkit-text-decoration-thickness:1px;text-decoration-thickness:1px;-webkit-text-decoration-color:#326891;text-decoration-color:#326891;}.css-qjk116 a:visited{color:#326891;-webkit-text-decoration-color:#326891;text-decoration-color:#326891;}.css-qjk116 a:hover{-webkit-text-decoration:none;text-decoration:none;}Vaccine mandates are not new, nor is resistance to vaccination. As far back as 1721 in Boston, a vaccine opponent threw a small bomb through the window of Cotton Mather, who was promoting inoculation against smallpox during a deadly outbreak. By the early 1900s, smallpox vaccination again emerged as a contentious issue in Massachusetts, giving rise to the Jacobson case.By the 1920s, many schools in the United States required vaccination against smallpox, according to the History of Vaccines, a project of the College of Physicians of Philadelphia. When vaccines for diseases like pertussis, polio and measles became widely available in the 1940s and ’50s, the American public, inclined to have faith in science and government, voluntarily accepted them, said David Rosner, a Columbia University historian who specializes in the intersection of politics and public health.The 1960s brought social upheaval and an anti-establishment mood — and with it, the beginnings of the antivaccine movement, which led many states to enact mandates, Mr. Rosner said. Often, there is pushback, especially with newly developed vaccines.When the varicella vaccine was developed to combat chickenpox in 1995, for instance, Idaho refused to mandate it. But it was ultimately added to the state’s list of required vaccinations for children born after Sept. 1, 2005.Administering a Covid-19 vaccine in Moultrie, Ga., in July. Gov. Brian Kemp of Georgia said Mr. Biden’s move “is blatantly unlawful, and Georgia will not stand for it.”Matthew Odom for The New York TimesOne Republican governor, Pete Ricketts of Nebraska, drew a distinction between Covid-19 shots and childhood vaccines, insisting in an appearance on “Fox News Sunday” that childhood vaccine mandates do not violate personal freedoms because parents have had “a long history” with them. Of Covid-19 shots, he said, “This is a process that’s going to take time to bring people along, and that’s why it should be a personal choice.”But public health experts say the safety of the community supersedes personal liberty when everyone is at risk from a communicable disease.“It’s always a little noisy and uncomfortable” when vaccine requirements are first imposed, said Dr. Jha of Brown University. But over time, he said, “people get vaccinated and whatever infectious disease you are trying to deal with fades into the background and people move on, and that’s what I expect to happen here.”Still, never before has a vaccine been so caught up in partisan politics. Dr. Rosner sees something deeper at work.“This is part of a much larger dissolution of American society,” he said. “It is part and parcel of the resistance to all forms of social harmony and sense of social purpose that the country is undergoing right now.”Eleven states, including Arizona, Florida and Texas, have already expressly banned Covid-19 vaccine mandates, either through legislation or a governor’s order, and questions are bound to emerge over whether the president’s mandates will trump those state policies or laws. (The answer is yes, Mr. Gostin said.)Dr. Marcus Plescia, the chief medical officer of the Association of State and Territorial Health Officials, warned in an interview last month that the backlash against Covid-19 vaccine mandates could prompt state legislatures to “also tinker with the idea that maybe all of these childhood vaccines are an overreach of government.”So far, at least, there is no indication of that. And even in Republican-led states where Mr. Biden’s mandates are inciting outrage, the Delta variant is making the case for him. In Mississippi, one of the hardest-hit states, hospitals were so overwhelmed last month that the University of Mississippi Medical Center put up a field hospital in its parking garage.Today, the state is no longer last in the nation for Covid-19 vaccination, as it was throughout the spring and into early July. More than half of Mississippi adults are fully protected against the coronavirus.

The plan calls for an initial investment of at least $15 billion — half of what President Biden initially proposed.WASHINGTON — The White House, stepping into delicate negotiations on Capitol Hill over funding to prevent future pandemics, unveiled on Friday a $65.3 billion preparedness plan that it likened to the Apollo missions to the moon, and called on Congress to immediately invest at least $15 billion for the effort.But the $15 billion figure is only half of what Mr. Biden initially proposed, and the announcement on Friday drew complaints from health experts who warned lawmakers not to squander an opportunity to use the lessons of the coronavirus pandemic to fully prepare the nation for the next one.The plan, drafted by President Biden’s science adviser, Eric S. Lander, and his National Security Council, would establish a full-time “Mission Control” office to coordinate the work of agencies across the government to spot emerging threats and ready the nation to fight them. It calls for $65.3 billion to be spent over the next seven to 10 years.Roughly a third of the total investment, $24 billion, would be allocated to developing, testing and manufacturing new vaccines for a broad range of viral threats. Nearly $12 billion would be for developing therapeutics, and $5 billion for diagnostic tests; the rest would help develop early warning systems, improve the nation’s pandemic preparedness stockpile and build capacity for manufacturing vital supplies.“We’ve got to seize the unique opportunity to transform our scientific capabilities so we’re prepared for the increasing frequency of biological threats on the horizon,” Dr. Lander said, adding, “And it’s vital that we start with an initial outlay of $15 to $20 billion to jump start these efforts.”.css-1xzcza9{list-style-type:disc;padding-inline-start:1em;}.css-3btd0c{font-family:nyt-franklin,helvetica,arial,sans-serif;font-size:1rem;line-height:1.375rem;color:#333;margin-bottom:0.78125rem;}@media (min-width:740px){.css-3btd0c{font-size:1.0625rem;line-height:1.5rem;margin-bottom:0.9375rem;}}.css-3btd0c strong{font-weight:600;}.css-3btd0c em{font-style:italic;}.css-w739ur{margin:0 auto 5px;font-family:nyt-franklin,helvetica,arial,sans-serif;font-weight:700;font-size:1.125rem;line-height:1.3125rem;color:#121212;}#NYT_BELOW_MAIN_CONTENT_REGION .css-w739ur{font-family:nyt-cheltenham,georgia,’times new roman’,times,serif;font-weight:700;font-size:1.375rem;line-height:1.625rem;}@media (min-width:740px){#NYT_BELOW_MAIN_CONTENT_REGION .css-w739ur{font-size:1.6875rem;line-height:1.875rem;}}@media (min-width:740px){.css-w739ur{font-size:1.25rem;line-height:1.4375rem;}}.css-9s9ecg{margin-bottom:15px;}.css-uf1ume{display:-webkit-box;display:-webkit-flex;display:-ms-flexbox;display:flex;-webkit-box-pack:justify;-webkit-justify-content:space-between;-ms-flex-pack:justify;justify-content:space-between;}.css-wxi1cx{display:-webkit-box;display:-webkit-flex;display:-ms-flexbox;display:flex;-webkit-flex-direction:column;-ms-flex-direction:column;flex-direction:column;-webkit-align-self:flex-end;-ms-flex-item-align:end;align-self:flex-end;}.css-12vbvwq{background-color:white;border:1px solid #e2e2e2;width:calc(100% – 40px);max-width:600px;margin:1.5rem auto 1.9rem;padding:15px;box-sizing:border-box;}@media (min-width:740px){.css-12vbvwq{padding:20px;width:100%;}}.css-12vbvwq:focus{outline:1px solid #e2e2e2;}#NYT_BELOW_MAIN_CONTENT_REGION .css-12vbvwq{border:none;padding:10px 0 0;border-top:2px solid #121212;}.css-12vbvwq[data-truncated] .css-rdoyk0{-webkit-transform:rotate(0deg);-ms-transform:rotate(0deg);transform:rotate(0deg);}.css-12vbvwq[data-truncated] .css-eb027h{max-height:300px;overflow:hidden;-webkit-transition:none;transition:none;}.css-12vbvwq[data-truncated] .css-5gimkt:after{content:’See more’;}.css-12vbvwq[data-truncated] .css-6mllg9{opacity:1;}.css-qjk116{margin:0 auto;overflow:hidden;}.css-qjk116 strong{font-weight:700;}.css-qjk116 em{font-style:italic;}.css-qjk116 a{color:#326891;-webkit-text-decoration:underline;text-decoration:underline;text-underline-offset:1px;-webkit-text-decoration-thickness:1px;text-decoration-thickness:1px;-webkit-text-decoration-color:#326891;text-decoration-color:#326891;}.css-qjk116 a:visited{color:#326891;-webkit-text-decoration-color:#326891;text-decoration-color:#326891;}.css-qjk116 a:hover{-webkit-text-decoration:none;text-decoration:none;}Mr. Biden’s request for $15 billion to be included in a sweeping budget bill Democrats intend to pass in the coming weeks represents a significant compromise. In March, the White House announced that its American Jobs Plan would include $30 billion for pandemic preparedness. But on Capitol Hill, where moderate Democrats are pushing to lower the price tag of the $3.5 trillion package, lawmakers have considered spending $8 billion on pandemic preparedness.“It would be a travesty if, in this time of the worst pandemic in a century, the administration and Congress, both sides of the aisle, didn’t get together and provide substantial funding to greatly reduce the risk of future pandemics,” said Dr. Tom Frieden, who ran the Centers for Disease Control and Prevention in the Obama administration.In July, when it looked like Democrats on Capitol Hill might slash the president’s $30 billion request to $5 billion, Dr. Frieden and Tom Daschle, a former Senate Democratic leader who made health care his signature issue, wrote an opinion essay in The Hill that argued such a cut was unthinkable after the worst public health crisis in a century.Mr. Daschle said Friday that both $15 billion and $65 billion were “a fraction of what is needed now.” The Bipartisan Commission on Biodefense, a private organization of which he is a member, has proposed $100 billion over 10 years, he said.“I am very concerned that if we don’t commit the resources now, it will only get harder, and less likely, in the years ahead,” Mr. Daschle wrote in an email. “Now is the time to apply lessons learned.”Some Democrats have repeatedly called for the initial $30 billion to be included in the budget package. Among them are Senator Patty Murray, Democrat of Washington and the chairwoman of the Senate health committee, and Senator Elizabeth Warren, Democrat of Massachusetts. Ms. Warren and six of her Democratic colleagues recently wrote to the House and Senate leaders of both parties, calling on them to include $30 billion in the budget package “to prevent and prepare for future pandemics.”.css-1xzcza9{list-style-type:disc;padding-inline-start:1em;}.css-3btd0c{font-family:nyt-franklin,helvetica,arial,sans-serif;font-size:1rem;line-height:1.375rem;color:#333;margin-bottom:0.78125rem;}@media (min-width:740px){.css-3btd0c{font-size:1.0625rem;line-height:1.5rem;margin-bottom:0.9375rem;}}.css-3btd0c strong{font-weight:600;}.css-3btd0c em{font-style:italic;}.css-w739ur{margin:0 auto 5px;font-family:nyt-franklin,helvetica,arial,sans-serif;font-weight:700;font-size:1.125rem;line-height:1.3125rem;color:#121212;}#NYT_BELOW_MAIN_CONTENT_REGION .css-w739ur{font-family:nyt-cheltenham,georgia,’times new roman’,times,serif;font-weight:700;font-size:1.375rem;line-height:1.625rem;}@media (min-width:740px){#NYT_BELOW_MAIN_CONTENT_REGION .css-w739ur{font-size:1.6875rem;line-height:1.875rem;}}@media (min-width:740px){.css-w739ur{font-size:1.25rem;line-height:1.4375rem;}}.css-9s9ecg{margin-bottom:15px;}.css-16ed7iq{width:100%;display:-webkit-box;display:-webkit-flex;display:-ms-flexbox;display:flex;-webkit-align-items:center;-webkit-box-align:center;-ms-flex-align:center;align-items:center;-webkit-box-pack:center;-webkit-justify-content:center;-ms-flex-pack:center;justify-content:center;padding:10px 0;background-color:white;}.css-pmm6ed{display:-webkit-box;display:-webkit-flex;display:-ms-flexbox;display:flex;-webkit-align-items:center;-webkit-box-align:center;-ms-flex-align:center;align-items:center;}.css-pmm6ed > :not(:first-child){margin-left:5px;}.css-5gimkt{font-family:nyt-franklin,helvetica,arial,sans-serif;font-size:0.8125rem;font-weight:700;-webkit-letter-spacing:0.03em;-moz-letter-spacing:0.03em;-ms-letter-spacing:0.03em;letter-spacing:0.03em;text-transform:uppercase;color:#333;}.css-5gimkt:after{content:’Collapse’;}.css-rdoyk0{-webkit-transition:all 0.5s ease;transition:all 0.5s ease;-webkit-transform:rotate(180deg);-ms-transform:rotate(180deg);transform:rotate(180deg);}.css-eb027h{max-height:5000px;-webkit-transition:max-height 0.5s ease;transition:max-height 0.5s ease;}.css-6mllg9{-webkit-transition:all 0.5s ease;transition:all 0.5s ease;position:relative;opacity:0;}.css-6mllg9:before{content:”;background-image:linear-gradient(180deg,transparent,#ffffff);background-image:-webkit-linear-gradient(270deg,rgba(255,255,255,0),#ffffff);height:80px;width:100%;position:absolute;bottom:0px;pointer-events:none;}.css-uf1ume{display:-webkit-box;display:-webkit-flex;display:-ms-flexbox;display:flex;-webkit-box-pack:justify;-webkit-justify-content:space-between;-ms-flex-pack:justify;justify-content:space-between;}.css-wxi1cx{display:-webkit-box;display:-webkit-flex;display:-ms-flexbox;display:flex;-webkit-flex-direction:column;-ms-flex-direction:column;flex-direction:column;-webkit-align-self:flex-end;-ms-flex-item-align:end;align-self:flex-end;}.css-12vbvwq{background-color:white;border:1px solid #e2e2e2;width:calc(100% – 40px);max-width:600px;margin:1.5rem auto 1.9rem;padding:15px;box-sizing:border-box;}@media (min-width:740px){.css-12vbvwq{padding:20px;width:100%;}}.css-12vbvwq:focus{outline:1px solid #e2e2e2;}#NYT_BELOW_MAIN_CONTENT_REGION .css-12vbvwq{border:none;padding:10px 0 0;border-top:2px solid #121212;}.css-12vbvwq[data-truncated] .css-rdoyk0{-webkit-transform:rotate(0deg);-ms-transform:rotate(0deg);transform:rotate(0deg);}.css-12vbvwq[data-truncated] .css-eb027h{max-height:300px;overflow:hidden;-webkit-transition:none;transition:none;}.css-12vbvwq[data-truncated] .css-5gimkt:after{content:’See more’;}.css-12vbvwq[data-truncated] .css-6mllg9{opacity:1;}.css-qjk116{margin:0 auto;overflow:hidden;}.css-qjk116 strong{font-weight:700;}.css-qjk116 em{font-style:italic;}.css-qjk116 a{color:#326891;-webkit-text-decoration:underline;text-decoration:underline;text-underline-offset:1px;-webkit-text-decoration-thickness:1px;text-decoration-thickness:1px;-webkit-text-decoration-color:#326891;text-decoration-color:#326891;}.css-qjk116 a:visited{color:#326891;-webkit-text-decoration-color:#326891;text-decoration-color:#326891;}.css-qjk116 a:hover{-webkit-text-decoration:none;text-decoration:none;}“The Covid-19 pandemic has made clear that underinvesting in our public health infrastructure, our biomedical research pipeline and our medical supply chain has disastrous consequences,” the senators wrote.Committees are still negotiating the details of the budget package, and several people familiar with the plan said the White House announcement on Friday might be an effort to press leaders on Capitol Hill — especially Senator Chuck Schumer, Democrat of New York and the majority leader — to get behind the administration’s full $65.3 billion plan and to commit to at least $15 billion in the budget measure.Mr. Schumer has so far been noncommittal. “I’ve been working and I’ll keep working to make the investments needed to ensure we are fully prepared for future pandemics,” he wrote last month on Twitter.Dr. Lander was joined on Friday by Elizabeth Cameron, the senior director for global health security and biodefense on the National Security Council — a job she also held in the Obama White House, where she drafted a preparedness document known as the pandemic playbook. She said the Biden plan “very much draws on those efforts,” as well as “on lessons from this pandemic.”According to documents released by the White House, the plan has five central goals: improving and expanding the nation’s arsenal of vaccines, therapeutics and diagnostics; improving surveillance of infectious disease threats; strengthening the public health system, with a “particular focus on reducing inequities”; building up the supply chain and the stockpile for personal protective gear and other items; and “managing the mission,” by creating a new Mission Control office — a task Dr. Lander likened to the Apollo missions to send astronauts to the moon in the 1960s.“If you’re getting to the moon, and you have a great booster rocket but you haven’t got a capsule capable of landing or computers capable of directing, it’s not going to work,” he said.

President Biden, who has pledged to fight the coronavirus pandemic by making the United States the “arsenal of vaccines” for the world, is under increasing criticism from public health experts, global health advocates and even Democrats in Congress who say he is nowhere near fulfilling his promise.Mr. Biden has either donated or pledged about 600 million vaccine doses to other countries — a small fraction of the 11 billion that experts say are needed to slow the spread of the virus worldwide. His administration has also taken steps to expand Covid-19 vaccine manufacturing in the United States and India, and is supporting production in South Africa and Senegal to expand access to locally produced vaccines in Africa.But with the administration now recommending booster doses for vaccinated Americans starting next month, outraged public health experts and many Democrats on Capitol Hill are calling on the president to move more aggressively to scale up global manufacturing. In an analysis published on Thursday, the AIDS advocacy group PrEP4All found that the administration had spent less than 1 percent of the money that Congress appropriated for ramping up Covid-19 countermeasures on expanding vaccine manufacturing.Tracking Coronavirus Vaccinations Around the WorldMore than 5.08 billion vaccine doses have been administered worldwide, equal to 66 doses for every 100 people.Congress put a total of $16.05 billion in the American Rescue Plan this year, in two separate tranches, that could be used to procure and manufacture treatments, vaccines and tools for ending the pandemic. But PrEP4All found that all told, the administration had spent $145 million — just $12 million of it from the American Rescue Plan — to expand vaccine manufacturing. The United States has donated 115 million surplus doses, and has purchased 500 million more from Pfizer and BioNTech to be distributed through Covax, more than any other country. But that is still a minute fraction of the 12 billion doses Duke University’s Global Health Innovation Center predicts the world needs by the end of 2021. James Krellenstein, a founder of PrEP4All and the author of its report, said “if they don’t change course pretty soon, the Biden administration is going to be remembered in terms that the Reagan administration is remembered today in not dealing with the AIDS crisis.”

Congress appropriated $16 billion to ramp up Covid-19 countermeasures, but a new report found that the Biden administration had spent very little of it on expanding vaccine manufacturing capacity.WASHINGTON — President Biden, who has pledged to fight the coronavirus pandemic by making the United States the “arsenal of vaccines” for the world, is under increasing criticism from public health experts, global health advocates and even Democrats in Congress who say he is nowhere near fulfilling his promise.Mr. Biden has either donated or pledged about 600 million vaccine doses to other countries — a small fraction of the 11 billion that experts say are needed to slow the spread of the virus worldwide. His administration has also taken steps to expand Covid-19 vaccine manufacturing in the United States and India, and is supporting production in South Africa and Senegal to expand access to locally produced vaccines in Africa.But with the administration now recommending booster doses for vaccinated Americans starting next month, outraged public health experts and many Democrats on Capitol Hill are calling on the president to move more aggressively to scale up global manufacturing. In an analysis to be published on Thursday, the AIDS advocacy group PrEP4All found that the administration had spent less than 1 percent of the money that Congress appropriated for ramping up Covid-19 countermeasures on expanding vaccine manufacturing.Congress put a total of $16.05 billion in the American Rescue Plan this year, in two separate tranches, that could be used to procure and manufacture treatments, vaccines and tools for ending the pandemic. But PrEP4All found that all told, the administration had spent $145 million — just $12 million of it from the American Rescue Plan — to expand vaccine manufacturing. The bulk of that went to retrofitting production lines at Merck, the pharmaceutical giant, which is teaming up with Johnson & Johnson to produce one billion vaccine doses starting in early 2022.White House officials dispute the $145 million figure, but did not respond to repeated questions about how the administration planned to use the bulk of the $16 billion. Senator Patty Murray, Democrat of Washington and the chairwoman of the Senate health committee, has also asked for a more detailed accounting, her office said.On Capitol Hill, 116 Democrats, including Senator Elizabeth Warren of Massachusetts, have called for putting $34 billion to increase vaccine manufacturing capacity in the upcoming budget reconciliation act. This month, they wrote to the president asking him to endorse the idea, but have not gotten a response, said Representative Raja Krishnamoorthi, Democrat of Illinois, who is leading the effort in the House.“This lack of attention to executing a robust vaccination strategy abroad is arguably one of their biggest missteps with regard to Covid,” said Mr. Krishnamoorthi, who said he lost three members of his extended family in India to Covid-19..css-1xzcza9{list-style-type:disc;padding-inline-start:1em;}.css-3btd0c{font-family:nyt-franklin,helvetica,arial,sans-serif;font-size:1rem;line-height:1.375rem;color:#333;margin-bottom:0.78125rem;}@media (min-width:740px){.css-3btd0c{font-size:1.0625rem;line-height:1.5rem;margin-bottom:0.9375rem;}}.css-3btd0c strong{font-weight:600;}.css-3btd0c em{font-style:italic;}.css-w739ur{margin:0 auto 5px;font-family:nyt-franklin,helvetica,arial,sans-serif;font-weight:700;font-size:1.125rem;line-height:1.3125rem;color:#121212;}#NYT_BELOW_MAIN_CONTENT_REGION .css-w739ur{font-family:nyt-cheltenham,georgia,’times new roman’,times,serif;font-weight:700;font-size:1.375rem;line-height:1.625rem;}@media (min-width:740px){#NYT_BELOW_MAIN_CONTENT_REGION .css-w739ur{font-size:1.6875rem;line-height:1.875rem;}}@media (min-width:740px){.css-w739ur{font-size:1.25rem;line-height:1.4375rem;}}.css-9s9ecg{margin-bottom:15px;}.css-uf1ume{display:-webkit-box;display:-webkit-flex;display:-ms-flexbox;display:flex;-webkit-box-pack:justify;-webkit-justify-content:space-between;-ms-flex-pack:justify;justify-content:space-between;}.css-wxi1cx{display:-webkit-box;display:-webkit-flex;display:-ms-flexbox;display:flex;-webkit-flex-direction:column;-ms-flex-direction:column;flex-direction:column;-webkit-align-self:flex-end;-ms-flex-item-align:end;align-self:flex-end;}.css-12vbvwq{background-color:white;border:1px solid #e2e2e2;width:calc(100% – 40px);max-width:600px;margin:1.5rem auto 1.9rem;padding:15px;box-sizing:border-box;}@media (min-width:740px){.css-12vbvwq{padding:20px;width:100%;}}.css-12vbvwq:focus{outline:1px solid #e2e2e2;}#NYT_BELOW_MAIN_CONTENT_REGION .css-12vbvwq{border:none;padding:10px 0 0;border-top:2px solid #121212;}.css-12vbvwq[data-truncated] .css-rdoyk0{-webkit-transform:rotate(0deg);-ms-transform:rotate(0deg);transform:rotate(0deg);}.css-12vbvwq[data-truncated] .css-eb027h{max-height:300px;overflow:hidden;-webkit-transition:none;transition:none;}.css-12vbvwq[data-truncated] .css-5gimkt:after{content:’See more’;}.css-12vbvwq[data-truncated] .css-6mllg9{opacity:1;}.css-qjk116{margin:0 auto;overflow:hidden;}.css-qjk116 strong{font-weight:700;}.css-qjk116 em{font-style:italic;}.css-qjk116 a{color:#326891;-webkit-text-decoration:underline;text-decoration:underline;text-underline-offset:1px;-webkit-text-decoration-thickness:1px;text-decoration-thickness:1px;-webkit-text-decoration-color:#326891;text-decoration-color:#326891;}.css-qjk116 a:visited{color:#326891;-webkit-text-decoration-color:#326891;text-decoration-color:#326891;}.css-qjk116 a:hover{-webkit-text-decoration:none;text-decoration:none;}James Krellenstein, a founder of PrEP4All and the author of its report, was more pointed. “If they don’t change course pretty soon,” he said, “the Biden administration is going to be remembered in terms that the Reagan administration is remembered today in not dealing with the AIDS crisis.”Addressing the world’s coronavirus vaccine needs is a complicated endeavor, with many layers of challenges. Vaccine makers around the world, including those in Russia, China and India, have predicted a total of 12 billion doses by the end of 2021, according to Duke University’s Global Health Innovation Center, which tracks vaccine manufacturing and publishes the Launch & Scale Speedometer website. Eight months into the year, an estimated five billion have been delivered.Some manufacturers are falling behind. Novavax has had production problems. Johnson & Johnson, which initially planned for one billion doses this year, has made slightly more than 103 million, Mr. Krellenstein said, citing data from the scientific intelligence firm Airfinity. That is in part because its contract manufacturer, Emergent BioSolutions, ruined up to 15 million doses, prompting the Food and Drug Administration to shutter its Baltimore plant for three months.If 12 billion doses were indeed produced and equitably distributed by year’s end, the world’s needs could be met. But, the Duke institute wrote, “those are both big ifs.”Several other countries as well as the United States are already recommending booster shots, which will cut into the supply. And the virus changes shape so rapidly — the highly infectious Delta variant is now dominant around the globe — that the vaccines developed last year may soon be outdated, said Dr. Richard Hatchett, the chief executive of the Coalition for Epidemic Preparedness Innovations, which helps lead the international vaccine effort known as Covax.In the short term, poor nations need doses, and Mr. Biden is correct when he says the United States has donated more than any other country. The United States has already donated 115 million surplus doses from the nation’s own supply, and has purchased 500 million doses from Pfizer and BioNTech to be distributed through Covax. With the United States planning for booster shots, one official said, there is no surplus right now.“Their financial contributions are huge — no other country has pledged as much as the U.S.,” Dr. Hatchett said. But, he added, “it’s not to say that they can’t and shouldn’t do more.”Dr. Hatchett said he would like to see a more nuanced discussion of the logistics of not only making vaccines for poor and middle-income nations, but also administering them. The New York Times recently reported that Covax was having trouble getting those shots into people’s arms. Unused doses are sitting idle on airport tarmacs in poor nations that lack the money and capacity to buy fuel to transport doses to clinics, to train people to give the shots — and to persuade people to take them.Mr. Biden took his first steps to address the vaccine shortage in March, when the White House announced the Merck deal as well as a partnership with Japan, India and Australia aimed at expanding manufacturing capacity. That included a pledge to help Biological E, an Indian manufacturer, produce one billion doses by the end of 2022.A White House official said the United States International Development Finance Corporation, which is making the investment, “expects to begin disbursing funds within the next several weeks.” The official did not offer specifics, or an amount.Mr. Biden promised in June that the United States would begin an “entirely new effort” to increase vaccine supply and vastly expand manufacturing capacity, most of it in the United States. He also put Jeffrey D. Zients, the White House coronavirus response coordinator, in charge of developing a global strategy. Mr. Zients pledged to work with U.S. manufacturers to “vastly increase supply for the rest of the world in a way that also creates jobs here at home.”.css-1xzcza9{list-style-type:disc;padding-inline-start:1em;}.css-3btd0c{font-family:nyt-franklin,helvetica,arial,sans-serif;font-size:1rem;line-height:1.375rem;color:#333;margin-bottom:0.78125rem;}@media (min-width:740px){.css-3btd0c{font-size:1.0625rem;line-height:1.5rem;margin-bottom:0.9375rem;}}.css-3btd0c strong{font-weight:600;}.css-3btd0c em{font-style:italic;}.css-w739ur{margin:0 auto 5px;font-family:nyt-franklin,helvetica,arial,sans-serif;font-weight:700;font-size:1.125rem;line-height:1.3125rem;color:#121212;}#NYT_BELOW_MAIN_CONTENT_REGION .css-w739ur{font-family:nyt-cheltenham,georgia,’times new roman’,times,serif;font-weight:700;font-size:1.375rem;line-height:1.625rem;}@media (min-width:740px){#NYT_BELOW_MAIN_CONTENT_REGION .css-w739ur{font-size:1.6875rem;line-height:1.875rem;}}@media (min-width:740px){.css-w739ur{font-size:1.25rem;line-height:1.4375rem;}}.css-9s9ecg{margin-bottom:15px;}.css-16ed7iq{width:100%;display:-webkit-box;display:-webkit-flex;display:-ms-flexbox;display:flex;-webkit-align-items:center;-webkit-box-align:center;-ms-flex-align:center;align-items:center;-webkit-box-pack:center;-webkit-justify-content:center;-ms-flex-pack:center;justify-content:center;padding:10px 0;background-color:white;}.css-pmm6ed{display:-webkit-box;display:-webkit-flex;display:-ms-flexbox;display:flex;-webkit-align-items:center;-webkit-box-align:center;-ms-flex-align:center;align-items:center;}.css-pmm6ed > :not(:first-child){margin-left:5px;}.css-5gimkt{font-family:nyt-franklin,helvetica,arial,sans-serif;font-size:0.8125rem;font-weight:700;-webkit-letter-spacing:0.03em;-moz-letter-spacing:0.03em;-ms-letter-spacing:0.03em;letter-spacing:0.03em;text-transform:uppercase;color:#333;}.css-5gimkt:after{content:’Collapse’;}.css-rdoyk0{-webkit-transition:all 0.5s ease;transition:all 0.5s ease;-webkit-transform:rotate(180deg);-ms-transform:rotate(180deg);transform:rotate(180deg);}.css-eb027h{max-height:5000px;-webkit-transition:max-height 0.5s ease;transition:max-height 0.5s ease;}.css-6mllg9{-webkit-transition:all 0.5s ease;transition:all 0.5s ease;position:relative;opacity:0;}.css-6mllg9:before{content:”;background-image:linear-gradient(180deg,transparent,#ffffff);background-image:-webkit-linear-gradient(270deg,rgba(255,255,255,0),#ffffff);height:80px;width:100%;position:absolute;bottom:0px;pointer-events:none;}.css-uf1ume{display:-webkit-box;display:-webkit-flex;display:-ms-flexbox;display:flex;-webkit-box-pack:justify;-webkit-justify-content:space-between;-ms-flex-pack:justify;justify-content:space-between;}.css-wxi1cx{display:-webkit-box;display:-webkit-flex;display:-ms-flexbox;display:flex;-webkit-flex-direction:column;-ms-flex-direction:column;flex-direction:column;-webkit-align-self:flex-end;-ms-flex-item-align:end;align-self:flex-end;}.css-12vbvwq{background-color:white;border:1px solid #e2e2e2;width:calc(100% – 40px);max-width:600px;margin:1.5rem auto 1.9rem;padding:15px;box-sizing:border-box;}@media (min-width:740px){.css-12vbvwq{padding:20px;width:100%;}}.css-12vbvwq:focus{outline:1px solid #e2e2e2;}#NYT_BELOW_MAIN_CONTENT_REGION .css-12vbvwq{border:none;padding:10px 0 0;border-top:2px solid #121212;}.css-12vbvwq[data-truncated] .css-rdoyk0{-webkit-transform:rotate(0deg);-ms-transform:rotate(0deg);transform:rotate(0deg);}.css-12vbvwq[data-truncated] .css-eb027h{max-height:300px;overflow:hidden;-webkit-transition:none;transition:none;}.css-12vbvwq[data-truncated] .css-5gimkt:after{content:’See more’;}.css-12vbvwq[data-truncated] .css-6mllg9{opacity:1;}.css-qjk116{margin:0 auto;overflow:hidden;}.css-qjk116 strong{font-weight:700;}.css-qjk116 em{font-style:italic;}.css-qjk116 a{color:#326891;-webkit-text-decoration:underline;text-decoration:underline;text-underline-offset:1px;-webkit-text-decoration-thickness:1px;text-decoration-thickness:1px;-webkit-text-decoration-color:#326891;text-decoration-color:#326891;}.css-qjk116 a:visited{color:#326891;-webkit-text-decoration-color:#326891;text-decoration-color:#326891;}.css-qjk116 a:hover{-webkit-text-decoration:none;text-decoration:none;}But since then, the Delta variant has shifted the focus to the new domestic crisis. Dr. Krishna Udayakumar, the director of the center at Duke, faulted Mr. Biden for pursuing an approach that “continues to be piecemeal” — an assessment echoed by J. Stephen Morrison, a global health expert at the Center for Strategic and International Studies in Washington.“They don’t have a strategy, nor do they have a structure to execute it,” Mr. Morrison said.White House officials say that it is not possible for them to scale up production quickly, in part because of a scarcity of raw materials, and that doing so would take three to five years — an assertion that Dr. Tom Frieden, who directed the Centers for Disease Control and Prevention during the Obama-Biden administration, dismissed as “nonsense.”Dr. Frieden, now the president of Resolve to Save Lives, a health nonprofit, pointed to Lonza, a Swiss biotechnology company, which entered into an agreement with the vaccine maker Moderna in May 2020, retrofitted its facility in Portsmouth, N.H., and was producing vaccine six months later.“People say, ‘Oh, it’s going to take months,’” Dr. Frieden said. “Well, Covid is with us for years. The best time to plant a tree is 20 years ago. The second best time is today.”Dr. Frieden and others also want the Biden administration to lean more heavily on Pfizer and Moderna to transfer their technology to manufacturers around the globe. The Financial Times reported this week that South Korean vaccine makers are poised to expand, but are struggling to secure intellectual property licensing deals with the two companies.Mr. Biden is likely to make some kind of announcement about addressing the pandemic when the United Nations General Assembly convenes in New York for its annual meeting in September. The administration is considering creating a government-owned manufacturing plant that would be run by a private contractor — a plan endorsed by PrEP4All. But a person familiar with the proposal said it was only a possibility at this point.There are challenges with such an approach, particularly if experienced vaccine makers do not participate, as the situation with Emergent BioSolutions demonstrated.Mr. Krishnamoorthi said the Democrats’ plan was modeled on PEPFAR, the President’s Emergency Plan for AIDS Relief, an initiative started by President George W. Bush that has invested $85 billion to address the global AIDS epidemic.Public Citizen, the nonprofit consumer advocacy organization, has a plan calling for the government to invest $25 billion in developing regional manufacturing hubs around the world, which it says would produce enough vaccine for low- and middle-income countries in a year.“He’s said, ‘We’ll be an arsenal for the world’ — that’s a little vague,” said Peter Maybarduk, who directs Public Citizen’s Access to Medicines program. “What we see instead are dribs and drabs, like the excess of the U.S. supply, maybe if we’re not using it for third shots at home.”