As updated coronavirus vaccines hit U.S. pharmacy shelves, adults without health insurance are discovering the shots are no longer free, instead costing up to $200.

The federal Bridge Access Program covering the cost of coronavirus vaccines for uninsured and underinsured people ran out of funding. Now, Americans with low incomes are weighing whether they can afford to shore up immunity against an unpredictable virus that is no longer a public health emergency but continues to cause long-term complications and hospitalizations and kill tens of thousands of people a year.

The program’s elimination marks the latest tear in a safety net that once ensured people could protect themselves against the coronavirus regardless of their financial situation. Health experts worry that the paltry 22% rate of adults staying up-to-date on vaccines will erode further. And they fear that the roughly 25 million people without health insurance in the nation will be especially vulnerable to COVID-19 because they tend to be in poorer health and avoid medical care when sick.

Nicole Savant, a 33-year-old part-time paralegal and dog walker, lost her Medicaid benefits last year when her income rose. She wants the latest shot because she knows people who died of COVID before the vaccines became available and because she faces a higher risk of severe disease being overweight.

She was floored when she was quoted $201.99 at an appointment to receive the vaccine at a St. Louis-area CVS. She wasn’t sure if she even had that much money in her bank account.

“I have so little money, and I have other needs as well, like monthly medications,” said Savant, who doubts she will get the vaccine if she has to pay out of pocket. “I would hope for the best, which I really don’t want to do.”

At least 34 million doses of last year’s vaccine were administered to adults, according to the Centers for Disease Control and Prevention. Of those, 1.5 million were funded through the Bridge Access Program, which was originally set to end this December, allowing vaccinations ahead of the usual winter wave.

But it expired ahead of schedule because Congress rescinded $6.1 billion in coronavirus emergency spending authority as part of a deal to avert a government shutdown. Congress also declined to fund the Biden administration’s proposal for a Vaccines for Adults program that could provide routine immunizations, including for the coronavirus, for free, similar to an existing Vaccines for Children program.

Private insurers, along with the Medicare and Medicaid government programs, are required to pay for coronavirus vaccines. The Bridge Access Program offered a backup option for people encountering insurance snags.

The CDC said it identified an additional $62 million to buy coronavirus vaccines targeting the latest variants for distribution through state and local health agencies – which local officials say is a sliver of the overall need. CDC spokeswoman Jasmine Reed said the partnership with state and local officials can provide shots to 1 million insured and underinsured Americans.

Raynard Washington, who leads the Mecklenburg County health department in North Carolina, said it’s difficult for financially strapped health agencies to tap their own funds for coronavirus vaccines. Under CDC contracts, health officials spend $78 a dose for the vaccine from the drug company Moderna and pay $100 for the version from Pfizer-BioNTech, compared with $15 to $20 for flu shots.

Washington, who also leads the Big Cities Health Coalition, an organization representing metropolitan health departments, said vaccine manufacturers should charge health departments less to help vaccinate more people without insurance.

“What’s at stake is we are reverting back to a system where a person’s financial ability to be able to pay will determine their ability to be healthy,” Washington said.

Pfizer and Moderna said their vaccines would be available through patient assistance programs that offer free vaccines, but spokespeople did not offer details on the scope and eligibility of those programs. Novavax, whose vaccine was approved by regulators last week, said it does not have a patient assistance program for the upcoming fall season. Moderna and Novavax did not respond to questions about the rate they charge health officials. Pfizer defended its pricing practices.

“Pfizer has priced the vaccine to ensure the price is consistent with the value delivered and with the goal of uninterrupted access for every American,” the company said in a statement provided by spokesman Kit Longley.

Community health centers that often provide low-cost care to uninsured people administered 24 million shots when the federal government provided them, according to the National Association of Community Health Centers. Now, the facilities will have to scale back those programs and rely on local health officials for vaccines, some of whom would have little to share, said Luis Padilla, the association’s chief health officer.

“This country doesn’t provide enough for public health infrastructure and resources,” Padilla said.

The approval of updated coronavirus vaccines on Aug. 22 sent some Americans dashing to get shots before the end of the month. The CDC webpage about the Bridge Access Program, until Friday, said it ended in August without making clear it funded only the previous vaccines, which could no longer be administered after the new shots were authorized.

Adrianna Ruiz, 32, and their girlfriend showed up Wednesday to a CVS appointment in Atlanta hoping to get vaccinated before a Labor Day weekend cross-country road trip to California to help a friend with cancer move their belongings.

Ruiz lost insurance after getting laid off from a nonprofit job in July but believed the vaccine would be free based on the CDC website. But a CVS employee confirmed the program was no longer in effect. Ruiz gets about $300 in weekly unemployment benefits.

“If I want to eat and pay bills, then I can’t afford to pay $200,” Ruiz said.

Instead of getting new shots, Ruiz looked up options to enroll in subsidized insurance plans during the road trip. The precautions they are embracing on the journey, including taking a PCR test before embarking, wearing N95 respiratory masks at gas stations and packing lunches to eat on picnic blankets in parks, have become more urgent.

Shannon Donnell, a critical care nurse in New York, plans to eat the out-of-pocket costs of an updated coronavirus vaccine. She works on contract without health benefits and said the plans she qualified for through the state’s Affordable Care Act marketplace were too costly with $500 monthly premiums and a $5,000 deductible.

She believes in the urgency of vaccines after watching COVID patients die while she worked in Manhattan during the devastating surge in spring 2020 and later cared for unvaccinated patients struggling to breathe in a Texas COVID intensive care unit right as the shots arrived. Coronavirus patients no longer flood the intensive care units where she now works, but when they arrive, they are often immunocompromised or unvaccinated.

“It feels like health care workers are still being left to fend for ourselves in many ways,” Donnell, 48, said. “No one is stepping up to say, ‘Hey, I’ll cover that for you’ before you go into your shift of covering COVID patients.’ ”

The Bridge Access Program also extended an opportunity for free coronavirus vaccines to international visitors and undocumented immigrants, who have limited health insurance options.

Vasu, a 56-year-old undocumented and uninsured immigrant in Chicago, hoped to get vaccinated again after hearing about friends getting sick, including one in his 30s whose symptoms lasted for months, and after the outbreak at the Democratic National Convention. A friend offered to pay for her vaccine when Vasu lamented in a Facebook message that the end of the Bridge Access Program left her “screwed.”

“We are talking about a large group of people who are going to lose access or are too nervous about accessing vaccines,” said Vasu, who spoke on the condition she be identified only by a middle name to avoid the scrutiny of immigration authorities. “The government keeps saying it’s your responsibility to be vaccinated. But you are not making it easy.”

The changing landscape for the coronavirus vaccine stands in stark contrast to 2021 and 2022 when free shots were widely distributed. But the urgency of vaccination has subsided as the virus’s toll lessens now that nearly every American has built up immunity from previous infections or shots and hospitals are no longer overwhelmed. People 65 and older, who are at the highest risk of severe illness and death, qualify for free vaccines through Medicare.

Still, health officials recommend young and middle-aged adults receive updated coronavirus vaccines because most Americans have risk factors for complications and because the vaccine reduces the threat of the lingering debilitating symptoms of long COVID.

Adriane Casalotti, chief of government and public affairs at the National Association of County and City Health Officials, said the success of the early distribution of coronavirus vaccines “showed us what can be done when you make vaccines accessible and easy to get.”

“But that shifted now,” she added. “We are back to the traditional health-care system we’ve had, and the struggles we’ve had in that health-care system.”