It was April, more than three months into the vaccination campaign against covid-19, and Jim Freeman, 83, still had not gotten his first dose.

Freeman had been eligible for months as part of the 75-and-older target group deemed most vulnerable to death and serious illness in the pandemic. But he could not leave his home to make the journey to one of the mass-vaccination sites in San Mateo County. Freeman, who has Parkinson's disease, has extremely limited mobility and no longer can walk.

"He watches TV at night and sees all these people in line getting vaccines, but he couldn't do it," said his daughter Beth Freeman, 58. "It was really frustrating." She contacted the county and state public health departments and even her local congresswoman for help, but none had a solution.

Finally, after weeks of failed attempts to get someone to vaccinate her father at their home, Beth spent $700 to rent a special wheelchair-accessible van and, with the help of a home health aide, nervously drove her father to the county's mass-vaccination site.

Even as the nation has moved on to vaccinating everyone 16 and older, the vast majority of homebound people have not yet been vaccinated, said Kelly Buckland, executive director of the National Council on Independent Living. "As far as I can tell, no one's really doing it. Maybe a few places in the country, but not on the mass scale it needs to be."

Across the nation, an estimated 4 million Americans are homebound by age, disability or frailty, unable to easily leave their homes to receive a covid vaccine.

Buckland noted that, while homebound people are not out in public where the virus is circulating, they don't live in a bubble. Most rely for care on family members or a rotating staff of home health aides who come and go and often have their own homes and families. "For people with disabilities, you can't close yourself off. You don't have the option. People have to come into your home every day to give you services."

The Biden administration in late March dedicated $100 million to help vulnerable older adults and people with disabilities get vaccinations. But many caregivers and homebound people say they aren't yet feeling the impact of that effort.

California, where tens of thousands of residents like Jim Freeman are still waiting their turn for vaccination, offers a sharp lens on the challenges.

Marta Green, a California official helping oversee vaccine distribution, said during an April meeting of the state's Community Vaccine Advisory Committee that California is "working on a partnership" to send ambulances to vaccinate homebound people where they live. In response to questions about how many homebound people had been vaccinated so far, a spokesperson for the California Department of Public Health said the effort was "just beginning" and estimates were not available.

As part of a $15 million no-bid contract with California to administer the state's vaccination program, Blue Shield of California is obligated to provide vaccine access to homebound people. The company, nonetheless, declined to provide responses to specific questions about such efforts. Spokesperson Erika Conner said the company has "diligently explored opportunities for this work" and recommended that homebound people contact their local public health departments or health care providers.

The logistics of inoculating homebound people with a vaccine that requires cold storage is not simple. Once thawed, a vial of Pfizer-BioNTech vaccine contains six doses that must be delivered within six hours, while a Moderna vaccine vial contains 10 to 15 doses to be used within 12 hours. With each vaccination visit lasting about an hour plus the travel time, there isn't much room for error, especially in rural areas where residents may live far apart. The one-dose Johnson & Johnson vaccine offers more flexibility, but the pause due to safety concerns resulted in delays.

"Yeah, it's not easy. If it were easy, we'd already have done it," said Dr. Mike Wasserman, a geriatrician and member of the California vaccine advisory committee. "But that's not an excuse. These are the folks who if they get the virus they're going to die. I don't accept it."

Wasserman said he'd give the state a "D" for its efforts to reach the homebound for vaccination. For some, he added, it might already be too late. "If you're 80 years old and you live in a 1,000-square-foot home with 10 other people, you're probably dead already."

In the absence of a coordinated state-driven effort, California counties are attempting a patchwork of approaches.

In Los Angeles County, the public health department has partnered with the sheriff’s department and 15 fire departments to vaccinate homebound residents, with some success. Health officials projected that 50% of the county's 10,000 homebound residents will have received one dose by the end of April.

In Fresno County, with more than a million residents, health officials said they are compiling a list of homebound people who want help getting a vaccine. So far, fewer than 20 people in that category have been contacted and received the vaccine.

In San Mateo County, where Freeman lives, the health department has identified at least 1,000 individuals who are homebound and in need of the vaccine; so far, 100 have been vaccinated.

Before she resorted to renting the $700 mobility van for her father, Beth Freeman contacted county workers. They offered to send a bus to pick up her father and take him to a vaccination site, but she couldn't imagine how that would work for him, both in terms of the physical logistics and the risk of exposure. She asked the nurses who visited her father twice a week through Sutter Health's care-at-home program for help — after all, they had given him the flu shot. But no luck. The nurses said they were not allowed to offer the covid vaccine.

Finally, on April 6, Beth made the difficult decision to transport her father despite his limited mobility. "I did not want to take him out of the house for this. It was risky for his health. But at some point I realized it wasn't going to happen any other way," she said. "He wanted to see members of his family and time was ticking."

She said her father was up all night worrying, and his body was stiff. But with help from a home health aide, she used a special lift to hoist him into a wheelchair and wheeled him down two ramps and into the rented van, where she strapped him to the chair. They drove 20 minutes to the San Mateo County Event Center, her eyes darting from the road to the rearview mirror to check on her father, and then waited 40 minutes in the drive-thru line.

"When I rolled down the window, the nurses were like, What the hell? Why is he only coming to us now?" she said. The experience was so stressful for her father, she added, that he slept on and off for the next two days.

This week, they repeated the ordeal for his second dose — including laying out another $700 for the rental van. "All this, while he sees nurses at home twice a week?" Beth Freeman said. "What a missed opportunity."

This article was reprinted from khn.org with permission from the Henry J. Kaiser Family Foundation. Kaiser Health News, an editorially independent news service, is a program of the Kaiser Family Foundation, a nonpartisan health care policy research organization unaffiliated with Kaiser Permanente.