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States are ‘diverging from CDC guidance,’ resulting in an unequal vaccine rollout, experts say

February 17, 2021, 11:00 AM UTC

Jeff’s father is a pancreatic cancer survivor. As part of his treatment, the 66-year-old New Jersey resident had to have his pancreas removed, which subsequently led to his developing diabetes. In addition to being over 65, Jeff’s dad has underlying health conditions directly associated with a higher risk of serious COVID illness.

Jeff, who chose to use a pseudonym for this article, is frustrated that his father didn’t receive his first vaccine dose until a week ago, while people in other states were able to get a shot much earlier.

Jeff and his father had to navigate a web of appointment scheduling services before locking a shot down. And yet, Jenny, also a pseudonym, is a thirtysomething New Yorker and was able to easily secure an appointment for a dose of the Pfizer/BioNTech vaccine despite not being an essential frontline worker or harboring any underlying ailments that would make her more susceptible to the coronavirus. Those who spoke to Fortune from across the country described a laissez-faire approach to what was meant to be a phased vaccine rollout prioritizing the highest-risk patients in the first months of the immunization campaign.

Public health officials and medical experts express consternation with that reality, but they point to a tangled web of disparate state policies, overstrained health care workforces, and the practical risk of letting vaccines go to waste. The impact is clear: Some people who shouldn’t be eligible to receive a COVID vaccine right now are getting them, while others who need them are stuck in immunization limbo.

“Overall, we find states are increasingly diverging from CDC guidance and from each other, suggesting that access to COVID-19 vaccines in these first months of the U.S. vaccine campaign may depend a great deal on where one lives,” writes the nonpartisan health care think tank Kaiser Family Foundation (KFF) in a January report. “In addition, timelines vary significantly across states, regardless of priority group, resulting in a vaccine rollout labyrinth across the country.”

Dr. Melanie Swift, a physician who is helping lead the renowned Mayo Clinic health system’s COVID vaccination campaign in Minnesota, notes that we’re dealing with “a highly variable patchwork quilt of state-run public health programs.”

“The CDC is a recommending body, not a regulatory body,” she says, “and they have absolutely no control over vaccine distribution. This is all left to the states, and they have different degrees of latitude and authority based upon, honestly, what their governor allows them to do.”

Swift says this particular set of problems is showcasing an inconvenient truth of American health care: Public health systems work well when a policy is truly state-specific, such as nutritional assistance programs and local safety rules. It’s a different story when you’re facing an outbreak of the magnitude of the coronavirus.

“The pandemic is not paying attention to state borders,” Swift says. “The pandemic doesn’t care whether you’re a Minnesotan or an Iowan. And unfortunately, the system of having every state have its own approach to the pandemic leads to dramatically different rollouts of the vaccine.”

As with so many health policy issues, this is also a problem of privilege—or lack thereof. While Minnesota may have stringent standards for vaccine eligibility, other states may not be policing the process at all, says Swift, leading to all of the usual societal disparities: The savviest consumers with fast Internet connections and the best access to medical services wind up getting the vaccine first while the underserved communities hardest hit by COVID are hung out to dry.

This isn’t a story of villains. Experts from across the nation who spoke with Fortune said that shaming people for getting a vaccine is counterproductive, even though the ideal would be to siphon the doses to those who need it most in a given moment.

It’s a story of what happens when complex policy, practicality, and a pandemic converge—and the very serious human repercussions that follow, setting up a dynamic in which your zip code and rung on the socioeconomic ladder determine whether you can get a vaccine in a timely manner.

How the vaccine verification system works

Each state has its own rollout process for COVID vaccine eligibility. You may have qualified for a shot weeks ago in one state if you’re over the age of 65 but not until later in another. And community outreach for the immunization campaign can differ wildly between, say, West Virginia and Ohio.

There’s a coordination conundrum that gets to the heart of the verification problem. Health care workforces are simply exhausted from grappling with overburdened hospitals and ensconced in a seemingly endless cloak of American death. Adding a regulatory burden to their plates may not always be realistic despite their best efforts, and local governments must assist in that effort.

Darrin D’Agostino is the executive dean and vice president for health affairs at Kansas City University, a role that puts him on the front lines of the immunization campaign in Missouri. When asked about the practical hurdles to verifying COVID vaccine eligibility, he echoed the Mayo Clinic’s Dr. Swift and added that protection of personal data also plays a role in this dilemma.

“What you’re actually asking me is about the connection between what the state and federal responsibility to protect the public is and the protection of health information for individuals,” he says. “This is different in every state, so I can’t speak about our surrounding states with detail, but I can tell you that some places are trying to verify as much as possible within the scope of the protected information, while other states are a little bit looser, saying, Do you have any of these conditions?”

D’Agostino went on to note that he, too, has anecdotally heard of people saying they qualify for a vaccine when that may not technically be true, while others are hewing to a different standard and being very rigid in complying with the phased rollout. However, he says, he believes Kansas City University’s campaign is doing the best it can to adhere to the immunization schedule and that young, healthy, low-risk adults who may have received a vaccine would only have done so because the dose would have been wasted and tossed away if left unused.

But it’s complicated. About two weeks ago, KCU ran seven separate vaccination clinics, staffed by physician faculty and hundreds of student volunteers, in conjunction with three separate entities: the National Guard, the state health department, and federally funded health clinics at the local and community level that cater to underserved populations.

Verification processes can diverge among those various entities, and KCU’s primary responsibility, according to D’Agostino, is to make sure it’s safe for an individual to get a vaccine. “There are two places where verification occurs. There’s verification for phase-specific appropriateness, and then there is verification that you can receive the vaccine,” he says. “What we are doing is confirming the appropriateness of vaccine into the person, not the phase group that they’re in. That’s happening at the scheduling level, which my medical students and faculty are not involved with.”

Swift of the Mayo Clinic also says this is what the verification process resembles in Minnesota, largely at the discretion of the state public health department, and notes there are two separate elements to this process: the age-based component and the occupational component.

As someone overseeing the administration of vaccines to a health care workforce, it’s easy for Swift to verify if someone within her organization qualifies. From an age perspective, it’s not too difficult to check someone’s government ID to see if they’re old enough to be eligible under state law.

The problem comes with the occupational qualification issue when it’s someone who doesn’t work for your organization. “We’ve grappled with this locally. Our first group of nonemployees to vaccinate have been community health care workers that are not affiliated with our institution or any of our other hospitals in the region,” says Swift. “We address that by funneling all the requests through our local public health department. They establish their registration system where local employers could go online to complete a registration for their office.”

But that’s easier said than done. “The connection here has been through the employer. And so it has been a process for public health to connect with the employer and the employer to provide the list of the people that work there who are eligible,” according to Swift.

As the phased rollout continues, there’s another issue: verifying the status of those with underlying medical conditions that may qualify them for a COVID vaccine appointment. That’s a process that has already begun in multiple states, but yet again, the checks-and-balances system is wildly divergent. A large organization such as the Mayo Clinic may be able to leverage its medical records to identify high-risk patients and actively reach out to them, but others who spoke with Fortune said you may simply have to self-attest to having a qualifying condition.

It isn’t unimaginable to see people fall through the cracks given that complexity. And Swift reiterates that states simply aren’t being consistent.

Other experts who spoke with Fortune note the scope of the challenges despite the CDC’s efforts to synthesize as much data as possible in order to streamline the vaccination process. First, the federal government must allocate vaccine doses and ship them to states, a process that relies on a federated system set up by the agency called VTrckS. This is a multipronged digital portal that serves 64 separate jurisdictions so the government can keep track of the needs of prisons, Native reservations, the military, and local areas for vaccine distribution. After that, it’s on to the next links in the chain, and things get even more complicated, which can further gum up the works when it comes to eligibility verification.

“Then the state is telling each health system and delivery channel: You’ll receive ‘X’ supply,” says Dr. Rebecca Weintraub, an associate physician at Brigham and Women’s Hospital and assistant professor at Harvard Medical School.

Weintraub is juggling the gamut of medical roles during the pandemic. She’s a doctor, an academic, the lead for the COVID vaccine delivery efforts at Ariadne Labs, and she has also been an on-the-ground vaccinator for patients across Massachusetts for the past 10 weeks.

“Those vaccine delivery channels are setting up their schedules and trying to reserve for both the first and the second doses,” she says. “So they’re trying to predict, you know, three or four weeks later, how many doses will I receive so I can open up this many appointments.”

This process, while understandable during an unprecedented crisis, is fertile ground for confusion and inequities. Yet another example of those differing approaches? Look to West Virginia, which is tackling the vaccine campaign with a local touch and old-fashioned data gathering.

“We’ve done a lot of data analytics. We’ve done a lot of epidemiology work,” says retired Major General Jim Hoyer of the West Virginia National Guard. “We have 100 National Guardsmen supporting epidemiology efforts at the state and local level here. So we did a pretty good job of knowing our data early on.”

Hoyer is now at West Virginia University and was also assigned by Gov. Jim Justice to lead the state’s interagency COVID response task force. Yet even with all that data at hand, in a state where many residents are older and at high risk, there isn’t a uniform system when it comes to checking eligibility.

“It’s a decentralized process, to the point of when they go to a clinic that’s established, that they’re going to provide identification and proof of age, a driver’s license, some document to that effect,” says Hoyer. “We have since, over the last three weeks, established a central registry system for the state.”

It’s a work in progress that for the time being may force locales to get creative and improvise on a case-by-case level so that the neediest get their COVID vaccine doses.

“There was a call that actually came from the U.S. senator’s office, saying, ‘Hey, we just got a call. There’s a Korean War veteran who is homebound and can’t get out to get the vaccine, 91 years of age,'” Hoyer recounts. “That coordination goes back through the state COVID task force all the way down to the local, federally qualified health clinic who actually had served that veteran, and they send somebody out to vaccinate.”

Ethics and practicality

At the Ohio State University Wexner Medical Center, Dr. Andrew Thomas, an internal medicine physician and the chief clinical officer for the organization, feels strongly about the ethical imperative to prevent vaccine line-jumping.

“I certainly can’t justify a 30-year-old trying to line-jump for the vaccine if they have no other reason based on an essential worker status or health care employee status,” he says. “I can understand they want to protect their own health, and we want them to, but the problem is, there’s just not enough supply right now of the vaccine to do that.”

That supply-and-demand dynamic may well reverse itself in the coming months as eligibility for a vaccine opens up to groups that aren’t as gung-ho about getting them while manufacturing capacity simultaneously ramps up.

Thomas echoes what many other experts told Fortune: There are multiple categories for vaccine prioritization ranging from age, to career, to underlying health conditions, and a combination of employers, public health systems, and hospitals must grapple with all that data.

At the Ohio State University COVID vaccination sites, you’d have to present an ID for verification, even if you’re someone who is already in that health system’s patient portal. Being in the patient portal makes things easier since you already know what a vaccine recipient’s age and underlying medical condition are.

Still, much of the process can boil down to self-attestation and something of an honor system. Harvard’s Weintraub and other medical experts have made the case that at the end of the day, it’s better to get as many shots into arms as possible, irrespective of the technical phases.

“In Massachusetts, we ask you: Are you eligible for the vaccine you attested, prior to scheduling your appointment? ‘Yes, I fit into these categories.’ And there’s no further documentation required,” she says. “There’s proactive outreach to groups, especially the elderly, saying you are eligible, you’re over 75, please schedule an appointment.”

It’s practical, but it manifests itself in socioeconomic inequities. Black and Latino populations have grappled with the worst of the pandemic, and yet their vaccination rates still lag behind nonminority peers.

For instance, as of Feb. 15, just 3% of the 6.2 million COVID vaccine doses administered in California went to Black Americans despite the demographic making up 6.5% of the state’s population, according to state Census and public health data. The disparity is even more egregious for Latino communities, who make up 40% of the population but have received just 16% of the administered doses.

Triage and its discontents

Ultimately, the purpose of a vaccination campaign is to achieve herd immunity. In order to do that, you need to have upwards of 70% of a population immunized.

But given America’s historical struggles with vaccine skepticism, that could prove a lofty goal. And delicate commodities such as the Pfizer and Moderna vaccines, which may spoil within a day once they’ve been thawed and reconstituted, are simply too precious to waste.

“The advice is, if you have eligible candidates, they can get it. And I can tell you if some of your friends ended up getting in through the efforts that we were doing here in Kansas City, at Kansas City University, specifically, it was only because there was a leftover vaccine,” says D’Agostino. “Remember, this is adding a whole separate layer of complexity because each one of those people now needs a booster shot,” referring to the fact that the Pfizer and Moderna vaccines are two-dose vaccines.

“And if they’re not in the appropriate phase, we have to make sure that they’re in the appropriate health software to ensure that they get another vaccine. So it’s complex, but the reality is, they’re more than likely getting what was left over, and these would have been wasted in other situations.”

Of course, it’s preferable to get a shot into someone’s arm if the alternative is to waste a vaccine. But the disparate stories of who faces verification hurdles and the inequities it produces in a global COVID vaccine drive underscores what’s been clear from the first days of the pandemic: The frustrating communication problems and lack of unified strategy across the spectrum of public and private players have birthed an unequal immunization playing field, particularly for vulnerable communities.

There’s a psychological downside to these disparities, too, which should encourage states to be vigilant, or at least consistent, in their standards, according to Swift.

“There are those occasions, you know, where you are going to either lose a dose because it’s expiring at the end of the day, or have to waste it, or give it to someone else who might be 64 and a half, or whatever,” she says.

“But you should make your best effort to still target the vaccination to that eligible group. It just increases the trust of the public in the system, because people will get cynical and down at heart if they start to hear more and more of these stories of people not getting vaccination, or getting vaccines when they’re not eligible.”