LeadershipCryptocurrencyInflationGreat ResignationInvesting

Missing their shots: Inside Pennsylvania’s rough COVID vaccine rollout

April 1, 2021, 10:30 AM UTC

It was a February snow day that made Christine Meyer snap—and realize she had to take Pennsylvania’s vaccine rollout into her own hands.

Meyer, an internal medicine physician who owns a 20,000-patient practice in Exton, Pa., in the Philadelphia suburbs, had spent weeks fielding calls from patients who were eligible for COVID-19 vaccines but who couldn’t find an appointment—at pharmacies, at doctors’ offices, via local health departments, or through the state’s vaccine-information website. Most of them were over 75, and many struggled to register online through systems that required tech savvy.

When a snowstorm hit, canceling in-person appointments, Meyer asked her clinicians and staff to spend the day helping patients register for jabs. She posted about it on her practice’s Facebook page—and within two hours she had 1,200 people emailing her office for help, crashing her servers. Soon Meyer created a volunteer-run matchmaking service on Facebook, allowing seniors—or their children or neighbors—to request help finding a vaccine. As of late March, the group had more than 60,000 members (including this Pennsylvania-raised reporter, trying to help her local parents). By then, few users were waiting to hear from the state: The forum was dominated by talk about when Walgreens, CVS, Rite Aid, and other pharmacies were releasing blocks of appointments, and how best to navigate their often-maddening websites.

“This vaccine thing honestly bowled me over,” Meyer told Fortune via video, her voice and hand gestures speeding up with frustration. “I put all of my faith, and all of my patients’ faith, in the health department—because that’s how it was supposed to work. But the process is broken.”

As Meyer and millions of Pennsylvanians have learned, the state’s vaccine-rollout problems run far deeper than a confusing sign-up process. The Keystone State, with more than 24,800 fatalities, is the state with the fifth-highest COVID-19 death toll. It also has one of the nation’s longest litanies of vaccine stumbles. At the end of January, Pennsylvania had received nearly 2 million doses but had distributed only 42%—ranking the state 49th, ahead of only Alabama, according to a Becker’s Hospital Review analysis of CDC data. As the state’s 2.4 million seniors scrambled to find vaccines for a disease they are particularly vulnerable to, the state sent 12,000 doses to pediatric offices—even though most children aren’t yet eligible for shots. The health department later warned that more than 100,000 people might have to reschedule their second appointments for the two-dose Moderna vaccine because of miscommunication with providers.

Meanwhile, public health authorities were sending far fewer doses per capita to the 2.5 million residents of the Philadelphia suburbs—Meyer’s territory—than to some of the state’s sparsely populated rural enclaves, a Philadelphia Inquirer analysis found. A state spokesperson disputes the analysis’s methods, but local officials echo its findings: At one point, says Monica Taylor, council vice chairperson of 565,000-person Delaware County, the county was “getting only 1,000 doses a week. It made it more like the Hunger Games.”

Pennsylvania’s rollout problems have mirrored those of many other large, racially and socioeconomically diverse states as they navigate a massively complex process. The national effort has required unprecedented coordination among a mismatched team of players, including a federal government that squandered months in an acrimonious presidential transition; cash-strapped state and local governments; and a patchwork of big health care providers, small clinics, and Fortune 500 pharmacy and grocery chains sorting through changing—and often conflicting—distribution and eligibility rules.

Still, Pennsylvania’s campaign has stood out for its problems, some of which are self-inflicted. Unlike some of its peers, Pennsylvania declined to create a centralized vaccination system, putting the burden on individual residents to navigate the appointment maze. A host of bureaucratic complications, distribution failures, and conflicts between state and local leaders have slowed things down even more—showing the danger of an every-party-for-itself approach. By late March, Pennsylvania had improved its rollout by several metrics. But it continues to struggle to reach its most vulnerable populations, including Black and Latinx residents.

The persistent problems have left doctors, local officials, and public health experts lamenting an excess of red tape and a lack of coordination. “The fact that there’s not a centralized process across the state means that you’re really depending on each individual organization doing their own thing and hoping that it works,” says Tracey Conti, a member of the Pittsburgh-based Black Equity Coalition and program director of family medicine at the UPMC McKeesport health care system. “It creates a lot of unknowns—and a lot of frustration.”

State officials acknowledge as much. Pennsylvania has gone through “a month of reckoning,” acting Health Secretary Alison Beam tells Fortune. “There is a lot of room to improve—and we only want to be moving forward.”

Newsletter-Red-Line-15

Pennsylvania’s most headlinegrabbing vaccine scandal wasn’t within the state’s control—but it continues to resonate across its rollout. In January, the city of Philadelphia, which gets its vaccine supply directly from the federal government, asked an unproven startup called Philly Fighting COVID to run its first mass vaccination clinic. Founder Andrei Doroshin, a 22-year-old neuroscience grad student at Drexel University, had become a local entrepreneurial hero in the early days of the pandemic, recruiting friends to 3-D print face shields for local hospitals. Then his startup, which initially operated as a nonprofit, won a $194,000 contract from Philadelphia’s health department to operate COVID-19 testing sites in underserved city neighborhoods.

But once it was asked to run the city’s vaccination clinic, Philly Fighting COVID abruptly abandoned its testing commitments in predominantly Black and Latinx neighborhoods, according to an investigation by public-media organization WHYY—which also reported that the startup had, without informing city officials, registered a for-profit arm. To complete his public transformation from hero to villain, Doroshin was seen—and later admitted to—taking home vaccine doses for his friends, on a day when eligible Philadelphians were shut out at his clinic. (Doroshin declined to comment through a spokesperson, who said that “we didn’t have the resources to do testing and vaccinations at the same time,” but “it was a mistake in hindsight” to stop testing.)

24,828

COVID-19 deaths in Pennsylvania as of March 24, the fifth-highest death toll in the U.S. Source: CDC

“I love reading about governments—on a local, county, and state level—that are getting it right. And in an alternate universe, Philly Fighting COVID could have been the best thing that happened to Philadelphia,” says Alison Buttenheim, an associate professor at the University of Pennsylvania School of Nursing (and a co-founder of the “Dear Pandemic” collective of COVID-19 scientific experts).

But in this universe, Philadelphia’s plan “placed the city at great risk,” a March report from city Inspector General Alexander DeSantis found. (A spokesperson for the city health department declined to comment.)

“Our government was working in a hurry and trying to respond to something really quickly,” says DeSantis, who is continuing to investigate the affair. “It was a process that broke.”

Hannah Beier—REUTERS

The scandal was an early black eye for Pennsylvania, and it highlighted a common problem nationwide—the lack of established vaccine partners for governments. Hospitals and large health care providers might seem like obvious distributors, but they face problems of their own. The pandemic exacerbated their enduring budget and personnel crunches; collectively, large health care systems were estimated to be losing almost $1 billion a day last year. “It’s expensive to go out there in the community and put shots in arms,” says a senior physician at a top Philadelphia hospital. “It requires a lot of logistics, space, and hiring people—and it’s not necessarily going to make a health system money.”

Federally funded community health centers may be best positioned to vaccinate minority and underserved populations, but those groups say they need bigger allocations of vaccines from governments to scale up.

Into this vacuum have stepped the large retail pharmacy chains—already experienced at distributing yearly flu shots. Walgreens and CVS alone are expected to give out about 25% of COVID shots nationwide this year, according to Barclays. Those chains also have stronger economic incentives around delivering vaccines. They expect revenue growth from the rollout itself—from government or insurance payments per shot; from selling more stuff to customers who come in for shots; and from collecting customers’ data for marketing purposes. The chains also claim to be more accessible to rural and racially diverse populations. CVS Caremark chief medical officer Sree Chaguturu notes that 85% of Americans live within 10 miles of a CVS pharmacy, and says that the company has tried to “be really thoughtful on store locations,” especially in terms of equity, when making decisions about which pharmacies in each state get its supply of vaccines.

I put all of my faith, and all of my patients’ faith, in the health department—because that’s how it was supposed to work. But the process is broken.

Christine Meyer, a physician and owner of a medical practice in Exton, Pa.

In Pennsylvania, coordination among these partners was especially slow to jell—owing in part to a change in command. On Jan. 19, President Biden appointed Rachel Levine, the state secretary of health, to be U.S. assistant secretary of health. The nomination was historic: Levine, a pediatrician, later became the first openly transgender official confirmed by the U.S. Senate. But it only added to the confusion in her home state.

Gov. Tom Wolf appointed his then deputy chief of staff, Alison Beam, as acting secretary of health. Beam had been involved in the state’s vaccine strategy, but she tells Fortune that she inherited “a lack of the necessary planning” for dealing with demand that outpaced supply, and a resulting “lack of controls” in how to allocate vaccines. (A source close to Levine says that the outgoing secretary “did everything feasible to put together a robust vaccine plan” but that “there’s no question improvements needed to be made after the initial phase.”)

Wolf and Beam have created a bipartisan legislative task force, which some local providers praise for increasing the frequency and clarity of information around the rollout. “The communication has increased tenfold over the past four to five weeks,” says Eric Kiehl, director of policy and partnership at the Pennsylvania Association of Community Health Centers, whose members provide health care to nearly 1 million underserved residents. But “that doesn’t change the big issue. Everybody’s calling and wanting vaccine, and we just don’t have it.”

In February, the state also gave Boston Consulting Group an $11.6 million contract to help improve its vaccine distribution. BCG has helped Pennsylvania pare down what Beam calls “an unwieldy provider network” of doctors and pharmacies who have been allocated vaccines, and it’s upgrading what Beam says is the state’s “undoubtedly arcane” data-reporting process. It also helped Beam work through a “tidal wave” of requests when the state warned that up to 100,000 residents might not get their second Moderna shots in time. (Citing CDC guidance, Pennsylvania addressed the shortage by asking residents to wait up to 42 days for their second shots, instead of the more usual 28.)

“We were working on the foundational infrastructure” and “simultaneously responding to these fires,” Beam says. Now, “we are driving the urgency.”

Newsletter-Red-Line-15

Since those early days, Pennsylvania has made up some ground. As of March 25, the state had climbed into the top half of states for vaccine distribution among the general population. More than 81% of its supply has been administered, according to the CDC, surpassing the national average of 78%, and 28% of state residents had received at least one dose. And on March 31, Beam announced that all adults outside of Philadelphia would be eligible for a vaccine by April 19 (although those in the city may have to wait until May 1).

But the rollout hasn’t penetrated far enough into some communities—especially communities of color, which have been disproportionately harmed by the pandemic. By mid-March only 3% of Pennsylvania’s vaccines outside Philadelphia had gone to Black residents, according to the CDC, even though Black people account for 7.5% of the state’s non-Philly population; similar disparities affect the smaller Latinx and Asian populations. These numbers don’t paint a complete picture, since the CDC has racial data available for only 53% of national vaccine recipients. Still, Pennsylvania seems to be underdelivering on a front where the nation already does poorly: Of Americans who have had at least one dose, 8.2% are Black and 9.3% are Latinx; while the U.S. population as a whole is 13.4% Black and 18.5% Latinx.

In Philadelphia, whose population is 44% Black, the inequities are just as stark. Rite Aid, the pharmacy chain based in Harrisburg, Pa., is one of the city’s dominant distributors, with an online registration system that’s theoretically equally open to all residents. In late March city government data showed that 83% of Rite Aid’s vaccine recipients were white, and that the pharmacy had inoculated nearly 11 white people for every Black person who received a shot. One problem: More than half of Rite Aid shots went to suburban residents who drove into the city—which is permissible under state guidelines.

A Rite Aid spokesperson says the company has increased the share of vaccine doses going to Black Pennsylvanians within the past month, and is “working tirelessly to overcome the many disparities” that cause vaccine inequity. Some factors are indeed outside its control, like the suburbanite invasion—which also illuminates some of the reasons why authorities nationwide are flunking vaccine equity. Black and brown people are more likely to be lower-income and less likely to have access to health care providers who can steer them into the vaccination pipeline. They’re also more likely to work in “essential,” non-remote jobs. All those factors create barriers to getting vaccine appointments through systems that privilege people with Internet access, the ability to work from home, and the free time to refresh scheduling websites multiple times a day.

To overcome these disparities, “it’s not enough to say, ‘I put a link out on a county website,’ where it was in essence buried,” says Ala Stanford, the pediatric surgeon who founded Philadelphia’s Black Doctors COVID-19 Consortium. Since January, her nonprofit has vaccinated more than 30,000 Philadelphians; more than 80% of the recipients are people of color. The organization runs walk-up clinics that administer shots only to residents of specific zip codes (usually those hardest-hit by COVID). “Everyone acknowledges the health disparities. And everybody talks about it—but no one makes an active plan,” Stanford says.

“I absolutely agree that we need to make inroads on equity,” says Beam, the health secretary. To do so, the state has started dedicating 8% of its federal vaccine allocations to nonprofits, groups like Stanford’s and “entities that show that they are reaching hard-to-reach populations,” Beam says, adding that she hopes “that share will be ever-increasing.”

50%+

Share of vaccines from Philadelphia Rite Aid Pharmacies that have been distributed to people who live outside the city. Source: Rite Aid

Racial equity is only one of the puzzles the state needs to solve. Access has also been a challenge for those 65 and older, although Pennsylvania’s numbers there had improved by the end of March. And Beam and Wolf have spent weeks embroiled in arguments with local authorities over how to increase distribution of vaccines to the Philadelphia suburbs.

In the meantime, individuals, community organizations, and private entities all over the state do what they can to cut through the confusion and get jabs in arms. By late March, Christine Meyer’s Facebook group had facilitated more than 13,000 vaccine appointments—and Meyer was even contemplating the day when the forum might no longer be needed.

Pennsylvania’s rollout is “not smooth, it’s not easy, it’s embarrassing in a lot of ways,” she says. Still, she adds, “I feel more hopeful—because I see people getting vaccines.”

A version of this article appears in the April/May issue of Fortune with the headline, “Missing their shot: A rocky rollout in Pennsylvania.”