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April 15, 2021
Public Health COVID-19
Gail R. Wilensky
Aug 24, 2023
Jun 7, 2023
May 24, 2023
Back to The Milbank Quarterly Opinion
Early in the COVID-19 pandemic, the view was expressed that, without federal direction, states would not have reliable vaccine distribution plans. In fact, some states have done very well distributing the vaccine, while others, at least initially, have faltered. That some states would do better than other states is not surprising. What is surprising is which states did well early on and which have done less well.
The five states that had the highest percentage of vaccines distributed by population as of the end of January 2021 are not the ones that might have been expected to be in this position. They were North Dakota at 90%, West Virginia at 85%, New Mexico at 83%, South Dakota at 81% and South Carolina at 78%. While all these states are geographically small and have smaller populations, not all small states (e.g., Alabama) have done well. Equally interesting, some of the states that set up more complex distribution systems, such as Maryland and Massachusetts, have also not fared well, at least early on. By the end of January, 5.2% of Massachusetts residents had received the first dose of vaccine, placing it 32nd among states. By the end of February, Massachusetts had improved to 16th place but still was not in the leadership role that it or Maryland might have been expected to take.
To no surprise, the states have generally blamed the federal government for their challenges—not knowing how much vaccine would be available to them nor exactly when it would be available. Nonetheless, some states have managed the vaccine distribution quite well. West Virginia is a particularly interesting example of successful distribution of vaccines—interesting because it is a state usually known for its high rates of poverty, obesity, and drug use rather than for its leadership in public health activities.
During the first two weeks that vaccines were available, the state had administered almost all of its doses. While the traditional trust in physicians, nurses, and pharmacists in West Virginia helped with distribution, it was the state’s willingness to allow local organizations to take the lead on how the vaccine should be distributed that seems to be more important in explaining the early success. West Virginia chose to opt out of the federal partnership with CVS and Walgreens in order to get vaccines to long-term care facilities (where the highest percentage of COVID deaths had occurred) and to rely on local pharmacies for that distribution. Because of the rural nature of the state and the use of pharmacies for social gathering as well as for dispensing medicines, pharmacies have long played a special role in West Virginia.
Unlike the more centralized systems that some states put in place, West Virginia also allowed counties to determine how vaccines would be distributed across counties. In some counties, hospitals took the lead; in other counties, local clinics hosted vaccination sites; and in still other counties, the health department was in charge of vaccine distribution.
Very different experiences have been reported by Maryland and Massachusetts—two states that have highly educated populations and sophisticated information systems. Massachusetts and Maryland are among the top 10 states in percentages of people holding at least a master’s degree, and are first and second in per capita wealth. Their experiences with COVID vaccine distribution, however, are not nearly as impressive as West Virginia’s.
Massachusetts has complained about the lack of vaccine availability and the lack of clarity about future shipments, which complicated the state’s ability to effectively schedule appointments for vaccine distribution. While both have been challenging for the state, it does not explain why its neighbor, Connecticut, was able to administer 63% of its allocated doses compared with 49% by Massachusetts as of late January. What did explain the lower take-up rates was the state’s prioritization of congregate care settings, such as homeless shelters, domestic violence shelters, and prisons, where the pick-up rate was relatively low, ahead of the elderly. It also put a wide range of health care professionals in its highest priority category, individuals who also had lower than expected take-up rates—approximately 50% for among employees in long-term care facilities. In addition, Massachusetts had relatively fewer sites to provide vaccinations than some states that experienced higher rates of vaccination. In mid-January, Massachusetts had 65 locations for its 6.9 million residents while Burleigh County, North Dakota, had 54 locations for its approximately 100,000 residents.
It was only in early February, after the prioritized groups in Massachusetts had been provided access that availability was given to individuals over age 75. They were then followed by people over age 65 and those with high-risk medical conditions. By late March, Massachusetts had jumped to 7th in state rankings of COVID vaccines.
Maryland, perhaps because of its unsuccessful experience in setting up its insurance exchange in the fall of 2013, used a multi-entry point system for vaccine registration rather than a single point registration. This meant that people had to register in a variety of different places in an attempt to secure a vaccine, forcing people to rely on a vaccine update page that was created by a college student who had figured out the release times that vaccines were being made available at different sites.
Maryland has also been slower to set up mass vaccination sites than some states. Prince Georges County, for example, was able to set up six mass vaccination sites which facilitated its distribution, but Montgomery County, which is the most populous and wealthiest county (according to the 2010 Census), took until early April to negotiate a mass vaccination site with the state. Maryland has also relied primarily on health systems to provide the vaccinations, which has proven to be problematic.
By late March, the pent-up demand in Maryland had grown very large with people over 65 with specified medical conditions added as an eligible population . By late April, all people over 16 will be eligible, and the demand is likely to stay very high.
Given the large amount of vaccine that has been ordered—800 million doses in total—there should be enough vaccine by late Spring/early Summer for all Americans in approved age groups who are interested in being vaccinated to get their vaccines.5 The Trump Administration ordered 200 million initial doses of the Pfizer-BioNTech and Moderna vaccines, which had received Emergency Use Authorization (EUA) in December 2020 and another 200 million before leaving office, and the Biden Administration ordered an additional 200 million doses in early February, as well as 200 doses of Johnson and Johnson’s vaccine after its late February EUA.
The bottom-line lessons for the distribution of vaccines in future pandemics is to not differentiate those at risk too finely, and to make greater use of local distribution sites—acting more like West Virginia.
Gail R. Wilensky, PhD, is an economist and senior fellow at Project HOPE, an international health foundation. She directed the Medicare and Medicaid programs and served in the White House as a senior adviser on health and welfare issues to President Georege HW Bush. She was also the first chair of the Medicare Payment Advisory Commission. Her expertise is on strategies to reform health care, with particular emphasis on Medicare, comparative effectiveness research, and military health care. Wilensky currently serves as a trustee of the Combined Benefits Fund of the United Mine Workers of America and the National Opinion Research Center, is on the Board of Regents of the Uniformed Services University of the Health Sciences (USUHS) and the Board of Directors of the Geisinger Health System Foundation, United Health Group, Quest Diagnostics and Brainscope. She is an elected member of the Institute of Medicine, served two terms on its governing council and chaired the Healthcare Services Board. She is a former chair of the board of directors of Academy Health, a former trustee of the American Heart Association and a current or former director of numerous other non-profit organizations. She received a bachelor’s degree in psychology and a PhD in economics at the University of Michigan and has received several honorary degrees.
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