Equitable and Efficient Distribution of a COVID-19 Vaccine

Key Challenges

It’s clear that everyone will not be able to get a COVID-19 vaccine at once. Even if we have 330 million doses available at once, it will be logistically impossible to simultaneously give everyone an approved vaccine.

But there are two challenges imbedded within this larger problem that only magnify the task at hand: the disproportionate vulnerability to this pathogen of certain populations (e.g., racial and ethnic minority communities, older Americans, Americans living with chronic illnesses), and the Administration’s pandemic response strategy.

Vulnerable Americans

Since the start of the COVID-19 pandemic, minorities have had higher rates of COVID-19 infection and mortality. Black Americans have contracted the virus three times as often as white Americans and have been hospitalized four times more often.²Inequalities are even greater when broken down by age: Black and Latino adults in their mid-30s to mid-50s die 6 to 10 times more often than their white peers.³ Hispanic and Asian Americans are more likely to be infected and hospitalized than white Americans.⁴ Additionally, minorities have reduced access to testing; in four of the six largest cities in Texas, testing sites are disproportionately located in whiter neighborhoods.⁵ Indigenous peoples have been hit disproportionately as well: Native Hawaiians and Pacific Islanders represent 0.3% of California’s population, but 1% of all the cases in the state.⁶ The Navajo Nation has an infection rate five times that of the rest of the United States.⁷

COVID-19 racial inequalities are even greater when broken down by age: Black and Latino adults in their mid-30s to mid-50s die 6 to 10 times more often than their white peers.

In addition to minorities, other vulnerable populations have been hugely affected. The impact on older Americans is the most notable. According to the World Health Organization (WHO), more than 95% of global COVID-19 deaths were among people ages 60 and older, and more than half of all deaths occurred in people ages 80 and older.⁸ In the United States, there has been a huge spotlight on the disproportionate deaths in nursing homes. The first outbreak in the United States was at the Life Care Center nursing home in Kirkland, Washington, where 35 residents died from COVID-19.⁹ Since then, one-third of all COVID-19 deaths have been nursing home residents or workers, with 153,000 infections at 7,700 facilities.¹⁰ And rates of infection are even worse for low-income older adults and those with disabilities.¹¹

Furthermore, Americans with chronic illnesses, such as heart disease or diabetes, are more likely to be hospitalized for COVID-19. Due to the pervasive way COVID-19 can damage cells in many parts of the body, people with existing diseases are more likely to get sicker from the virus.¹² They are 12 times more likely to die than otherwise healthy people who become infected.¹³

Another vulnerable group, health care workers have had a nearly 12-time higher risk of testing positive for COVID-19 compared to the general public. This rate was even higher in workers with inadequate access to personal protective equipment (PPE).¹⁴ The nation does not have a comprehensive way to track the infection rate and mortality of health care workers, so the rates of infection and mortality are difficult to estimate.¹⁵ Yet, Ohio has reported rates of COVID-19 illness as high as 20% among health care workers. The Henry Ford health care system in Detroit, Michigan reported more than 700 employees testing positive for COVID-19.¹⁶ Women health care workers are bearing the brunt of the illness due to their more frequent exposure to the virus, with 73% of the health care infections.¹⁷

The Administration’s Poor Track Record

In addition to that challenge, the Administration’s handling of this crisis has been horrendous. The Administration repeatedly failed to act swiftly and deliver the necessary resources throughout this pandemic. First, it was ventilators and hospital beds, then it was testing swabs and the chemicals needed to run the COVID-19 tests. President Trump delayed invoking the Defense Production Act to require companies to ramp up production of N95 masks, face shields, and other supplies, forcing health care workers to wear single-use masks repeatedly as hospitals ran out of gear.¹⁸ Meanwhile, states were forced to outbid each other and the federal government to get necessary supplies to their residents, often paying astronomically inflated prices. For example, the cost of a life-saving ventilator went from $12,000 to $65,000.¹⁹ Illinois had to charter private planes to deliver needed masks to their states. Kentucky was expecting an order of equipment, only to find out that FEMA had bought it all.²⁰

Just take Remdesivir—the investigational treatment for COVID-19 with a current Emergency Use Authorization issued by the U.S. Food & Drug Administration.²¹ The federal government failed to distribute the treatment efficiently. It initially shipped the drug to hospitals with no patients who could use it.²² Meanwhile, hospitals with some of the highest case numbers never received any of the early shipments. Wyckoff Heights Medical Center was among the 182 hospitals in New York that did not get any doses of Remdesivir; more than 230 people have died from COVID-19 there.²³ After this initial failed distribution, the Department of Health and Human Services (HHS)  then decided to leave states and hospitals to grapple with decisions about how to allocate the scarce medicine. An HHS spokeswoman said the switch allowed the states to “develop clear, individualized criteria for their communities,” but declined to explain why that plan hadn’t been enacted from the beginning. This state-led plan has proven to be more effective: New York has kept Remdesivir deliveries small in size and spread them out across a larger network of hospitals.²⁴

In short, the Administration has no basis for anyone to trust it with the distribution of a vaccine.

Solution: Empower States and Hold Them Accountable

Congress should enact a vaccine distribution plan that prioritizes the most vulnerable: health care and other essential workers, minority communities, older Americans and nursing home residents, and people with disabilities and chronic illnesses. That approach is equitable because, as noted above, the most vulnerable have been hardest hit by the coronavirus. It is efficient because stopping the virus spread among the most vulnerable who have the highest rates of infection is the surest way to slow the spread of COVID-19.²⁵

Congress should enact a vaccine distribution plan that prioritizes the most vulnerable: health care and other essential workers, minority communities, older Americans and nursing home residents, and people with disabilities and chronic illnesses.

This approach is similar to early discussions within the CDC and the Advisory Committee on Immunization Practices (ACIP), an advisory panel of experts including ethicists and representatives from the health field. They are developing a multitiered schedule for the first 1.2 million doses and then the next 110 million. They are focused on key issues like who should be considered essential workers, what underlying health conditions in vulnerable patients should be taken into account, what living environments—such as nursing homes and homeless shelters—put people at the highest risk, and should they prioritize people of color.²⁶

The distribution plan should be completely transparent. The public deserves to know how the vaccine will be distributed and who will get it first. Any plan the Trump Administration approves will be met with considerable skepticism because the public doesn’t trust its handling of the COVID-19 pandemic. And it’s clear from its handling of COVID-19 supplies and Remdesivir that this Administration is not prepared at this point to oversee national vaccine distribution.

Instead of trusting the Administration to get it right, Congress should start by empowering states and then follow-up with strict Congressional oversight, as outlined below.

1. Create a state-based rapid deployment program.

Congress should require states to produce distribution plans that prioritize vulnerable groups. In return, the federal government should provide states with a series of federal resources that will empower them. Here’s how this would work.

First, each state, the District of Columbia, and the five US territories should submit a plan to HHS that spells out how they will guarantee vaccine distribution for each vulnerable group—including health care and other essential workers, minorities, seniors and nursing home residents, and people with disabilities and chronic conditions. The plan should specify how resources will be distributed among hospitals, counties, cities, and tribal and indigenous communities.

It should also detail how these vulnerable populations will get safe, reliable, convenient, and affordable access to vaccines where they are. The bulk of funding and resources to distribute vaccines should go to the cities and counties where underserved and high-risk populations reside. The physical distribution will be a mix of public and private channels. For example, essential workers and health care workers might receive a vaccine at work, while people with disabilities and chronic conditions might need to receive a vaccine at home, while seniors might receive the vaccine from their primary care doctor or in their residential setting, such as a skilled nursing facility. States must detail how these populations will be reached and how each vaccination will be tracked to ensure equitable distribution. For example, states must identify how demographic data will be collected to ensure equity.

Second, alongside those plans, Congress should provide $10 billion to make the following resources available to states:

• The United States Postal Service, Peace Corps, and National Guard should be available to states who want help with vaccine distribution. For example, states should be able to activate a federal plan developed under the Clinton Administration and tested during the Obama Administration for postal carriers to travel with medical personnel for in-home vaccine administration.²⁷ Peace Corps volunteers have been recalled and have training (or are readily trainable) in basic medical assistance and can easily be deployed. The National Guard with its mission of community support during a crisis is an alternative to President’s Trump proposal to send the military into neighborhoods that may have their own fraught relationships and potential concerns about militarization.²⁸
• Data infrastructure. $400 million should go to scale-up the information technology framework necessary for orderly, safe, and effective vaccine distribution. Current state-based immunization registries often don’t have modern recordkeeping and reporting systems. Funding should support the latest security standards for vaccine reporting and coding, interoperability with a wide range of provider electronic medical record systems, and the capability to send vaccine information back to medical offices. It is plausible that the vaccine will be a multi-dose drug, or there may be multiple vaccines approved for different populations. This funding is critical for vaccine ordering, inventory management, patient record-keeping, and immunization reporting to public health authorities.²⁹ Without it, people who move across state lines or aren’t able to prove which vaccine they received could easily fall through the cracks, reducing the chance of achieving herd immunity.
• Provider funding. Providers, including primary care clinicians, pharmacists, and community health providers serving low-income groups through Medicaid should receive increased funding to at least Medicare payment levels for vaccine administration funded by the federal government without the normal state matching fund requirement since state budgets have been squeezed by the pandemic. Low Medicaid payment levels are often an obstacle to care for many low-income communities. Increasing vaccine reimbursement would incentivize providers to increase their COVID-19 vaccine administration, as well as ensure up-take of regular childhood vaccines that have been delayed due to the pandemic.
• Education campaign and personal vaccine incentives. With heightened public awareness, the public needs accurate and reliable information about getting a vaccine. Given all the other demands on public health agencies and the high rates of vaccine hesitancy, Congress should create a special fund for education efforts. Right now, only 43% of Americans would definitely get a free COVID-19 vaccine.³⁰ That leaves a large swath of the population needing convincing that a vaccine is necessary.³¹ States could also use the fund to offer personal incentives to get vaccinated if demand for the vaccine does not reach as many people as needed to create herd immunity against the virus.

2. Establish Vaccine Equity Watchdogs in Every State

Congress should also establish a federal watchdog system in every state to ensure equitable and efficient distribution. It could tap the General Accountability Office (GAO) for this role so that it can control the oversight rather than relying on the Trump Administration to police itself.

For each state, the GAO should report every week on the following measures of vaccine distribution:

• Number of vaccines administered by prioritized population subgroups.
• Tracking of vaccine administration for follow-up doses, if required.
• Regions within a state that have hit target levels for herd immunity.
• Recommendations for remedial action for areas with below par distribution.

If states or areas don’t achieve distribution targets, then Congress should require the Federal Emergency Management Agency (FEMA) in conjunction with the National Guard to go to those communities and assist with distribution.

Conclusion

Even though we don’t currently have a vaccine, the time to plan for one is now. Congress must act to ensure equitable and efficient distribution given the Trump Administration’s abysmal record in handling the crisis so far. That is the way to avoid a free-for-all and protect all Americans.