The Rollout We Deserve

Reporters love the word botched. It describes the making of mistakes while also suggesting clumsiness; it’s the sound of someone knocking over furniture. There’s no story about things gone wrong that can’t be improved by calling it botched. The word has seen yeoman duty since the arrival of vaccines for SARS Co-V-2 in December. The problems with allocating, delivering, distributing, and administering the vaccine have been as big a story as how the shots are likely to change the pandemic and our lives. But what’s clear is that the rollout hasn’t been botched. It’s occurred just as one could have predicted.

The problems of the past two months (and the improvised and decentralized way of fixing them) reflect an approach to health care that the United States has chosen and rechosen for at least a half-century. The only thing about the vaccine rollout that everyone agrees on is that it hasn’t gone well. That may turn out to be a signal event in the evolution of America’s health “system.”

What’s driven vaccine administration in the United States is the fixation on local control. This country believes that, even in a medical emergency, states make better decisions than the national government, and that cities (and maybe even counties) do better than states. This belief long predates the pandemic. It’s worth a look at where else it exists, and at what cost.

Medicaid, created in 1965 as a shared state-and-federal program to provide health care to the poor, allowed states from the start to tweak the program’s rules to create “experimental, pilot, or demonstration projects.” Over the years, 432 such projects have been approved. Some have worked out, others not. But there’s been little effort to find the best and make them universal. Instead, the diversity is an end in itself.

When the Affordable Care Act (“Obamacare”) started in 2010, the federal government, which already paid most of Medicaid’s costs, gave states new incentives to expand the program to larger numbers of low-income people. Twelve states have refused the offer, and many are ones whose citizens are poorer and unhealthier than average. Mississippi is a dramatic case.

In 2019, 13 percent of adults under 65 nationwide had no health insurance. In Mississippi, it was 19.5 percent. Mississippi could have used the help. It has the lowest life expectancy (74.5 years), highest infant mortality rate (8.3 per 1,000 births), and largest fraction of past-due medical debt (37.4 percent of bills in 2015) of any state in the nation. This month, Mississippi’s legislature once more voted down Medicaid expansion, which by one estimate would bring $1 billion to the state and serve an additional 300,000 people each year. “We are looking to get people off welfare, not add to the welfare rolls,” said the senator who chaired the committee offering the bill.

A nation that favors local control to that degree isn’t likely to have a national plan to vaccinate its citizens, even during an epidemic. Despite scares from attacks or epidemics of vaccine-preventable diseases over the past 25 years—“bird flu” in 1997, anthrax in 2001, H1N1 influenza in 2009—the United States lacks a hypodermic-ready system for administering hundreds of millions of shots quickly. Instead, it has a proliferation of strategies.

In response to this pandemic, stand-alone pharmacies are the backbone of West Virginia’s response. Elsewhere, chain pharmacies are important; Walgreens is giving shots in 15 states and Puerto Rico. The National Guard has been called up in 16 states and territories. Some places, such as California, Florida, and Maryland, are running mass-vaccination sites. The federal government has begun to open a projected 100 vaccination centers.

“Public-private partnerships,” touted as a way to bring efficiency to notoriously wasteful American medicine, are especially popular. In South Dakota, five private health systems, four pharmacy networks, and the federal government’s Indian Health Service and Veterans Health Administration are delivering the injections. Health departments in the state’s 66 counties have been bypassed. Primary care physicians, who are the doctors that people go to see in 55 percent of office visits, are playing no role in vaccine administration, unless they are part of a large private health system.

There’s been only a little more uniformity about the order in which people should be offered vaccination.

Front-line medical workers, first responders, and nursing home residents are at the top of everyone’s list. After that, an array of variables—age, job, housing arrangement, current health—determine who’s next in line. As of mid-February, teachers in Hawaii are eligible for vaccination, while in Maine they’re not yet. If you’re a teacher over age 50 in West Virginia, you can get a vaccine. For Nevada teachers, it depends on where you live.

As Covid-19’s disproportionate toll on people of color has become clear, some jurisdictions are grafting “equity agendas” to their plans. The District of Columbia is reserving a fraction of its vaccine for people 65 and older in three city wards “where residents are disproportionately affected by COVID-19, including number of cases and mortality rate,” according to a press release from the District health department. These are majority-Black wards.

In contrast, Vermont for the moment is basing eligibility purely on age. After vaccinating the agreed-upon top-tier people (and including members of ski patrols in the first-responder category), it opened eligibility to anyone 75 or older. “We’re going straight for our most vulnerable, and going to preserve life,” explained the state’s health commissioner, Mark Levine. “[It’s a] much clearer message that’s more acceptable, although the advocates will still try their best.” But it’s clear and acceptable, perhaps, because Vermont is 94.2 percent white and has no city with a population over 50,000.

The record-keeping for all this has gotten little attention, but it requires an immense underworld of data-sharing. The United States has 61 “immunization information systems” (IISs) run by states, territories, and three cities. Created to record children’s vaccination records, they now contain about 60 percent of adult records too (although the fraction varies greatly from state to state). IIS software, however, isn’t standardized. Only half the systems can easily exchange information with electronic health records in hospitals or doctors’ offices.

Among the Centers for Disease Control and Prevention’s current headaches is integrating these networks and sweeping in new vaccinators (such as pharmacies) through “data use and sharing agreements.” The CDC isn’t doing this just to tidy things up. The purpose goes right to the heart of the pandemic response—“rapidly assessing patterns of vaccination among the population; identifying pockets of undervaccination; monitoring vaccine effectiveness and safety; assessing spectrum of illness, disease burden, and risk factors for severe disease and outcomes,” according to an agency publication.

In the meantime, people who’ve been vaccinated are urged to hold on to the card they get with their shot. Development of the vaccines may have been futuristic, but the verification of who’s gotten them is out of the past.

“I do it the old-fashioned way,” Wayne J. Riley, president of SUNY Downstate Health Sciences University, said recently in a Zoom call run by the American College of Physicians. He held his phone up to the screen and showed a picture of his vaccination card. He had a rueful smile. “One of the problems that we encountered here in New York City is that the New York City department of health has its own vaccine registry, but it wasn’t able to connect to the hospitals because of a lack of IT integration. This seems like a 20-year-old problem. … We haven’t quite figured that out.”

Does all of this add up to a botched rollout? It’s certainly a confusing and contentious one. But it’s not a mistake. It reflects the preferences and priorities of American patients, the people who care for them, and the politicians they elect. It’s the way we choose things to be.

But American health care is evolving ineluctably toward central planning, conformity across states, and single-payer financing. That’s the only way to rationalize an activity that consumes 17.7 percent of gross domestic product and grows faster than inflation each year, that employs 12 percent of the nation’s workforce, and that’s entering a new golden age (gene editing, immune therapy, and, yes, lots of new vaccines). The big question is how much of the current system has to collapse, or how many people have to be harmed by its inefficiencies and inequities, before the evolution is complete.

The importance of the Covid-19 pandemic may lie more in how it helps answer that question than in what it teaches us about virology and epidemiology.