No 'consistent rationale': Why vaccinations are open to all in some states and not others
Maureen GroppeWASHINGTON – When Alaska led the nation in offering COVID-19 vaccinations to all adults this month, officials could point to the state’s vaccination pace – the best in the country.
But as a growing number of states have removed eligibility requirements for getting vaccinated, it’s become less clear why some act faster than others.
Mississippi, which eliminated requirements in mid-March, ranks near the bottom in the share of adult residents who have been vaccinated.
Of the 28 states that have either opened eligibility to all or will do so in the next two weeks, 17 have below-average adult vaccination rates, according to figures available Sunday from the Centers for Disease Control and Prevention. Eleven lag other states on fully inoculating those 65 and older, one of the highest-risk groups.
Governors often cited increasing vaccine supplies as the driver of the decision to remove eligibility limits. But as the number of available doses grows, there’s still a large variance on who can get a vaccine, though most states are likely to meet President Joe Biden’s goal of making every adult eligible by May 1.
Prep for the polls: See who is running for president and compare where they stand on key issues in our Voter Guide
“Where you are in line kind of depends on where you live,” said Jennifer Tolbert, director of state health reform at the Kaiser Family Foundation. “There does not seem to be a consistent rationale.”
Various explanations for pace, eligibility for vaccines
Experts said reasons for the differences include how confident governors are in the increased projections of doses, demographic differences among states and whether states have had trouble filling vaccination appointment slots. The latter could be a reflection of how easy states have made it to get vaccinated. It could also mean residents have been less interested in getting shots.
“Some states may be experiencing vaccine hesitancy sooner than other states,” said James Blumenstock, senior vice president of pandemic response and recovery for the Association of State and Territorial Health Officials. “And therefore, that means they’ve got to sort of open up the gate to allow other categories in just so that precious time is not lost.”
Officials are particularly concerned about avoiding unclaimed appointments as more contagious COVID-19 variants spread.
“We really want to get to that goal of getting as many people vaccinated as possible, as quickly as possible, especially with variants,” said Hemi Tewarson, an expert at the Duke-Margolis Center for Health Policy who has been closely following states’ efforts.
Concerned about a "possible trend" of increasing infection and hospitalization rates, Illinois Gov. J.B. Pritzker gave health officials permission Friday to make vaccines available to anyone who wants them if demand in an area has waned.
"Each county is different and local health departments know better how to vaccinate people in their communities as soon as and as equitably as possible," Dr. Ngozi Ezike, director of the Illinois Department of Public Health, said in a statement.
Some states have kept the focus on moving systemically through the vaccination priority levels recommended by the CDC.
"As it relates to other states, you know, we're taking the approach we're taking," New Jersey Gov. Phil Murphy said last week. Garden State residents under 65 aren’t eligible unless they have certain high-risk medical conditions or hold certain jobs. “We're trying to as methodically and doggedly get to as good a place as we can."
Trish Riley, executive director of the National Academy for State Health Policy, said some states put a greater focus on assuring that vaccines go to those most in need and most at risk.
“And other states think that, you know, throw the doors open and let's get everybody in and get as many shots as possible,” Riley said. “They’re just different approaches to the same problem.”
COVID-19 updates:Cases rising again in the USA; vaccines safe and effective for babies, study shows
Equity shouldn't get left behind
Riley and other experts said there’s a concern that faster moving states don’t let up on making sure the most vulnerable are vaccinated.
“The equity story isn't over with vaccines for all,” said bioethicist Harald Schmidt at the University of Pennsylvania. “By simply saying, 'Oh, you know, we've opened for all and now come and get it,’ that can't be good enough, neither for equity, nor for public health.”
Different approaches have been a hallmark of the vaccination rollout that began under the Trump administration, which left many decisions up to states.
The CDC guidance on how to prioritize populations was helpful, Riley said, but posed challenging questions for states on how, for example, to define an essential worker. Should hospital billing clerks share the same top priority as nurses and doctors? Is a waiter less essential than a hotel clerk?
Some decided it was simpler to vaccinate strictly by age, after inoculating health care workers and nursing home residents.
That includes Connecticut, which switched to an age-based approach in March and plans to open vaccinations to all adults by April 5.
When Alaska made vaccines available to everyone 16 and older, there weren't enough vaccines for all, Tewarson said, but simplifying eligibility made messaging and distribution easier.
“It took away some of the process and effort they were putting into trying to tier the different populations and prioritize,” Tewarson said.
Nearly 3 in 10 adult Alaskans have been fully vaccinated, one of the highest rates in the nation. About 6 in 10 Alaskans age 65 and older are vaccinated, also one of the best rates for that high priority group.
COVID-19 vaccine near me:Digital tools to help you find vaccination locations
'I've missed you so much':Vaccinated grandparents reunite with their families
No definitive rules
Federal guidance does not specify what share of a priority tier should be vaccinated before a state moves on to the next tier. The suggested factors to consider include when appointments are less than 80% filled for several days, when vaccine doses substantially increase, when a state’s target vaccination rate for a group has been met and when doses in certain areas are at risk of going unused.
The measure of progress by priority tier that is most easily comparable from public data is the vaccination rates for senior citizens. Seniors account for 80% of COVID-19 deaths.
If states are vaccinating this group at a lower rate, it suggests there might be barriers – such as the ease of making, and getting to, vaccination appointments – that should be addressed, Tolbert said. Those barriers may exist for other high-risk or hard-to-reach populations, including the poor, minorities and people in rural areas.
“We could see some of those equity issues get worse if there’s not a concerted effort to continue to ensure that, as they begin to vaccinate more and more people, the states are also focusing on outreach and other efforts to ensure that there is a more equitable administration of the vaccine,” she said.
Missouri, which has one of the lowest rates of vaccinations for both seniors and all adults, is behind because of poor public health infrastructure and because the state disproportionally allocated vaccines to rural areas over cities, said Dr. Sarah George, an infectious disease specialist at Saint Louis University.
As infections are on the rise, George wants everyone to get vaccinated as soon as possible, but she hopes the state’s decision to make all adults eligible April 9 won’t take away from catching up on vaccinating high-priority groups.
“I would like us to do both,” she said.
Asked whether it’s a mistake for states that are behind in vaccinating seniors to expand eligibility to all adults, Jeff Zients, the coordinator of the White House’s coronavirus task force, reiterated Biden’s goal of opening vaccinations to the general public by the end of April.
“But we have to keep prioritizing the most vulnerable populations,” he said. “And if there are states that are lagging behind, we're working with those states.”
Contributing: Scott Fallon of The Record in Bergen County, New Jersey.
More:US coronavirus map: Tracking the outbreak
More:Governors bullish about beating Biden’s May 1 vaccine directive – if the doses keep coming