With the first COVID-19 vaccines being administered in the U.K., with experts speculating the U.S. could approve new vaccines in the next few days, the end of the pandemic is finally in sight. Naturally, people are already dreaming of the things they could do once this is all over—presumably, after enough of the population is vaccinated to make our usual rhythms safe again. But it will still be months until the general public has access to the vaccine.
So far, experts estimate that there will be 35 million to 40 million doses of the Pfizer and Moderna vaccines available in the U.S. by the end of year, which, because the vaccine requires two doses, would vaccinate 17.5 million to 20 million people. That’s less than a tenth of the country’s population, which means the other 90 percent will need to wait their turn. But how, exactly, will you know it’s your turn? Those details are still being ironed out and will be yet another challenge for public health officials to communicate and implement.
The most important thing to know is that the vaccine will be released in phases to select groups of people. Last week, the U.S. Centers for Disease Control and Prevention’s Advisory Committee on Immunization Practices officially recommended that first doses in the U.S.—called phase 1a—should be distributed to health care workers and people living in primary care facilities, two groups that are disproportionately likely to be exposed to the coronavirus. Phase 1b would include essential workers, and 1c would cover adults over 65, and people with underlying health conditions.
It will be relatively easy to make sure vaccines distributed in phase 1a get to prioritized groups. Those doses are likely to be delivered to, stored at, and given out at large academic research centers or medical clinics where health care workers already do their jobs, so providers could fairly easily verify that people receiving the vaccine are indeed eligible. From there, it’s not yet clear how vaccinations might proceed, but ultimately, it will be up to states or territories to decide the specifics. So far, their plans do not include detailed definitions for eligible groups or how that eligibility will be communicated, but have instead (rightfully) focused on mobilizing state resources and exploring the logistics of transporting, storing, and administering the vaccine. According to an analysis by the Kaiser Family Foundation, there’s lots of variability in what info plans provide, like numbers of potential vaccine providers or their ability to report data from state immunization databases. If states update their plans to define which groups will be next in line for vaccines, it’s possible those policies could vary widely, too. For instance, who counts as an essential worker? Which underlying health conditions qualify people to receive the vaccine?
Those questions would also likely fall to states and territories to decide. “What if we have 51-plus definitions of who falls into these groups?” asks Jen Kates, a senior vice president at the Kaiser Family Foundation and the organization’s director of Global Health & HIV Policy. “That’s not creating equity across the country.” Other state-specific decisions could further affect equity in vaccine access; because it’s up to each state to decide how to allocate the vaccine across its counties and regions, some areas might have more doses, leading people to cross county lines to more easily get vaccinated, says Amesh Adalja, a senior scholar at the Johns Hopkins Center for Health Security.
Assuming that states will eventually define who is included in these phases, it’s also still unclear whether there will be any process for reviewing people’s eligibility. Per CDC rules, vaccination providers must submit a form where they agree to adhere to recommendations from the Advisory Committee on Immunization Practices, including guidance about prioritized groups, but it’s unclear how much providers would be expected to verify whether people do belong to those groups—or even how well they could. If you have a primary care provider and get the vaccine through them, that could be straightforward, since they would have access to your medical records on hand. What about a pharmacy, though? They could potentially verify eligibility by, say, looking at your medications, but that assumes you get all your prescriptions filled there and that your medications clearly indicate your medical condition—and perhaps above all, it’s creepy. Beyond checking in with your health care provider, there’s no clear way to verify anyone’s conditions, according to Katie Greene, a vaccine policy expert at Duke University. There’s no central data repository that has all this info, so providers would be hard-pressed to require you provide proof of your medical conditions. “The most I can see them doing is making you fill out a form and testify to it,” says Greene. “They’re not going to verify you have diabetes.”
CVS, which is partnering with the federal government to provide vaccines to residents of long-term care facilities, did not directly address questions related to whether it will check for eligibility in later phases, but say it is prepared to follow state guidelines. “States will have to determine priority guidelines, so there’s a chance that initially only certain groups will have access to vaccines in our stores,” says Michael DeAngelis, the company’s senior director of corporate communications. DeAngelis says the timing of rollout to groups outside 1a is “purely speculative, but that could be as soon as March.” (Walgreens, another federal partner, did not respond to questions about its vaccine rollout plans, including whether it expects to check eligibility.)
According to Adalja, that’s more or less what providers did during the last pandemic. Once the H1N1 vaccine became available in late 2009, the Advisory Committee on Immunization Practices also recommended that high-risk groups like health care workers, people with medical conditions, and pregnant women receive priority to receive the vaccine, and people who wished to receive the vaccination self-reported their risk factors. “That’s going to be more complicated here, because there’s going to be much bigger demand for the vaccine,” Adalja says.
There’s a chance providers or local and state governments will find ways to notify people when they’re eligible for a vaccination, but if these past few months of pandemic response are any indication, that process is likely to be less than straightforward. Just as it’s fallen to individuals to figure out where they can get tested (or whether they can get tested without symptoms or a verified exposure), or how to work within local rules about business operations and gatherings, people will likely also have to sleuth around to figure out how and when they can get vaccinated.
Some states have preliminary plans to reach groups who have been disproportionately affected by the pandemic—Black, Native, Latino/a, and Asian people are more likely to die of COVID-19 than white people, and people experiencing homelessness have seen outbreaks at shelters. But given the general state of health care in the U.S., the wealthier and whiter you are, the better your chances are of having ready access to the vaccine. If the process indeed relies on the honor system, there will be ways to game it. But it will be important to actually wait your turn. Remember that these priority groups have been designated as a way to minimize death and suffering, as well as containing the spread of the virus. (As a thirtysomething person who has the privilege of working from home, I would love to get the vaccine ASAP and visit my family, but I will likely be in the last group eligible for vaccination.) And even those who are not among the first to be vaccinated will likely see some benefits; Vaccination will lower community spread, making our everyday activities less risky than they are right now.
With adequate guidance from the federal government and well-orchestrated state distribution plans, the U.S. will hopefully only experience a few months where demand for vaccine far outstrips the supply. Until then, though, states will have to decide how they’ll manage the long line of folks clamoring for a vaccine. “It’s an area that needs some work,” says Kates.
Update, Dec. 10, 2020: This article was updated to include comment from CVS.
Future Tense is a partnership of Slate, New America, and Arizona State University that examines emerging technologies, public policy, and society.
