The U.S. Is Changing How States Will Get COVID-19 Vaccines

As COVID-19 vaccine efforts have gotten underway, the United States federal government has been allocating a specific number of COVID-19 vaccines to each state.

Allocations were initially based on the adult population of each state. However, the Trump administration has changed how it will allocate doses per state; it will now prioritize states that administer the vaccines the fastest.

Experts say the new allocations have confused states, which are now scrambling to ramp up inoculation efforts to avoid losing their doses. Faster rollouts may not even be possible, as there are reports that there is no federal reserve of held-back doses of the COVID-19 vaccines.

“It is very hard to know what’s going on,” Eric Toner, MD, a senior scientist in the Department of Environmental Health and Engineering at the Johns Hopkins Bloomberg School of Public Health, tells Verywell. “One thing that does seem clear is that we should not expect the current flow of vaccine from the feds to increase in the near future.” 

Changes to Allocation for States

In mid-December 2020, the Trump administration’s accelerated COVID-19 vaccine initiative—Operation Warp Speed—announced plans to allocate vaccine doses based on states’ and territories’ over-18 population. It also allocated a population-based amount to Indian Health Service.

On January 12, 2021, Health and Human Services Secretary Alex Azar announced in a press briefing that allocations were set to change. Within two weeks, allocations would be based on the population of adults 65 and older in each state instead of an allocation based on the state's total adult population.

Azar also called on states to begin offering vaccines to people age 65 and older, as well as people with underlying health conditions that put them at greater risk for severe COVID-19. He urged states to move on to the new plan rather than waiting to complete vaccination efforts in earlier categories. 

Available Dose Allocation

When it comes to available doses, Azar said priority would be given to states with faster vaccine rollouts—a decision that could leave some states short. 

In the briefing, Azar said that “We will be allocating them based on the pace of administration as reported by states and by the size of the 65-and-over population in each state. We’re giving states two weeks’ notice of this shift to give them the time necessary to plan and to improve their reporting if they think their data is faulty.” 

Toner says that the decision blinded states. “This is the largest public health vaccination effort ever. And it can't change that quickly," he says. "It undermines the whole premise of wanting to have a well-thought-out vaccination protocol that targets those people that are at highest risk.”

Is There a Federal Reserve of Vaccines?

The Trump administration has said that it will release all the vaccine supply that was being held in reserve for people to get their second doses.  

In the press briefing, Azar said “We’re now making the full reserve of doses we have available for order. Because we now have a consistent pace of production, we can now ship all of the doses that had been held in physical reserve, with second doses being supplied by doses coming off of manufacturing lines with quality control.”

However, reports are surfacing that a federal reserve of COVID-19 vaccines does not actually exist. On January 15, 2021, Oregon Governor Kate Brown tweeted:

Beyond what states already have in stock, additional doses of either the Pfizer-BioNTech or the Moderna vaccines will have to be obtained through the supply chain. If states are not able to anticipate the promised boon in vaccine supply, then they will not be able to ramp up their vaccination efforts.

“Expanding the eligible groups right now is creating a huge mismatch between supply and demand,” Toner says. “States should resist expanding their vaccination plans until this is cleared up.”

The Logistics of Vaccine Allocation

Independent of vaccine availability, Toner says that the sudden shift in policy surrounding vaccine rollout and allocation is confusing for states. For one, states are suddenly expected to vaccinate more people than initially anticipated or risk losing out on their allocation. 

“There’s no way that they can responsibly do that,” Toner says. “They don’t have the mass vaccination centers set up. They don't have all the retail pharmacies set up. I think it was a serious mistake.” Toner also worries that such a drastic change will lead to rollout confusion and long lines.

Some states have set up—or are in the process of opening—large vaccination sites at NFL stadiums, MLB parks, fairgrounds, and convention centers to speed up rollout.

The Centers for Disease Control and Prevention (CDC) has recommended that healthcare personnel and residents of long-term care facilities get vaccinated first—in phase 1a of the rollout plan. The next group, phase 1b, will include some frontline essential workers and people age 75 and older.

“I think that was reasonable,” Toner says. “It was ethically sound, and it was doable.” However, with Azar’s briefing, Toner says that the numbers drastically change. “We’ve now added 150 million more people to that, essentially half the country. And so that is not feasible in the short term.” 

The Ethics of Vaccine Rollouts

In addition to questions of logistics, the changes also raise questions of ethics. The ethics surrounding whom to vaccinate and when are complicated. 

“The fundamental tension about how to respond to a public health crisis under conditions of scarcity is a tension between utility and fairness,” Joel Wu, JD, MPH, MA, HEC-C, clinical ethics adjunct professor at the Center for Bioethics at University of Minnesota’s School of Public Health, tells Verywell. 

On the utility side, Wu says that the initiative is to vaccinate as many people as quickly as possible. On the side of fairness, that has to be done in a way where the benefit does not just accrue to one set of the population at the expense of other people.

“If you take an approach that is entirely utilitarian, you may actually end up vaccinating the most people and reducing the most death and disease," We says. "But it really just harms poor people, people who live in rural communities, and minorities. So that’s a pretty intolerable and unethical position.” 

However, Wu also acknowledges that slow rollout plans are also unethical. “The inefficient use of scarce resources is also problematic,” he says. “So the question is: Is there a compromise between the utility and the fairness?”

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