Don’t let COVID-19 vaccines expire

In late December, Gov. Andrew Cuomo signed an executive order imposing up to a $1 million fine and loss of all state licenses for health care workers who knowingly give the COVID-19 vaccine to ineligible people. The governor also floated the idea of criminalizing unauthorized vaccination. Now Cuomo is threatening to fine hospitals if they don’t distribute their vaccines fast enough. 

The governor’s heavy-handed tactics have more than a whiff of desperation about them. Only about 2 million Americans got their first of two COVID-19 shots in 2020, about 18 million short of the Trump administration’s year-end goal. New York has given 1.4% of its population the first of two shots, which is far short of where we should be, but still better than the average state. Perhaps more meaningfully, given that the main limiting factor for vaccination is how much vaccine is released to the state by the federal government, 31% of the doses that New York has received from the feds have found their way into someone’s arm as of January 4. Florida has administered just 23% of the doses the feds have sent. 

More COVID-19 vaccines will be approved soon and vaccine production is ramping up, but we’ve got a long way to go. We need to vaccinate somewhere between 70% and 85% of the total population, twice, to achieve herd immunity. And the new, more easily transmitted variant of the virus could run rampant in the months ahead if vaccine distribution isn’t wide enough to tamp it down. 

Unfortunately, the governor’s bluster is inviting unintended consequences that could actually make vaccination go more slowly. COVID-19 vaccines have to be used within a certain amount of time after they’re defrosted, or they become useless. (Even under ideal freezer conditions, the currently approved COVID-19 vaccines only have a six-month shelf life. Distribution is so slow that the editorial board of The New York Times raised the specter of the miracle vaccines going bad even in the freezers.) 

Cuomo’s plan to fine providers for unauthorized vaccinations all but ensures that some doses of vaccine will be thrown out. By contrast, the Washington D.C. Health Department has a rule that any vaccine doses that are about to expire must go to whoever wants them. D.C. is ahead of New York in vaccine distribution: 2.2% of the District’s residents have gotten their first shot. 

Cuomo’s executive order is meant to clamp down on outright fraud, which is a laudable goal – but the language of the executive order is broad enough to punish well-meaning health care providers who use an expiring vaccine rather than let it go bad. 

These so-called “temperature excursions” happen more often than you’d think. A Christmas Day power outage in Connecticut started the clock ticking on 200 doses. When a compressor failed at a Northern California hospital pharmacy, 600 doses of vaccine thawed and had to be used in the next 2 hours. An all-out push to distribute the vaccine culminated in a text message inviting anyone who wanted a shot to present themselves immediately, regardless of status. Vaccines went to people who weren’t technically eligible yet, but California Gov. Gavin Newsom said the state wasn’t going to punish anyone who gives a vaccine that would otherwise go to waste: “(We) aren’t enforcing against just common sense and the energy of someone who says: ‘Look, I don’t want to waste this dose. Why don’t I get it to someone?’” 

Cuomo has offered no such reassurances. If a New York hospital were faced with a similar scenario, every health care worker who knowingly vaccinated out of turn could be fined at least a million dollars and lose their license. That’s a far cry from the scandal that motivated the executive order and talk of new criminal laws: the Parcare Community Health Network’s alleged fraud against the state of New York. Officials say the network misrepresented itself to obtain the Moderna vaccine from the state. 

Cuomo could easily modify his executive order to exempt health care professionals acting in good faith who give away expiring vaccines. Health care professionals shouldn’t have to worry about letting an unexpected surplus go bad, or being punished for giving doses to anyone who’s available. The key here is good faith. Contriving to have doses left over, earmarking “extra” doses for influential people, or selling the vaccine would still be out-of-bounds because they’re not good-faith attempts to use up a perishable product. 

We want to make sure that the vaccine is given out fairly, but we shouldn’t let preoccupation with optimal fairness slow down the vaccine rollout. Every person who gets vaccinated benefits everyone else by pushing us closer to herd immunity. 

At his daily press conference on Tuesday, Cuomo threatened to fine hospitals $100,000 if they don’t use all the doses they’ve been given by the end of the week. Cuomo didn’t mention that it was his idea to take mass vaccination out of the hands of county health departments, who have been drilling for years to vaccinate their populations, and put the vaccine distribution strategy in the hands of regional centers, typically located in hospitals. 

Cuomo noted that some hospitals have only given one-fifth of the doses that they’ve been allocated, while others have used far more of their supply. It’s unclear why some hospitals are putting doses into arms so much faster than others. Vaccine refusal by staff may account for some of the lag. Sixty percent of nursing home employees in Ohio declined to be vaccinated. Hospitals may be lagging because they’re swamped by the pandemic. Hospitalization levels have doubled since early December. Some have argued that it was a bad idea to change course and make hospitals so central to the vaccine rollout in the first place. Whatever the cause, threatening hospitals with fines is unlikely to speed up the process. Threats of million-dollar fines for health care providers only add to the climate of uncertainty and anxiety. 

All this saber-rattling is not addressing the root problems behind the slow rollout. Vaccine rollout isn’t slow because of fraud. It’s slow because the federal government has abdicated its responsibilities and forced every state to make up a distribution strategy on the fly. 

Cuomo characterized the COVID-19 vaccination effort as “the most ambitious governmental operation ever undertaken,” and he’s not exaggerating. The Trump administration abdicated its role to create a national vaccination strategy. Each state is left to decide how to allocate vaccines. And each state will rely heavily on a patchwork of providers including under-funded county health departments, private clinics, pharmacies, and urgent care centers. In New York, each region must devise its own plan for vaccine distribution and submit it to the state for approval this week. 

New York has a five-phase plan that roughly corresponds to the CDC’s recommendations for vaccine allocation. Health care workers and nursing home patients and staff are vaccinated in Phase 1. Phase 2 includes first responders, teachers, grocery store workers, and some other essential workers. Phase 3 is for adults over 65 and people under 65 with pre-existing conditions that put them at high risk. Phase 4 is for all other essential workers, and Phase 5 is for healthy adults and children. 

Some pundits have urged states to scrap the whole phase system and distribute vaccines purely by age, and they have some compelling arguments. Age is a simple, transparent criterion. In theory, it could be more efficient to assign a place in line based on a single number: Your birthdate. It’s certainly easier to prove how old you are than it is to prove that you have a preexisting condition or an essential occupation – and there’s less opportunity for the rich to elbow their way to the front of the line. And since older people are at much higher risk of dying from COVID-19, vaccinating the oldest people first would save more lives. 

However, New York has chosen to put essential workers ahead of seniors in order to restore or maintain core societal functions like in-person schooling, firefighting and transit. Putting essential workers ahead may not prevent as many deaths as allocating purely by age, but we have to keep society going while we push toward herd immunity. It’s not entirely a zero-sum game, either. As Cuomo noted at his press conference on Tuesday, the large public sector unions that represent teachers, firefighters, and transit workers have their own health care distribution systems, which means they can vaccinate their members without competing with the general public for appointments. 

The states are laboratories of democracy and there is an experiment underway to test whether putting seniors first would streamline vaccine delivery. In late December, Florida Gov. Ron DeSantis, a Republican, abruptly decided to make everyone 65 years old and up eligible for a vaccine in the first phase, alongside health care workers and nursing home residents and staff. It didn’t simplify the process. Seniors are 20% of Florida’s population, or about 4.5 million people. Just over 1 million doses have been delivered to Florida so far, according to the CDC’s vaccine tracker site. DeSantis was pandering to a huge constituency. But telling 4.5 million people they’re “first in line” for 1 million doses has created a fiasco. County health department websites are crashing under the strain and elders camping out overnight in the hopes of getting their shots. 

New York received fewer doses of vaccine per capita from the federal government than Florida got, but we’ve already vaccinated slightly more of our population than Florida has. 

What’s more, New York has transferred more of the vaccine it has received into people’s arms. The Sunshine State has administered just 23% of the doses that have been delivered to it, while New York has administered 31% of the doses it has received. If vaccination by age were really so much simpler, we would expect Florida to be vaccinating people faster than New York, but they aren’t. 

Israel is capturing admiring global headlines because they’ve already vaccinated 15% of their population, more per capita than any other nation. Israel is prioritizing vaccines for those 60 and older, but that’s not why vaccination is going so fast. Israel’s vaccination program is humming along because they’ve got a highly digitized national health care system, and a coherent national plan for distributing the vaccine. Under its universal health insurance system, all Israelis belong to one of four HMOs. Prime Minister Benjamin Netanyahu personally negotiated an early and favorable deal with Pfizer to buy vaccines – and Pfizer was especially eager to do business with Israel because their digitized national health system produces such useful data on how the vaccine is working. 

While vaccinating purely by age might be the optimal strategy if we were starting from scratch, Florida’s example suggests that we can’t solve deep, systemic problems with the fragmented, inefficient and unequal American health care system by tinkering with accessibility criteria. The United States is in bad shape to vaccinate its population for COVID-19 and that can’t be fixed with a simpler allocation formula or with punitive fines that will only make health care providers less likely to make full use of the limited doses that we have.