Cross-posted from COVID-19 and The Law, where it originally appeared on January 27, 2021.
Since the Food & Drug Administration granted emergency use authorization for the COVID-19 vaccines produced by Pfizer-BioNTech and Moderna in December 2020, there have been many debates on vaccine allocation and prioritization.
As noted by Harvard Law School Professor Glenn Cohen in a recent interview with Annie Kapnick for the COVID-19 and The Law series, the issue of vaccine distribution is “complicated” because of competing factors decision-makers must consider. The relative weights placed on these factors has led to very different prioritization schemes. Initially, the Centers for Disease Control and Prevention (CDC) recommended a hybrid plan that appeared to prioritize individuals who were most likely to contract the virus (e.g., first responders, grocery store workers) over individuals most vulnerable to severe symptoms or death from the virus if contracted (e.g., individuals over the age of 65 not in long-term care facilities). In the United Kingdom, the prioritization groups were primarily based on vulnerability. Similarly, when looking more narrowly at the various plans being implemented at the state level in the United States, there are high degrees of variation.
This post does not seek to evaluate the merits of these or other specific vaccine allocation plans. Rather, it will address a risk that all plans likely face: the potential of individuals using their wealth and access to “cut the line” and be vaccinated ahead of schedule.
Concierge Doctors, Donations, and Vaccine Tourism
So why is using wealth to cut the vaccine line a problem? The use of wealth and influence to get ahead is by no means a novel phenomenon. Healthcare is not immune to this problem. For decades, there has been data that shows the potentially devastating impacts of wealth in the context of resource allocation. In the 1980s, for example, congressional hearings showed that wealthy individuals received organ transplants faster because they were willing to pay more. Throughout the course of this pandemic, wealth has impacted health outcomes. Early in the pandemic, there were reports of wealthy and prominent figures individuals receiving testing ahead of average Americans. Well-connected individuals like Rudolph Giuliani received experimental treatments while families lost their loved ones because, as President Trump’s physician noted, it is “one of the perks of being the personal lawyer to the commander in chief.”
Wealth is arguably even more dangerous when it derails a vaccine schedule rooted in scientific and public health research to determine when someone will receive a vaccine. While anyone is capable of contracting the virus, the data shows that there are pockets of the community – including low-income communities – that are more vulnerable to faster spread or higher mortality. Government and public health officials allow the data to guide their risk-adjusted allocation decisions. When an irrelevant exogenous factor such as wealth is used to cut the line, it directly impacts the availability of the vaccine for someone who statistically would benefit more from receiving now rather than later.
Nevertheless, reports have been mounting about this pernicious practice.
One technique that has exacerbated inequities in vaccine distribution is the use of “concierge doctors.” These medical professionals are part of medical practices that charge clients exorbitant annual fees – often thousands of dollars – for unlimited, round-the-clock access to personalized medical care. Since the release of the vaccines, these medical practitioners, especially in cities like New York and Los Angeles, have been fielding calls from their patients demanding the vaccine outright. In other instances, there have been reports of individuals offering “donations” of up to $25,000 to hospitals where practitioners have admitting privileges and could help donors skip the line.
Vaccine tourism is also on the rise. This is travel motivated primarily by the ability to take advantage of a destination’s more flexible vaccine distribution policy, a practice available only to those with the funds to do so. Florida, which was one of the first states to offer the vaccine to individuals aged 65+, has emerged as one of the key destinations for this practice. There have been many reports of an uptick in travel into the state by tourists with little or no connection to the state as well as by “snowbirds” who reside in the state seasonally. This trend extends to foreigners as well, which was discussed in a recent Wall Street Journal report that highlighted, amongst several examples, an increase in requests received by a charter flight company from Canadians willing to pay between $25,000 and $80,000 for same-day round trip tickets into the state.
The exploitation of concierge medicine and vaccine tourism are just two examples of the influence of wealth on vaccine distribution. They are by no means the only ways this is happening nor do they substitute the ability of individuals to simply tap into networks that their wealth has helped to cultivate. In West Palm Beach, Florida, for example, there is an active investigation into MorseLife Health System’s alleged practice of giving vaccines to wealthy donors and the members of a nearby country club. As one individual who was offered the vaccine by the facility’s CEO stated, “[T]hey are not just giving it to any people. They are giving it to people who give them money.” The entitlement combined with ability speaks to the heart of the problem.
There are several ways government officials can combat the wealth problem without sacrificing the speed at which vaccines are being administered to those who are eligible. While these solutions target the direct influence of wealth, it is important that the government address indirect ways that wealth may impact one’s ability to receive a vaccine dose. For example, 24-hour vaccination centers, like the recently announced Citi Field site in New York, allow individuals who do not have financial flexibility to take off of work or otherwise rearrange their schedules to be vaccinated.
A recent Executive Order signed by New York Governor Andrew Cuomo can serve as a model for other states seeking to tackle the problem of “cutting the line.” Executive Order No 202.86 targets those responsible for vaccine administration by imposing “civil penalties of up to one million dollars per dose administered and/or the revocation of any state-issued license” on licensed healthcare provider(s) who administer the vaccines to individuals who have not attested otherwise certified to be an eligible member of a prioritized group(s). The information is collected and monitored by the state’s Department of Health. Cuomo has also proposed making “fraud or fraudulent sale or fraudulent [COVID-19] vaccination” a criminal offense as well. Governors in other states, including Governor Gavin Newsom in California, have signaled a willingness to impose similar rules.
When individuals navigate to New York City’s COVID-19 Vaccine Eligibility website, they are greeted with the following statement:
- If you are eligible for a vaccine based on your age, you must show proof of age and New York residency, such as New York State driver’s license, IDNYC, passport, mail (residency), rent statement (residency) or birth certificate (age).
Residency requirements like this can play a significant role in reducing vaccine tourism. State officials have the flexibility to adapt these requirements to fit the unique characteristics of their state. This ensures that when decision-makers are making their allocation determinations at both the federal and state levels, they are doing so with more stable population figures. This would lower the instances of non-high-risk, out-of-state individuals reducing vaccine availability for in-state residents who are in greater need based on data and science. After pressure from local leaders and communities, Florida has recently issued new residency rules.
Better Federal Coordination
Many of the troubles we see related to vaccine distribution and administration – including the use of wealth to cut the line – stem from sluggish, decentralized rollout. Make no mistake: the biggest fixes to the issues raised in this post include increased vaccine production, increased funding for struggling state and local health departments, and better federal coordination of one the largest vaccination programs in the country’s history. The Biden-Harris Administration has stated that making these changes and others are a priority. As the legislative elements of its plan are worked on in Congress, it is incumbent that the Administration ensures that federal agencies do what they can to protect all Americans, especially those at high risk.