Do COVID vaccine eligibility rules do more harm than good?

Mike Bebernes
·Senior Editor
·7 min read

“The 360” shows you diverse perspectives on the day’s top stories and debates.

What’s happening

Public health officials across the United States spent months developing strategies for distributing the first precious doses of coronavirus vaccine. But now, just a few weeks into the vaccine rollout, many of those initial plans have already been scrapped.

At first, most states reserved the vaccine for frontline health care workers and elderly people in long-term care facilities in anticipation that limited supplies would be the biggest hurdle to widespread vaccinations. But logistical bottlenecks quickly proved to be another major challenge. Many states have struggled to find eligible recipients for the vaccine supply they have, leading life-saving doses to sit on shelves and — in some cases — be thrown away. As of Wednesday, only 53 percent of the 44 million vaccine doses that have been distributed to states have been used.

In mid-January, the Trump administration issued new guidelines recommending eligibility be expanded to include all people 65 and older and people with certain medical conditions — groups that total more than 150 million people. More than half of the states have followed suit by establishing age-based eligibility criteria. But that has created its own challenges. In some parts of the country, demand has dramatically outstripped supply, causing long lines and confusion.

Why there’s debate

The abrupt change in distribution plans highlights a central tension that health officials have struggled with in developing their strategies: Should the goal be to protect the people who face the most risk or to get as many people vaccinated as possible?

Advocates of a targeted strategy say the top priority should be reducing the number of deaths. Though they represent a fraction of the country’s population, residents of long-term care facilities like nursing homes account for more than 35 percent of COVID-19 deaths in the U.S. Expanding vaccine eligibility to other groups before the most vulnerable have been protected could lead to thousands of unnecessary deaths, some argue. Getting rid of job-based eligibility will also put essential workers who are most likely to contract and spread the virus at risk, they say.

Drastically increasing the number of people seeking the vaccine creates room for inequities and even outright abuse, others say. Without targeted eligibility, well-connected people who may face relatively low risk will be able to get the vaccine while people with less access to health care, who are disproportionately people of color, won’t.

Others say speed should be the No. 1 goal, even if that means protection doesn’t go to those who face the most risk. Overly complicated eligibility criteria based on people’s living situation or profession create confusion and bog down the process. With somewhere around 250 million Americans needing to be vaccinated to reach herd immunity, anything that slows distribution will cause the pandemic to last longer, they argue. There’s also hope that vaccine shortages will be less of a problem with the Biden administration pledging to buy 200 million more doses of the two vaccines currently in use and the potential that more vaccines may become available in the near future.

What’s next

Public health experts are hopeful that the approval of new vaccines will help solve many of the supply problems plaguing the U.S. vaccine rollout. There’s particular attention being paid to a vaccine candidate from Johnson & Johnson, which requires only a single dose as opposed to the two doses needed for the Pfizer and Moderna vaccines already on the market. Johnson & Johnson reported promising results from its clinical trials on Friday and is expected to seek emergency approval for U.S. distribution as early as next week.


Focus on most vulnerable

Speeding up vaccinations doesn’t mean abandoning all rules

“Increasing the volume of vaccinations need not come at the expense of getting doses to the people most at risk from Covid-19. Because it’s important to ensure that people getting vaccinated meet current eligibility criteria, mass vaccination clinics can focus on people over 65, whose age can be easily verified.” — Thomas J. Bollyky, Jennifer B. Nuzzo and Prasith Baccam, New York Times

With the virus spreading rapidly, limiting deaths should be top priority

“If the vaccine is rolled out slowly, which is currently the case, and if community transmission is high, which is also currently the case, then it becomes better to prioritize adults over 60 to minimize mortality." — Public health data scientist Daniel Larremore to NPR

The elderly face the greatest risk and should be the focus of vaccine efforts

“The coronavirus is not an equal opportunity killer. The vast majority of its victims have been elderly.” — Editorial, Las Vegas Review-Journal

Limiting eligibility will help prevent line-jumping

“Generally speaking, having a strong demand for COVID-19 vaccines is a good problem. … But until we reach a point where there is more supply than demand, the scarce doses must go only to those who need the protection the most, not the highest bidder.” — Editorial, Los Angeles Times

Broad eligibility will make racial health disparities worse

“The bottleneck is about to get worse, and we fear communities of color will be left further behind.” — Editorial, Baltimore Sun

Without targeted vaccinations, the most vulnerable will be left behind

“A ‘first come, first serve’ approach will leave out many of the most vulnerable, who may not be able to phone a hotline right as it opens or camp out overnight to get a shot. Those with connections will almost certainly find a way to jump ahead, and access rather than need will determine someone’s place in line.” — Leana S. Wen, Washington Post

Focus on speed

The goal should be to administer as many vaccines a day as possible

“The imperative for public health is to distribute the vaccines fast, even if the sequence is imperfect. … Our collective imperative is to get it into as many arms as possible to boost our cumulative defense as the virus is surging.” — Editorial, (Newark) Star-Ledger

Expand eligibility to avoid waste, but ramp up efforts to vaccinate the most vulnerable

“We must release all the available doses of the Covid-19 vaccines — but we must go further by expanding the categories of who can get the vaccine to avoid wasting doses and simultaneously increasing both funding and support for getting the shot in people’s arms in ways that explicitly address considerations of equity and don't let people use their influence or resources to cut the line.” — Megan Ranney, CNN

Overly complex criteria can lead to doses being wasted

“Unfortunately, a complex tiered approach presents a barrier to vaccine administration. Who will ensure a person is a critical worker or has a certain disease? Do you bring a pay stub or your physician’s note to the clinic or pharmacy? What qualifies as an underlying condition? This adds delay and can cause vaccine waste if vaccinators don’t have enough people available to receive shots before doses expire.” — Linn Goldberg and Louis Speizer, Oregonian

Tight eligibility criteria is slowing down the effort to end the pandemic

“Americans have been warned … there will be a vaccine shortage. Health care officials were instructed to abide by a strict prioritization schedule and this created a ‘shortage mentality’ that’s slowed the distribution of available vaccines.” — Arielle Kane, The Hill

Protecting the vulnerable should be a goal, not a strict mandate

“The part that needs to change is the strict adherence to the pecking order. This is meant as guidance only, but is being too strictly enforced. … It is tragic that regulations are getting in the way of immunizations.” — Marc Siegel, Fox News

Broader criteria will help combat vaccine skepticism

“Ensuring that everyone already convinced of the vaccine's efficacy has access to inoculation should be our first priority. Transitioning to a first come, first served model is the most efficient way to achieve this. It is the obvious first step to ensure an adequate amount of the American population becomes vaccinated, as it eases the burden of convincing the skeptical.” — Anthony DiMauro and Leonard Robinson, Business Insider

If rules are too complicated, vulnerable people will get lost in the shuffle

“The prioritization schemes in many states are complicated and vague. This all may appear to be a way to ensure fairness, but in reality we know from similar programs that those with more connections, free time and know-how will be better able to navigate this maze while the process slows it down for everyone else — especially those who need it.” — Zeynep Tufekc, New York Times

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Photo illustration: Yahoo News; photos: Getty Images