This post collects my takeaways from the oversight hearing on the vaccine rollout held on February 25 by the legislature’s Joint Committee on Covid-19 and Emergency Preparedness and Management. The hearing lasted 6 hours and may be viewed at this link. You can also listen to my Zoom discussion after the hearing at this link.
I was only an observer at this virtual hearing. In my view, the legislators sitting on the panel did a good job echoing the range of comments and questions that I have heard from many constituents over the past few weeks. My notes below emphasize the answers as opposed to the comments and questions.
The state’s vaccine finder site pits people against each other in a maddening contest to grab available appointments as they become available each week.
In a legislative hearing last week, the testimony offered some clues as to why the state has so far failed to offer a friendlier process. Ideally, we would have a site where residents could register their interest and receive notification as they become eligible, and appointments become available.
It emerged that the state did recognize the need early last year. The state was among the first to purchase licenses for PrepMod. According to a search conducted by the CDC, PrepMod is the only off-the-shelf software suite for states seeking to manage a vaccine rollout.
The PrepMod suite does include a module called “COVID Ready” that allows people to register interest in vaccine, but vaccine providers need to have software of their own to interface with COVID Ready and complete the full invitation and scheduling loop. The CEO of PrepMod indirectly acknowledged the gap as she lamented the nationwide underinvestment in technology capacity in public health departments.
The state chose not to sprint to build and deploy the software necessary to fill the recognized gap. The Governor gestured to one reason for that choice, namely that many vaccine providers in the state were not interested in working with PrepMod. The big hospital systems – which together cover over half the people in the state — have their own patient databases and their own patient scheduling systems.
The hospital systems do not need to register vaccine seekers. They already have most of the information they need to identify the patients who are eligible in each phase. In fact, the hospital systems have been doing better than that – they have been targeting their highest risk patients and reaching out to them proactively.
Nobody quite said this in the hearing, but it appears that the state made a judgment call that it could manage the COVID rollout in the same way that it manages the annual flu vaccine rollout: The hospital systems cover a lot of the available demand for vaccine and the rest is handled without a centralized registration and scheduling process. Outreach and scheduling for a large fraction of the public, those outside the hospital systems, is left to a patchwork quilt of local public health departments, community health centers, doctors’ offices, pharmacies, and other providers.
The state failed to appreciate that the much higher sense of urgency about vaccination against COVID-19, the lower availability of vaccine, and the storage and handling requirements of the vaccine would make the flu vaccine distribution model untenable.
When vaccines became available in December, states made different decisions as to how prioritize people for vaccination. All were guided by CDC recommendations, but Massachusetts tried to completely vaccinate its most vulnerable populations before making vaccine more widely available, while other states moved more quickly to offer vaccines to senior citizens generally. This defensible decision made Massachusetts compare poorly in raw rankings of states by vaccination rate.
In response to public outcry about the perceived slow rollout, the Governor pivoted to a streamlined distribution model: organizing the mass vaccination sites, cutting hospital systems out of the process, and forcing local public health departments to band together into regional collaboratives if they wished to continue to distribute vaccines.
That is when the public started to pay the price for the state’s failure to invest in a first-class centralized scheduling system. The state has been scrambling to improve the system over the past few weeks working with a group from the Broad Institute, affiliated with MIT. The Governor and other state witnesses took full responsibility for the website problems and promised continuing improvements.
Equity and Shifting Roles in the Course of the Rollout
The state has already provided first doses to over two thirds of the over 75 population and the younger seniors are now moving through the system rapidly.
The head of the Beth Israel Leahy hospital system predicted that, within a month or two, the mass vaccination sites will start to empty out. Right now, the appointments are being snapped up as soon as they become available, but soon the eager demand will have been met.
Then we will have to work harder to bring in patients. Vaccinating people in poverty is hardest. People in poverty are less likely to know about the opportunities for vaccination, more likely to have doubts about the safety of vaccine, less able to access and operate web scheduling sites, less able to get time off for vaccination and less able to travel to distant sites. These factors contribute to predictable disparities in vaccination rates
The state is already devoting resources to outreach in poverty communities. Based on risk data, the state is partnering with the 20 communities with highest need. The Baker administration announced a grant program to support collaborative efforts with local organizations who are likely to be trusted as vaccine advocates in hard hit neighborhoods.
The state is allocating vaccine supplies to local health departments and community health centers in these communities so that they can set up clinics.
The state has also reversed itself on diverting vaccines from the hospitals to the mass sites. The hospitals are often located in poverty areas and/or have satellite clinics in poverty areas. The major health care systems are already working their patient lists to bring in those who meet eligibility criteria in the high poverty areas.
Ultimately, achieving high vaccination rates in poverty areas will take very personal outreach to patients – knocking on doors, going to workplaces.
The need for convenience goes beyond poverty areas. Many senior citizens and people with disabilities in other areas will have trouble working their way through the website and the mass vaccination sites. And some people are confident enough in their own health status that vaccination does not feel like a high priority for them. And, of course, there are those who are generally uncomfortable with vaccines.
For all of these groups, the strategies have to be much the same as for poverty populations. That is why it is unfortunate that in its effort to accelerate the vaccine rollout the Baker administration has cut dozens of local health departments out of the process.
Local health departments are connected to local senior centers, local employers and other local institutions. They had been running convenient clinics that reached eligible people who are unlikely to spend hours banging on a website or to travel to a strange facility.
The Baker administration’s current emphasis on large sites with higher throughput reflects both the pressure generated by the statistical horse race. And, to be fair, there is a valid argument that herd immunity and the local extinction of the virus depends of vaccinating as many people as possible and does not depend so much on whether high risk people are vaccinated.
But I am hopeful that as appointment uptake at the mass sites begins to slow and as vaccine supplies increase, the administration will reemphasize the role of local health departments. They can be an important part of the solution in many communities, not just high-risk communities.