Eligibility expansion just too slow for some
Medical experts say widening criteria isn’t automatically the right solution
Carolyn Kritzer of Munster, Indiana recently booked an appointment for her first dose of COVID-19 vaccine and described the process as “seamless.”
Once eligible, the 58-yearold went to her state’s centralized online system, typed in her information and secured a time slot in a matter of minutes. In contrast, her co-worker Ruth Mares — a 60-year-old essential worker who lives just a few miles over the state border in south suburban Lansing, Illinois — has been constantly checking and refreshing a variety of local pharmacy and health care websites, with no luck in finding an appointment so far.
The women are roughly the same age, work in the same field and live minutes from one another. Yet they’re navigating entirely different state processes and rules, with disparate results.
Mares believes that if her home were a few miles east in Indiana — which has a predominantly age-based approach and recently began vaccinating all residents 45 or older — she would be immunized by now.
“I would have already been done with it,” she said.
With potentially lifesaving vaccine still in short supply, many Illinois residents have looked longingly at nearby states — some with a reportedly easier process for making appointments, others that expanded eligibility or lowered age restrictions at a more rapid pace.
Indiana in early March opened criteria to those 50 or older, and then on Tuesday dropped the age requirement to 45 and up. Iowa’s governor recently announced that all Iowans might be eligible to get the shot on April 5, if supply expectations are met.
And Ohio on Friday expanded eligibility to those 40 years old and up, as well as patients with some highrisk medical conditions; by the end of March, all residents over the age of 16 are expected to be eligible.
This may have induced some vaccine envy among Illinois residents, even as their own state plans to widen criteria, albeit not as quickly: Gov. J.B. Pritzker announced earlier this week that vaccination eligibility will be expanded to all Illinois residents outside of Chicago by April 12. Other professions like higher education staff, government workers and media will be vaccine-eligible on Monday as well, according to state officials.
Yet some public health experts caution that expanded eligibility doesn’t automatically equate to mass vaccination success because there are so many factors at play, from the overall number of doses administered to equity of distribution to care for the most vulnerable populations.
Just because different groups or more people are eligible, that doesn’t necessarily mean more individuals are getting immunized.
In fact, Illinois has been slightly faster at getting shots into arms than Indiana and Ohio — two of the states that opened up age tiers sooner. The latest data shows Illinois administered nearly 36 shots for every 100 residents. Ohio’s rate is 34, and Indiana’s is 33, according to a Tribune analysis of data from the Centers for Disease Control and Prevention.
But there’s one notable difference between the states: who is getting prioritized for the shots. Ohio and Indiana have been among the fastest states in getting doses in the arms of senior citizens, a population at greater risk of contracting and dying from the virus.
Half of senior citizens in Indiana are fully vaccinated now, with Ohio at 41%. Illinois, in comparison, has just 36% of its seniors fully vaccinated, according to the latest CDC data.
Another way to look at it: In Indiana, senior citizens are nine times more likely to be fully vaccinated than a resident there under age 65. In Illinois, despite also being in an early priority group, seniors are just four times more likely be fully vaccinated than someone under 65. (The national median is five times.)
While older residents were prioritized in Indiana, some professions had earlier access to the shots in Illinois. For example, teachers have been getting immunized in Illinois for weeks now. Indiana just began vaccinating teachers and other school employees across the state in mid-March; before, they could only get shots at pharmacies participating in a federal program.
Illinois residents over 45 could assume Hoosiers get the better deal in terms of vaccine prioritization. But a younger educator in Indiana might disagree.
The perception that one state is doing better than another can be misleading, because leaders are trying to balance a variety of competing public health priorities, said Dr. Thomas Tsai, assistant professor in the Department of Health Policy and Management at the Harvard T.H. Chan School of Public Health.
There’s an urgency to get shots in arms as quickly as possible in a race against emerging COVID-19 variants, Tsai said. At the same time, immunizations need to go to those most at risk of contracting the virus and dying from it. Distributing should be equitable to all races and income levels, and shots have to get to rural and urban areas alike.
“It’s more complicated because we can’t boil it down to one single metric,” Tsai said. “There needs to be a dashboard of metrics. We need a grade-point average instead of just a grade.”
Illinois catches up
While vaccine rollout in Illinois was initially sluggish compared with most other states, the pace has since greatly improved.
As of Friday, Illinois was roughly in the middle of the pack, ranking 26th among all states for per capita doses administered, according to a Tribune analysis of CDC data. And it ranked first among the 10 most populated states.
Illinois is also slightly ahead of the national averages on three key metrics: percentage of the adult population with first doses, percentage with both doses, and the efficiency of administering the shots — the ratio of doses administered compared with the doses available, said William Galston, senior fellow in governance studies at The Brookings Institution.
“States that are doing a good job of administering the doses have a high efficiency rate, and Illinois is now a couple points above the national average,” he said. “Which doesn’t put Illinois in the top tier, but it isn’t a disaster area either.”
This comparison can be complicated because each state has established its own hierarchy of priorities, rules and systems.
“Those are policy decisions that states have made in 50 different ways,” Galston said.
While it’s still too early to draw definitive conclusions, he said states that have had greater vaccination success tended to use a more simplified and centralized process. Galston added that mass inoculation centers also “can speed things up.”
“Statewide, single-pointof-entry websites work better than a bewildering variety of local, institution-specific sites,” he said.
Illinois health officials credit the recent catch-up in part to the launch of numerous state-supported mass vaccination sites, as well as dozens of mobile teams that vaccinate underserved communities.
“Illinois entered phase 1b after some other states because we have a large number of health care workers and long-term care facilities and we wanted to ensure those were fully covered before moving on,” said Melaney Arnold, spokeswoman for the Illinois Department of Public Health. “Once we entered phase 1b, our numbers improved.”
She added that the state also continues to monitor the number of doses providers have in their inventories to make sure they’re going into arms and not sitting on shelves.
Pritzker spokeswoman Jordan Abudayyeh said the state has largely been following guidelines from the CDC’s Advisory Committee on Immunization Practices in deciding who to include in each phase.
Beyond prioritizing senior citizens, the guidelines don’t make distinctions by age but instead by profession and medical history, she said.
“We’ve asked for federal frameworks for a year, and now that we have them, we’re following them as closely as possible,” Abudayyeh said.
‘Pour water where the fire is burning’
While expanded eligibility might elicit hope for those eager to get vaccinated, some medical experts fear that widening criteria too quickly could leave behind the most vulnerable groups.
Many states were relatively slow to move past the first vaccination phase, which focused on health care workers and residents of longterm care facilities, said Dr. William Parker, assistant director of the MacLean Center for Clinical Medical Ethics at University of Chicago Medicine and an ICU doctor.
Now that vaccine distribution has picked up in Illinois and across the country, Parker worries about states moving too far in the other direction.
Alaska earlier this month expanded eligibility to anyone over 16 living or working in the state. Mississippi opened vaccinations to all residents on March 16. Anyone over 16 in Nevada will be eligible to get the shot as of April 5. All were well ahead of President Joe Biden’s May 1 deadline to have every adult nationwide vaccine-eligible.
But there could be unintended consequences if states simply give the vaccine to anyone in additional, younger age groups while supply is still limited, Parker said.
“You’ll end up prioritizing people who are quite low risk,” he said.
Policymakers should instead be prioritizing people in hard-hit neighborhoods, something Chicago has been doing through its Protect Chicago Plus plan, which targets high-risk communities in the city for vaccinations, he said.
Ensuring people in hardhit areas get vaccinated before low-risk people is more equitable and it better helps to control the spread of the virus as well as prevent deaths and hospitalizations, he said.
“Pour water where the fire is burning,” he said.
It made sense for Illinois to first allow health care workers to be vaccinated, followed by seniors and people with health conditions, he said.
But Parker believes it’s been a “policy failure” that the Chicago area hasn’t received as many vaccines per person as some other areas of the state; Chicago has been vaccinating many people who don’t live in the city, and that should be taken into account when it’s decided how many doses the city should be getting.
“Before we open it up to everyone and make it first come, first served to all people across the state, the areas that are lagging behind need to get supply,” Parker said. “It would be really sad if we’re vaccinating healthy 19-year-olds in (Downstate)
Adams County when my (patients with) high-risk conditions on the South Side of Chicago can’t get a shot.”
The CDC doesn’t publish data on race and ethnicity, and measuring that can be tricky because some states are better than others at collecting the race and ethnicity of those getting shots. That said, a look at each state’s website shows slightly more Black and Hispanic residents in Illinois have been vaccinated compared with some neighboring states that are expanding eligibility earlier.
In Illinois, as of Wednesday, 6.9% of Black residents had been fully vaccinated, based on a Tribune analysis of vaccination and census data. In Indiana, that rate is 6.5%, and in Ohio it’s 5.8%.
As for Hispanic residents, Illinois again leads both states, with 6.3% of Hispanics fully vaccinated, compared with 4.2% in Ohio and 4.0% in Indiana.
And, at least from what’s filled out in vaccination records, Illinois also leads those two states in white residents fully vaccinated: 16% of white residents in Illinois, compared with 15% in Indiana and 13% in Ohio.
Eligibility also only opens the possibility of getting immunized — and those familiar with navigating access point out that just because more individuals meet criteria, that doesn’t necessarily ensure the process becomes any easier or supply will increase to meet demand.
On social media sites, the news that vaccine eligibility will be expanding to most residents of Illinois was met with both praise and skepticism.
“Yay!” one woman commented on Facebook. “Thank you Gov. Pritzker.”
Others suggested that opening up the process to more people doesn’t automatically equate to better access — or more shots in arms.
“He can make everyone 16 and older eligible today, and it wouldn’t change a thing,” a local man posted on the same site. “Actually being able to get vaccine appointments will still be like looking for a needle in a haystack.”