If you couldn’t already tell, where you come in the vaccine line depends on where you live.
On Dec. 20, an expert panel at the Centers for Disease Control and Prevention released guidelines on how to approach the next phase of vaccinations, after the initial rollout to health care workers and nursing homes. The panel recommended vaccinating the very oldest adults and frontline essential workers next, followed by a larger group of older, vulnerable people and other essential workers as supply expanded.
But determining whether these people were actually prioritized — or when — was left up to individual states.
With few exceptions, states have abandoned these guidelines, either in part or in whole. As a result, certain essential frontline workers like grocery store clerks will soon be getting the vaccine in some states and not in others. Here’s an example, with each state’s adult population imagined as 100 people lined up for a vaccination.
Where are grocery store workers?
The recommended phases have morphed, splintered and multiplied. States were forced to make difficult decisions about health risks in the face of pressures that deemed some groups with power more important than others.
Many have revised their plans several times, deprioritizing some groups in favor of a different – and often more politically palatable – approach. It is becoming a source of frustration among the vaccine-eager public.
Consider teachers. Vaccinating them next would help schools reopen sooner. But in states where schools have already reopened, like Rhode Island, teachers were not originally prioritized. Even among states that placed teachers earlier in the vaccine line, there’s a wide gap in how they’re prioritized.
Where are teachers?
“The further we get away from the initial phase 1A, we’ve seen wider and wider dispersion with how states are approaching it,” said Dr. José Romero, Arkansas’ top health official and head of the C.D.C. panel that laid out the phases that states were recommended to follow.
Today, each state has its own plan for whom to prioritize and when. Few resemble the C.D.C.’s guidelines, raising questions about who comes first, who comes last and why. Times Opinion, working with Surgo Ventures and Ariadne Labs, took a close look at who states are prioritizing and how that has warped the vaccination lines expected before the vaccine’s rollout.
See how your state compares to C.D.C. recommendations:
Hover or tap phases for more information.
Here is full breakdown of how the phases in your state compare to C.D.C. recommendations.
Who Goes First, Grocers or Police?
The C.D.C. recommended that law enforcement and grocery store workers get vaccinated during the second phase, once the supply started to expand. Both groups play key roles in helping normal life to continue, and both face potential exposure in the course of doing their jobs. They are also similarly sized: Only about 2 percent of U.S. adults belong to each group.
But the police almost universally received earlier access. Often, police officers were offered the vaccine in the first wave, along with health care workers. Meanwhile, grocers were often given no priority access in many states.
Phase with law enforcement (among others)
Phase with grocers (among others)
Where should we put teachers?
There’s a lingering tension in many states between public officials who want to reopen schools and teachers’ unions that want the vaccine before teachers return to classrooms. Fourteen states rejected prioritizing teachers as early as the C.D.C. recommended.
One of those states was Rhode Island, where schools have largely been open since September. The state didn’t need to get teachers vaccinated first before they could open classes. Headed into March, teachers weren’t a prioritized group. (On Tuesday, Rhode Island’s new governor announced that the state would begin vaccinating teachers later this week.)
Teachers in Rhode Island (before March 9)
“We really wrestled with how we would do that, placing one occupation above those most at risk,” said Courtney Hawkins, Rhode Island’s human services director, during a meeting on Jan. 22 with medical experts advising the state on vaccine rollout. Officials said teachers who ought to be prioritized are already included in their plan: About half are prioritized in Rhode Island’s plan because of their age and health conditions.
Teachers were initially scheduled farther down in Washington State’s plan, until President Biden directed participants in the federal pharmacy program to prioritize vaccinating all teachers this month. The state immediately added teachers to its current phase, which largely included seniors and health care workers.
In a news release, the state’s health department acknowledged that the change “may cause a mix of excitement, concern, and confusion for different communities.”
The fracturing of vaccine access continues in some states that weren’t prioritizing teachers. After Mr. Biden’s announcement, Indiana expanded its eligibility — to adults over 50.
“From the beginning, our priorities have been to prevent hospitalizations and save lives, which is why we have prioritized those who are most vulnerable,” said Megan Wade-Taxter, spokeswoman for the state’s health department.
Younger teachers will have to go to pharmacies partnered with the federal government for the vaccine. A similar splintering of sites is playing out in Florida, where the governor has limited teacher vaccinations to only those over 50.
Where in line should we put adults over 65?
Though the oldest Americans were recommended to receive the vaccine in the second wave, those aged 65 to 74 were placed in the larger third phase by the C.D.C., after frontline essential workers. But Florida’s governor quickly ordered providers to prioritize all seniors along with health care workers in the first phase.
The federal government, too, soon pushed to prioritize all seniors. In the final days of the Trump administration, officials urged states to begin vaccinating adults over 65, with the C.D.C. director at the time, Dr. Robert Redfield, citing the “sobering” number of cases present among those populations. The new director in the Biden administration has echoed the recommendation.
The preference for seniors is particularly fraught in Florida, where older voters constitute a base of support for the Republican governor, Ron DeSantis.
“Other states have now followed Florida,” he said at a recent news conference. “C.D.C. had to backtrack. Seniors first is the right thing.”
Pennsylvania soon followed suit, adding adults over 65 into its already sizable first phase. The state’s highest-priority group for vaccination now includes over 40% of all adults.
Adults over 65 in Pennsylvania
“Many older people are more at risk. But let’s say they live in a suburban setting where they can socially distance,” said Harald Schmidt, a professor of medical ethics at the University of Pennsylvania. Those seniors might be fine waiting a bit longer for a vaccine.
But people in multigenerational households might face greater risk because some residents work with the public, he warned.
That is playing out among Florida’s seniors. In the state’s wealthiest county, St. Johns, 80% of seniors are vaccinated. But in Miami’s county, where poverty is higher and many more households are multigenerational, only 61% of seniors are vaccinated.
“There’s an impulse to say, ‘I want to give access to as many high-risk people as possible,’” said Whitney Robinson, associate professor of epidemiology at the University of North Carolina. But by expanding groups, she said, more people end up vying for a limited number of dosages. Inevitably, those in worse financial or social situations will struggle to get the vaccine.
For some, the C.D.C. recommendations were just too complicated to stomach. Last week, Gov. Janet Mills of Maine threw out the “complicated eligibility rules based on types of work and medical conditions that would be difficult to implement and verify,” as the C.D.C. recommendations were called in a statement from her office.
Adults over 65 in Maine
Instead, Maine residents would be prioritized solely on the basis of age (teachers were quickly returned to the priority list after the request from the president).
“The general public is more confused by this than the policymakers are, because they’re not used to morphing a decision over time,” Dr. Romero of the C.D.C. advisory panel said. “For policymakers, they know nothing is written in stone.”
Every state’s plan is at least somewhat defensible, reflecting different priorities that leaders were elected to act on. All say their plan is informed by science and public health. But each state’s plan is different. It takes only one look across the border to see the contradictions play out and the consequences.
Many people may feel emboldened to bend the rules of a system that feels unjust and unfair, stretching or flouting the eligibility requirements. Some become “vaccine tourists” and cross into a state where they are eligible. Correcting for these tendencies, many states are requiring proof of residency, which discourages immigrants from getting the vaccine, or certification of one’s medical condition, which hinders people with limited access to health care.
The final order may matter less if enough vaccines arrive. Alaska’s governor announced on Tuesday that the state would offer the vaccine to everyone over the age of 16, effectively moving into its final phase.
In the meantime, state and federal officials are risking a lot with these conflicting plans. The battle to control the virus will go much further than vaccinating everyone vying for a higher spot in line. Something that resembles herd immunity will rely on vaccinating the maximum number of people. Doing so will rely on trust. Our current process erodes that trust.