When Florida decided to defy federal guidelines and open its first round of Covid-19 vaccines to anyone over 65, queues of people built outside vaccination centres and seniors flocked in from out of state to receive a sought-after jab.
Now, the Trump administration has recommended that other states follow suit by expanding eligibility for vaccines, setting aside its initial concerns over whether doses could be made fast enough and focusing instead on the slow pace of take-up. The decision has more than doubled the number of people eligible for a jab from about 24m to around 50m.
That has sparked concern, however, that new federal guidelines to prioritise vaccinating anyone over the age of 65 could overwhelm already stretched health systems, especially if states allow people to turn up without an appointment, as happened in parts of Florida. According to the US Centers for Disease Control and Prevention’s initial guidelines, healthcare workers and people in care homes should have been the first to receive vaccines.
“We essentially need to make things simpler, whether that is simplifying the supply chain or simplifying the tiers of who is eligible for vaccination,” said Céline Gounder, a coronavirus adviser to president-elect Joe Biden. “But as we’ve seen in Florida that’s easier said than done.”
The federal government has expressed frustration, sometimes blaming state governors for being too prescriptive in who should be given priority.
While some states followed the CDC’s initial guidelines strictly — New York governor Andrew Cuomo even threatened to make it a criminal offence to allow people to jump the queue — Florida did not, choosing instead to throw open the gates to residents and non-residents aged 65 and over.
After the CDC released its new guidance, a number of states have revised their criteria to include over-65s, including New York and California, making millions more eligible for a jab. States are also likely to see their allocations jump in the coming weeks, after the Trump administration decided to release all doses of the vaccine, rather than holding half back for booster shots.
While many experts have welcomed those moves, some worry the problem is not so easily solved.
Florida’s approach appeared to have generated huge demand for the vaccine, with people queueing overnight to receive their shots, including “snowbirds” who come from other states and countries to winter in the Sunshine State.
Public health experts worry that it has left those who need the vaccine unable to have it. Leslie Beitsch, a public health expert at Florida State University, said: “[These] are the folks who are least able to stand in line and camp out overnight in the middle of winter.”
“I think that the first-come first-served method is horrible. Because that results in people waiting in long, long, long, lines,” said Steve Geller, the mayor of Broward County, Florida’s second largest. Even booking appointments online or by phone caused “immense frustration” when people could not get through, he added.
Nor has Florida’s approach obviously improved take-up. According to the latest CDC figures, the state has vaccinated 705,398 people, just 3.3 per cent of its population. New York, which moved only this week to expand its stricter vaccination eligibility to anyone over 65, has vaccinated 632,473 people — also 3.3 per cent of its population.
The main issue appears to be resources. Hospitals and care homes have to find staff to inject people while also coping with the latest wave of the disease itself, which has left over 130,000 people in hospital, more than at any stage since the beginning of the pandemic.
The latest data from the US health department show that over 1,000 hospitals across the US are reporting critical staff shortages, nearly a fifth of all hospitals in the country, according to a report in the Wall Street Journal. The health department did not confirm or deny those figures.
Jessica Daley, a vice-president at the Premier group, which represents over 4,000 US hospitals, said: “We are hearing from members that one of their largest challenges is managing their clinical staff, staffing shortages or overextending staff, because they are focused so much on treating and managing patients who have Covid.”
The situation has become so severe that Premier is now calling on lawmakers to call up members of the National Guard to help vaccinate people.
But the number of staff available to perform injections is not the only problem. Some doctors say the vaccine rush has meant that healthcare workers do not even have enough time to get vaccinated themselves.
Many care home managers have reported problems scheduling appointments with CVS and Walgreens, the pharmacy chains running the government’s care-home vaccination programme. CDC figures show take-up in care homes is significantly lower than the overall figure, though CVS and Walgreens say they are vaccinating as many people as possible.
Mr Biden called on Thursday for Congress to approve $20bn more for the vaccination programme, promising to launch community vaccination centres and mobile units. Some cities and states have opened mass vaccination sites at sports stadiums and convention centres and even at Disneyland in California.
But some worry it is too late for money to have much of an impact and argue that the federal government should take control of the process rather than leaving it to states.
“The federal government could send a few thousand vaccinators,” Ashish Jha, dean of the Brown University school of public health. “They have a public health workforce. They’re just not for reasons that neither I nor the states can figure out.”