In its understandable urgency to build a long-needed national strategy on COVID-19, the Biden Administration faces a patchwork of state-based initiatives that can simultaneously support and confound a new national strategy. The previous Administration made states the frontlines against COVID-19 and, working with the US Centers for Disease Control and Prevention (CDC), states have built considerable infrastructure against the pandemic with the help of federal funding.
This work, however, reflects state variations in priorities and capacities, with many developing comprehensive approaches while others resisted a more fulsome approach to COVID-19 prevention. President Biden has made clear his intention to work collaboratively with states. He recognizes the considerable capacity that states now have in place, and knows his policies will require flexibility to accommodate the different state approaches now in operation. Importantly, the President’s $1.9 trillion stimulus package, which includes considerable funding to address Covid-19, still needs to be enacted by Congress and implemented by the federal government. State work necessarily continues as those political negotiations unfold.
Last week, the Biden Administration issued its National Strategy for the COVID-19 Response and Pandemic Preparedness, a comprehensive roadmap of actions and investments to address the pandemic head on. The National Academy for State Health Policy (NASHP) interviewed a diverse group of state officials from a cross section of states – red, blue, and purple, and large and small. This is a snapshot of those conversations – not a survey of all states – to take their pulse and hear how the transition to the Biden plan can be achieved to:
- Avoid redundancy and confusion between state and federal efforts;
- Build on investments made to state capacity to date; and
- Address the unique challenges in each state.
As they reflected on key provisions in the Biden plan, several common themes emerged, but underpinning their states’ operational issues is the urgent need for consistent, predictable, and adequate vaccine supplies.
Vaccine distribution and planning: State officials expressed frustration with the lack of consistent, reliable, and timely information about vaccine supplies, noting that the last-minute information about weekly vaccine allocations gives states little time to inform providers, determine how many doses can be administered that week, and inform the public. This leads to consumer confusion and may lead to vaccine resistance if consumers become increasingly frustrated as scheduled vaccination appointments are suddenly cancelled. Appreciating the manufacturing issues and challenge in keeping up with demand, state leaders nonetheless called for more advance notice so they can plan when doses are due, as opposed to the currently weekly announcements, and assurances that promised doses will arrive as scheduled. One state official likened it to declaring a moon shot and taking off without knowing how much fuel was available. State leaders believe more advance and reliable scheduling of doses will expedite getting shots into arms. Some urged the federal government to provide a more accurate and accessible dashboard of where vaccines are in the pipeline and when states can expect to receive them.
Vaccine prioritization: CDC, with input from its Advisory Council on Immunization Practices (ACIP), released guidance that prioritized frontline health care workers. Former Health and Human Services Secretary Alex Azar later included people 65 and older. States have all developed priority plans for their vaccine rollouts, but they have not consistently followed CDC guidance. States set their own priorities, some concluding that the federal recommendations were impractical because of limits in available dosages and the inflexibility of the federal guidance in addressing state-based priorities. Some states defined essential workers differently, some targeted those with chronic illnesses, while others noted the need to vaccinate families who live multi-generationally, rather than just the elder in the family. Some states opened vaccinations to all over age 65, and others limited to those over 70 or 75. (View each state’s vaccination priorities here.) Recognizing the disproportionate impact of COVID-19 on communities of color, some states have specifically identified people of color as a priority, but many have struggled to vaccinate them at equitable rates. Some officials noted that frontline health workers include many people of color, but others urged a more aggressive outreach to high-risk populations.
As more vaccine and supplies become available, federal priorities need to coordinate with state initiatives. Residents of a state may be in line for vaccines or expect to be next in line. If there is suddenly a different national prioritization, it may need to grandfather certain populations now in line for vaccines or consider allocating vaccines in such a way to maximize a seamless transition to new priority groups and assure a consistent national strategy.
Vaccine administration: Many states need a larger workforce to carry out their vaccination distribution plans and funding to expedite administration. Many have waived licensing and scope-of-practice rules to encourage more vaccinators, including approving dentists and veterinarians and recruiting volunteers from the ranks of retired health professionals. States are launching hotlines and dashboards to track vaccine availability and in some cases to schedule appointments. Scheduling, tracking, and managing vaccination programs will become an increasingly complex task as more vaccines are available and particularly as long as two doses are required.
States use different data systems, primarily CDC’s Vaccine Administration Management System (VAMS), the independent Prep MoD, and Immunization Information Systems, and each has its limitations. For example, VAMS does not allow a consumer to schedule a second appointment until the first is completed, which adds time and complexity to the process. The Biden Administration proposes to bolster data systems. Currently, only 21 of 46 reporting states and Washington, DC can track vaccines by race and ethnicity, complicating efforts to ensure equity in vaccine distribution. Timely efforts to streamline and speed appointment scheduling and reporting to immunization registries would be welcomed by many states.
State policymakers note that provider-based vaccination clinics are opening quickly and attract patients with health coverage, assuring providers receive reimbursement for vaccine administration. Health Resources and Services Administration funding is available for non-covered populations, but some states report that the billing system is burdensome. Providers, facing the pressure of getting shots in arms, may not be billing and reporting in a timely fashion, delaying efforts to document how many doses are in the pipeline and how many have been administered.
Mass vaccination sites: States, working with hospitals, health systems, clinics, and others are converting sports arenas, recreational centers, and even an unused racetrack to large-scale vaccination sites. Some are co-located with testing centers or food distribution sites. Systems are in place to register, schedule, and deliver vaccinations and hundreds of mass sites are operational within states. The Biden Administration has developed a draft plan, called Concept of Operations, to use the Federal Emergency Management Agency (FEMA) to establish clinics across the country and to authorize and fund states to use the National Guard to help staff the effort. Now under review by states, the plan would support implementation of mass clinics. However, some state officials admitted that was not where they need help right now. Others say mass clinics are in place but getting additional staff help would free up public health workers now staffing these clinics so they could seek out and vaccinate vulnerable populations. Mobile and small clinics could provide 250 doses a day, which would be useful in remote and rural areas. Close collaboration with states will be required both to build on current and planned clinic capacity and because it appears these FEMA-supported efforts will not receive additional vaccine allocations, but rather come from the state’s allocation.
As vaccine supply grows and mass clinics expand, states are contemplating the impact on claims volume and what issues might arise from such a massive, intensive activity, and the billing it will require.
Reaching vulnerable populations: Federal support may be best targeted to help states reach the homebound with limited or no internet or smart phone access, the homeless, uninsured, and those in rural areas. Special consideration needs to be given to populations of color disproportionately affected by COVID-19 and undocumented immigrants. The capacity to maintain vaccination sites on a 24/7 basis will expand access to those unable to come during normal business hours. State officials embraced the idea of FEMA spearheading home visits, particularly to homebound elders and those with disabilities for whom getting to a clinic would be challenging. Many of these individuals are enrolled in Medicaid and will require costly medical transportation if they must travel to a clinic for vaccination. Clinics in communities of color, staffed by trusted community workers, are important strategies designed to reach key populations. As statewide registration opens, some states are using data visualization heat maps to identify target populations and place clinics in appropriate locations. These and related strategies can inform federal initiatives so working with state officials they can effectively reach targeted populations.
Messaging: The Biden Administration plan includes a significant national education and publicity campaign to encourage vaccination and directly address vaccine hesitancy. A consistent national message delivered by trusted voices can significantly assist states, but collaboration will be required to understand the issues, minimize mixed messages, and effectively communicate with various populations, including those who are distrustful of large government vaccination efforts.
Preventing the spread of COVID-19: The Biden plan calls for expanded masking, testing, tracing, and data gathering and calls on governors to act. Presently, 41 states and Washington, DC have mask mandates in place and 20 have active social distancing requirements, although these are varied and subject to change. Most states limit capacity in indoor places and many have evening curfews for certain businesses.
However, enforcing mask mandates has been challenging as has expanding limits on indoor gatherings, particularly where people remove masks for eating or socializing. Whether the Biden Administration’s efforts to educate the public will result in more voluntary masking compliance remains a question and, as vaccines become more widespread, the importance of continued masking and distancing will require more aggressive explanation.
The Biden Administration, not yet a week-old, has moved with lightning speed to lay out a comprehensive and promising national strategy and to engage governors. Beyond vaccine availability and funding, two fundamental challenges confront its implementation.
First, over the last 10 months states have had the primary responsibility for addressing the COVID-19 crisis. They have met the challenge and established testing, tracing, treatment, and now vaccination strategies designed for that state. Any federal response now needs to contemplate how to minimize confusion and build on and integrate those states’ initiatives and the infrastructure they have established. An effective and long-awaited national strategy can prevent the state-to-state competition that was required to secure personal protective equipment and testing supplies early in the pandemic and instead develop a clear and well understood pathway to vaccinating all in the United States. These are logistical and political challenges – daunting to be sure – but resolvable with the partnerships and funding the Biden Administration has proposed, and if the supply chain to distribute vaccine becomes more reliable.
More demanding will be the individual state- policy variations designed to prevent the further spread of the pandemic, a compelling issue as viral mutations emerge. The challenges of controlling the disease and dealing with its economic fallout are real and test anew the concept of federalism.
NASHP has always supported the notion of states as innovators, launching experiments to try new ways to address problems. But the COVID-19 virus knows no national or state boundaries. At what point, then, does the urgency of our public health emergency override the authority of states? If the public information campaign based on scientific evidence led by the Administration to advance prevention strategies fail to secure compliance in states, conditioning federal funds on compliance may be the Administration’s only option to secure the prevention strategies required to protect the public’s health and win the war against COVID-19.