‘Use it or lose it’ policy for COVID vaccines needs an equity focus

On May 4, a fortnight after opening COVID-19 vaccine eligibility for all U.S. residents, President Biden announced a new major goal: By Independence Day, 70 percent of adults should be vaccinated with one shot and around half (160 million) should be fully vaccinated. 

Clear targets are essential for galvanizing focused action. But these targets also call attention to who is most likely to get vaccinated under the new push — particularly because a central element in the announcement, known as the “use it or lose it” policy, risks increasing inequities. For public health and equity, we cannot just focus on high numbers alone. With a small tweak, “use it or lose it” can work in favor of more disadvantaged communities, rather than against them. The rule should prioritize independence of those for whom it matters the most, rather than of those who already have more of it.

Throughout the pandemic, more economically and otherwise disadvantaged populations have been hit harder in terms of unemployment, illness and deaths. Due to the consequences of systemic racism, these groups comprise larger shares of people of color. Yet, when it comes to vaccination receipt, the inverse is the case, and better-off groups are receiving vaccines at higher rates. 

Using the CDC’s Social Vulnerability Index (SVI), on April 19, when all residents became eligible for vaccines, 22 percent of the most disadvantaged, and 27 percent of the least disadvantaged were vaccinated, a difference of 5 percent. One month on, the gap has increased to 7 percent (32 percent vs 39 percent).

These differences cannot be attributed to the complex concept of ‘vaccine hesitancy’ alone. For example, the intention to be vaccinated among Black Americans has approximated that of whites and Hispanics (61 percent versus 69 percent versus 70 percent). But whites receive vaccines at 1.5 times the rate of Blacks and Hispanics (39 percent versus 25 percent versus 29 percent). Reducing barriers resulting from insufficient access to vaccines in convenient and trusted settings is therefore critical.  

This is where the new “use it or lose it” policy comes in.   

What the policy entails is this. Across the U.S., weekly allocations will continue to be made proportionate to population. However, where a state or city orders fewer units, these doses will be allocated to a central pool from which state or cities that are able to distribute more vaccines may order an additional amount of up to 50 percent of their weekly per-capita allocation. 

The policy’s intention is certainly understandable.  But it also risks that increasingly more vaccines go to areas where uptake is swifter, but populations are at relatively lower risk of getting and spreading COVID-19 — when both equity and public health would demand the opposite and direct more vaccines to areas that are more disadvantaged and at higher risk of getting and spreading the infection. 

Administratively, vaccines are allocated to 64 units of the CDC known as jurisdictions. These comprise all states, territories and some larger cities, and differ considerably in their shares of disadvantaged communities. For example, in New Hampshire, fewer than one in 10 people fall under the nationwide most disadvantaged group (using the CDC’s SVI). But in New Mexico more than four in 10 are in this group.

These differences in disadvantage need to be reflected urgently in the “use it or lose it” strategy. 

Instead of, for example, simply splitting all pooled vaccines among those states that are able to allocate them, jurisdictions with larger shares of disadvantaged people that are able to administer them should receive proportionately more of the extra-allocation from the pooled doses, and jurisdictions with smaller shares proportionately fewer doses.  

Needless, to say, jurisdictions should then also commit to making special efforts to allocate these doses to more disadvantaged communities, using indices such as the SVI. 

The majority of jurisdictions already have experience with disadvantage indices. While indices differ in design, all integrate a set of variables such income, education and quality of housing, to determine how disadvantaged, on average, people living in particular areas are. Planners applied indices within each sequential allocation phase and priority group, including: increasing vaccine allocations to more disadvantaged areas, planning dispensing sites, tailoring targeted communication and outreach strategies and monitoring uptake.

Federal planners also already recognized the importance of disadvantage indices under goal six of the National Covid Strategy. Further to adjusting the ‘use it or lose it’ strategy, they should additionally deploy it to improve equity in the distribution of other, directly related elements under the new initiative. In particular, to direct that walk-in vaccinations, mobile clinics and community-based vaccination sites are readily accessible in high disadvantage areas, and that community-based organization and outreach workers in such areas are adequately resourced, that is, that proportionately more resources are allocated to more disadvantaged areas. Focusing efforts in more disadvantaged areas is the only way of ascertaining whether supposedly lower demand indeed reflects lacking interest, or — as often seems more likely — simply reflects prior and ongoing structural barriers, or needlessly deterring identification requirements.  

Finally, a complementary target should be adopted alongside the already chosen ones. In an adaptation of Michigan’s Zero Disparity goal, among the 70 percent to be vaccinated by July 4, there should be no disparity in vaccination rates across racial and ethnic groups or by SVI. 

Such a target simultaneously serves equity and public health, and also matters considerably for economic recovery, by making it easier for low paid workers who were not prioritized as essential workers to be vaccinated.  

Celebrating higher vaccination rates on Independence Day while more disadvantaged groups are still burdened far more than others by COVID-19 in health and economic terms is not right (and note that we bracketed here entirely the unbearable inequities in global vaccine access, that need to be addressed urgently, in parallel). 

Before we think about fireworks in the sky, we should focus on the concerning link of health and place on the ground. Continuing to explore the potential of tools such as disadvantage indices recognizes that, essentially, we are all just neighbors, and that measures can be taken to improve everyone’s chances to live in independence.

Harald Schmidt is an assistant professor of medical ethics and health policy at the University of Pennsylvania. Lawrence O. Gostin is a professor and director of the O’Neill Institute for National and Global Health Law at Georgetown University Law Center. Michelle Williams is dean of the Harvard T.H. Chan School of Public Health.