Kansas, Missouri using ‘honor system’ to stop people from cutting in line for vaccine
Health leaders spent months deciding who would get the COVID-19 vaccine and when.
Doctors, nurses and nursing home residents first. Then first responders, those with underlying health problems, the elderly and the fuzzily defined essential worker. Finally, the general public.
But as the universe of people eligible to get vaccinated expands in the coming weeks, those inclined to jump the line might be able to get shots months before their turn. As the ranks of the vaccinated grows, the temptation to cut is likely to rise, fueled by the promise of protection from the virus and hope of a more normal life.
Kansas and Missouri have no plans in place beyond relying on human decency to stop line cutters during this intermediate period of vaccination before shots are available to the public at large. Both states call it Phase 1B.
“You’ll just go in and identify yourself as a doctor, dentist, childcare, teacher and they’ll give you the vaccine,” said Randall Williams, director of the Missouri Department of Health and Senior Services. “But there won’t be this list that you’ll check off. So it’s an honor system once we get into Phase 1B.”
Interviews with state and local officials, public health leaders and doctors show that few measures are in place to stop people from jumping the line, aside from asking whether someone seeking a shot falls into a priority category. There is little indication that vaccination sites will have the time or staffing needed to verify the truthfulness of the answers.
Even if vaccinators want to investigate, medical privacy laws could complicate any efforts to ensure that recipients have an underlying health condition that places them in a priority category.
In effect, health officials are left to plead with the public to respect the line and show restraint, even though hundreds of thousands, if not millions, may get their shots first.
Lee Norman, secretary of the Kansas Department of Health and Environment, said those wanting to be vaccinated will be asked why they’ve registered. But beyond that, he echoed Williams, explaining that officials are relying on basic courtesy.
“We’re hoping that people will self-police and the spirit of goodwill and community spirit will carry the day,” Norman said. “That, I think, is the most humane way I can say to manage people and treat them as adults that want to contribute to the greater good.”
Helping the at-risk first
It’s unclear how extensive line cutting will be. The unprecedented size of the COVID-19 vaccination campaign makes it difficult to predict.
As long as supplies remain limited, every person who cuts in line potentially leaves someone else in a priority category waiting. By the end of the year, vaccines from both Pfizer and Moderna are expected to be in circulation, with at least tens of thousands of doses arriving in both Kansas and Missouri every week.
Both states ultimately need enough for millions of people. But the federal government is allocating doses by population, leaving little chance that state officials can outmaneuver others for more.
By most accounts, Kansas and Missouri won’t have enough doses for everyone until spring at the earliest and summer at the latest. That means several months of rationing is ahead.
Lynelle Phillips, vice president of the Missouri Public Health Association, suggested a small number of people may try to game the system, but expressed hope that most would wait their turn.
“I don’t picture someone showing up at their physician’s office or a health department and masquerading as a front-line health care worker, or ‘I have diabetes’ when I don’t,” Phillips said. “I don’t picture people trying to do that, but maybe I’m Pollyanna about humanity.”
The bigger problem will be convincing the reluctant, Phillips said, adding that’s “much more our concern than the random person that jumps to the front of the line.”
A November Gallup survey found 37 percent of Americans wouldn’t agree to get vaccinated while 63 percent were ready. Health experts are pushing for upwards of 70 percent of the population in order to stop the spread of the virus.
Nancy Tausz, health services director for the Johnson County Department of Health and Environment, said that as with any other public health emergency involving mass vaccinations, “we don’t really check for residency or that type of thing.”
She acknowledged people are anxious to get vaccinated but said she expected the public to respect the rules and allow the most at-risk to come first.
“I really think that most of the people that we vaccinate in those tiers will be truthful and respect the process and just realize that we’re going to get to them as soon as we can,” Tausz said.
Kansas and Missouri are both following roughly the same order of priority. Vaccinations of health care workers are ongoing, with shots for nursing home residents expected to begin over the next week. First responders and other public health workers are also near the top of the list.
For now, the risk of line cutting is limited because vaccinations are taking place almost exclusively at hospitals. The same goes for nursing homes. Pharmacy giants CVS and Walgreens have contracts to vaccinate in nursing homes and the secure nature of most facilities makes it relatively easy to verify workers and residents.
Verification becomes more difficult after that. Once shots are available to teachers, child care workers and other essential personnel, vaccination sites will work their way through recipients from a host of professions. Some might have credentials, others not.
It’s also not clear how rigorous Kansas and Missouri will be in defining who is essential. Right now, distribution plans use vague, sweeping terms like “critical infrastructure” and “public facing workers.”
The Centers for Disease Control and Prevention, which has been making recommendations to the states, uses definitions provided by the Cybersecurity & Infrastructure Security Agency, or CISA. Its guidelines list a wide range of occupations considered essential. Among them:
- Food and agriculture workers, including farmers, meatpacking and grocery workers
- Energy workers, including those involved in producing electricity
- Transportation workers, such as truck drivers, postal carriers and bus drivers
“Officials should use their own judgment in making decisions regarding resource allocation and other public health measures,” CISA Acting Director Brandon Wales said in a Wednesday memo posted on the agency’s website.
While states aren’t required to follow the guidance, Kansas and Missouri have both said in planning documents they will follow recommendations from the CDC’s Advisory Committee on Immunization Practices. The group was scheduled to meet over the weekend to make more recommendations about who should be vaccinated next.
Dennis Kriesel, director of the Kansas Association of Local Health Departments, sits on an advisory group that’s weighing how doses should be prioritized in Kansas. State officials will ultimately decide who gets the vaccine and when.
Distribution models from John Hopkins Center for Health Security and the National Academies of Science, Engineering and Medicine are under consideration, he said.
“Most of it’s pretty similar, but those models … those plans are trying to take into account those people who actually are most likely to get the disease,” Kriesel said.
Kansas and Missouri’s distribution plans both list several teams and committees involved in shaping the states’ efforts. But few records of the groups’ deliberations are available.
The Star requested minutes and summaries of meetings held by KDHE’s COVID-19 Planning Committee and COVID-19 Vaccination Program Implementation Committee. In response, KDHE said no records existed.
“The committees have met regularly. There were no formal minutes or summaries taken as part of these meetings,” KDHE spokeswoman Kristi Zears said in an email.
The Missouri Department of Health and Senior Services hasn’t yet fulfilled a similar request.
Vaccination ‘marathon’ ahead
At some point, Kansas and Missouri will open up vaccinations to people age 65 and older as well as those with underlying health conditions, such as diabetes, cancer, obesity and heart problems. But verifying health status could prove effectively impossible.
Chad Johanning, president of the Kansas Academy of Family Physicians, said “a lot of logistical issues” exist with verifying health status, including health privacy laws. Verification efforts would fall largely on primary care physicians, Johanning predicted, “and I’m afraid this would further exacerbate our overworked primary care workforce.”
Age can be easily checked, however. And Johanning said it is usually a better predictor of death from COVID-19 than medical conditions patients might have.
“In a perfect world, there’s enough vaccines for everyone and this issue is not an issue anymore,” Johanning said in an email to The Star.
Rex Archer, Kansas City health director, told the City Council on Thursday that getting all city residents vaccinated would be a long, arduous process.
Already, health care workers in Kansas City are getting inoculated with the Pfizer-BioNTech vaccine. But even this first phase — getting the vaccine distributed to health care workers and patients in long-term care — will take until early next year.
“This is not a sprint; it’s a marathon, and there are lots of obstacles in this process,” Archer said.
Just in the past few days, Kansas and Missouri, along with other states, learned they would be receiving fewer doses next week. The episode underscores the logistical challenges ahead.
When there is enough for widespread distribution, there will be many places people can get vaccinated outside of a doctor’s office: drugstores, Walmart, some grocery stores and possibly Costco, whose CEO told CNBC that the company is planning vaccinations at it’s in-store pharmacies around early spring.
Walgreens and CVS Health have said they expect to have doses available to the general public in early spring. CVS plans to offer the vaccine at all of its 10,000 locations, with the capacity to give 20 million to 25 million shots a month, a company spokesman said.
Vaccinations will be appointment-only, with people signing up for both their first and second shots when they register on CVS.com or the company’s app.
“Hopefully that will spread out access to the vaccine since it’s going places other than just the health department,” said Tausz. “That just increases the access for everyone, not only here but across the country, if people are able to access the vaccine in more places.
“That will take some of the burden off for the public, they’ll be able to access that vaccine at various places.”
The Star’s Allison Kite contributed reporting
This story was originally published December 21, 2020 at 5:00 AM with the headline "Kansas, Missouri using ‘honor system’ to stop people from cutting in line for vaccine."
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