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The Intergovernmental Effort We Need to Vaccinate America

Supply isn't the only issue. Big logistical problems require federal leadership. How quickly can the Biden administration execute a 180-degree turnaround?

Health workers give vaccine shots to people sitting in cars.
Staff and volunteers distribute the COVID-19 vaccine to people as they remain in their vehicles at one of five mass-vaccination sites that opened Tuesday, Jan. 19, 2021, in L.A. County. (Al Seib/Los Angeles Times/TNS)
Make no mistake about it: President Joe Biden's success depends fundamentally on cracking the problem of vaccinating most of the nation's population against COVID-19. And make no mistake about that problem: We have a real mess on our hands. Dealing with that mess, and doing it fast, is going to require a level of intergovernmental cooperation and coordination, led by the federal government, that is unprecedented in recent times.

Two days after Biden's inauguration, Dr. Anthony Fauci bluntly told reporters that the Trump administration's lack of candor in the last year "very likely" cost lives. Now, Biden says, "it's going to take months to turn things around," with the death toll sure to rise in the meantime.

Biden's steps so far are encouraging: The new administration has rolled out a 198-page response plan, and work is underway to speedily ramp up the production of existing vaccines and approve new ones. But our problems are far bigger, because the system simply isn't equipped now to get a lot more vaccines into the arms of people eager to roll up their sleeves. So far, there's been a heavy bet on the states to take the lead, and for the most part that bet hasn't paid off.

To be sure, there's a huge supply problem, with the number of available vaccines falling far behind the demand. It will take months, and the quick production of new vaccines-in-waiting, to begin to catch up. That, in turn, requires cracking four big logistical problems.

First, there has been a massive muddle about who is first in line, with guidelines varying from state to state and changing along the way. There are 53 million Americans over the age of 65 and another 110 million younger Americans who have high-risk medical conditions, according to the Centers for Disease Control. That's half of the population, anxiously waiting in line for the 12-18 million doses of the Pfizer and Moderna vaccines being produced each week, with the plants running at full speed. The situation will begin to improve as new vaccines are approved in the coming months, but we need to set up a queue that everyone understands — and that doesn't vary wildly depending on where people live.

Second, we have to do a far better job of getting the vaccine from the airport into arms. Barely half of all the doses distributed to the states as of Jan. 24 had been administered, as the CDC's dashboard shows. To make things worse, the numbers have varied enormously across the country. On a per-capita basis, West Virginia and the Dakotas have gotten twice as many shots into the arms of citizens compared with Alabama, California, Georgia and Virginia.

Biden is considering opening up a hundred mass vaccination sites, managed by FEMA, to get vaccinations moving more smoothly. There's even discussion about having the federal government "develop, equip, provide information management, and staff and operate" the sites. A "FEMA Unleashed" strategy would be an enormous departure from the previous months, when the federal effort dumped the vaccines and the decisions about them onto state and local governments, whose public health offices had been rocked by political pressure, the challenges of managing the virus, and long-time underinvestment in their work.

FEMA, however, doesn't have an army of doctors and nurses to throw into the breach. Neither does any other part of the federal government, at least in the scale we'll need. Putting FEMA's considerable logistical skills to work, however, could make a huge difference in marshalling mega-centers to vaccinate thousands of people a day.

The third big logistical challenge is information and technology management. Local officials are complaining that they just don't know what the federal government is doing and what's expected of them. Local vaccination sites have been created only to be shut down because vaccines have run out. Citizens have clogged hotlines, and local websites have crashed. Florida resorted to Eventbrite to allow people to sign up for vaccinations, but long lines have frustrated citizens in many towns.

Most local governments simply don't have a good way of sorting citizens by their vaccine priority and connecting them to places where they can get their shots. Especially for seniors who sometimes have waited overnight in the cold, this is an urgent problem beyond the capacity of most local governments to solve.

And then there's the challenge of coordinating the efforts of the private sector. In North Carolina, Honeywell International combined its logistics technology with the health experts of Atrium Health and a sports management firm to bump up the state's capacity to administer doses. Starbucks and Amazon have stepped forward to offer IT help, and CVS and Walgreens have already been working the front lines of immunizing workers and residents in nursing homes. It will take the feds to pull together the expertise of private partners to solve the state and local challenges.

Fourth is the quiet crisis of the virus: It has disproportionately affected people of color. Blacks and Hispanics are much more suspicious of the vaccine, much less likely to know where they will be able to get vaccinated, and far less confident that they'll get the vaccine soon. The country will begin to crawl out of the COVID crisis soon, but without good data about how the disease affects different groups in society and how well the vaccine reaches them, some groups could be left far behind. We can't solve what we don't know, and we can't know what we're not measuring. Help, on both the information and policy side, is going to need a strong federal role.

The central strategic decision of the Biden administration has been to make a 180-degree change in course and put the federal government at the center of the vaccination effort. Its critical challenge is how fast it can turn the ship around. The looming question is what other major shifts in intergovernmental power will come in its wake, once the federal government asserts primacy in the federal system.

Governing's opinion columns reflect the views of their authors and not necessarily those of Governing's editors or management.


A professor emeritus and the former dean of the School of Public Policy at the University of Maryland, College Park.
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