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March 15, 2021

Are you eligible for a Covid-19 vaccine? Here's how states are deciding.

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Many states across the country allow people with certain medical conditions to get the Covid-19 vaccine, according to a New York Times survey—but the qualifying conditions vary widely from state to state, spurring a "free-for-all" among people trying to convince health and state officials to add various conditions to the eligibility list. 

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According to the Times, states during the initial months of the vaccine rollout aimed to allocate doses to older individuals, who generally are most likely to die from the virus, and people in professions that increase their risk of exposure to Covid-19. CDC in its guidance recommended that, after vaccinating those populations, states next prioritize vaccines for people with medical conditions linked to an increased risk of severe Covid-19.

Currently, a total of 37 states and Washington, D.C., permit some residents with certain health conditions to get the vaccine—but eligible health conditions vary widely from state to state, and even from county to county, the Times reports.

For instance, at least 35 states permit people with Down syndrome to get vaccinated, but some of those states don't offer the same eligibility to people with other types of development disorders. Similarly, at least 30 states permit certain people with Type 2 diabetes to get vaccinated, but just 23 states allow people with Type 1 diabetes to do so. Meanwhile, at least 19 states are expanding vaccine eligibility to certain people with cystic fibrosis, at least 15 are expanding eligibility for people who smoke, and at least 14 are expanding eligibility for people with liver disease, according to the Times.

In addition, 30 states let people who are overweight or obese get the vaccine. But that eligibility varies substantially, the Times reports, with some states requiring a body mass index (BMI) of 25 to be considered eligible and other states mandating a BMI of 30 or 40.

Further complicating the matter, while most states are requiring people to provide proof of their qualifying medical condition, at least 16 states and Washington, D.C., do not. And at least 12 states allow individuals who have received a note from a health care provider recommending them for the vaccine to be inoculated, even if their medical condition is not officially prioritized by the state.

A murky ethical situation

According to the Times, states in their efforts are largely following guidance from CDC, which itself has identified 12 conditions linked to a higher risk of severe Covid-19, including obesity, smoking, Type 2 diabetes, and Down syndrome. But medical ethicists have pointed out that in absence of large, rigorous studies on how the novel coronavirus affects people with other medical conditions, "there are few clear principles" to determine the appropriate order of priority access.

Further, some medical ethicists argue that CDC's list itself is potentially misleading, as it may imply that of the potential medical risks that a person might face have been assessed and compared. But as they point out, it's nearly impossible to compare the risks of Covid-19 between, for instance, a 50-year-old who has Type 1 diabetes, a 25-year-old who has sickle cell disease, and a 35-year-old who has an intellectual disability.

And while some studies have in fact been conducted to assess the relative risks of severe Covid-19 with certain health conditions and factors such as age, researchers just haven't had enough time to discover exactly how the disease interacts with other medical issues, the Times reports.

"We have a long history of doing risk-based recommendations based on lots of data," said Grace Lee, a member of CDC's vaccine advisory committee and a pediatrician at Stanford University. "The problem with Covid is, the information is coming in now, and it's different than it was even two months ago when we were deliberating about vaccine allocations."

A 'free-for-all'

These varying state guidelines—which themselves change from week to week—have created a "flurry of jockeying by advocacy groups" to convince health and government leaders to prioritize certain medical conditions, the Times reports.

For instance, in New York, about 36 health advocacy groups together sent a letter in January to Gov. Andrew Cuomo (D), urging him to make explicit that the state would prioritize people with HIV for the vaccine. Ultimately, New York became one of 14 states, as well as Washington, D.C., to officially add HIV to the list of eligible medical conditions, although a state spokesperson said this week that the state had always planned to include HIV patients on the list.

And in Ohio, Hanna Detwiler, a bone marrow transplant patient, tweeted to Gov. Mike DeWine (R) directly about her inability to access the vaccine last month, even though patients who had received a solid organ transplant were eligible. Last week, the state added her condition to its prioritization list.

But many patient advocates, even in areas where they've seen success for their initiatives, say the system is insufficient if only the loudest voices are heard. "That is not how our public policies should be decided, on who is better at advocating," Kara Ayers, director of the Center for Dignity in Healthcare for People With Disabilities, said.

For their part, state officials have said they are basing their decisions on a combination of research, logistics, and "political reality," the Times reports. For instance, Maryland currently permits vaccines for people with medical conditions only if they are currently in out- or inpatient treatment, Jinlene Chan, the state's acting deputy secretary for public health, said, because "right now we can only offer vaccines to a subset of our highest-risk individuals."

And even though vaccine supply should eventually catch up with the demand, bioethicists have pointed out that these vaccination priority lists can feel like an individual's social worth is being measured—a particularly difficult experience for many people who may already feel socially stigmatized by their underlying health conditions. "It feels like many of the prejudices I've fought my whole life I'm fighting all in one bucket to get access to this vaccine," Jessica von Goeler, a Type 1 diabetes patient fighting to get her state of Massachusetts to add her condition to its eligibility list, said (Harmon/Ivory, New York Times, 3/10).

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