If Your State is Struggling With the Vaccine Rollout, This Is Probably Why

Anyone following the rollout of coronavirus vaccines around the country is thoroughly familiar with the relentless drumbeat of depressing news reports about confusion and frustration in securing appointments, insufficient supplies and equity issues. 

In multiple conversations we’ve had with state and local officials over the last several weeks, a common theme has emerged: The federal government planned the rollout with states, leaving it up to state leaders to make decisions about how to involve lower levels of government. In an alarming number of instances, they didn’t do a very good job at closing this life-saving loop. Though greater supplies and management improvements may ease the path going forward, there are ample lessons to be learned from the mistakes already made.

Many of the intergovernmental issues that are cropping up now are invisible to the general public, but searingly familiar to us after 30 years of observing government. During normal operations, the relationship between governments adds or subtracts from the ability to deliver services efficiently, effectively and equitably. Misunderstandings and communication breakdowns multiply during a crisis.

Historically, counties have had a central role in the administration of public health. “We’ve been doing immunization in our communities for years,” said Blaire Bryant, associate legislative director for health at the National Association of Counties. But when the Centers for Disease Control and Prevention issued its playbook to guide vaccination distribution in October, she said, counties were barely mentioned.

Ultimately, this left many counties playing catch-up through the early months of the rollout. Without sufficient communications among all levels of government, planning efforts were delayed. “In a perfect world, we would have started working on this last summer,” said Rita Reynolds, chief information officer at NACo.

“There’s a lot to learn about intergovernmental relations through a pandemic,” said Graham Knaus, executive director of the California State Association of Counties. “It tests all our systems and one of the takeaways is about the importance of clear roles for different levels of government and the importance of transparent and collaborative decision-making.”

The logistics would have been difficult in the best of worlds. In addition to scheduling first and second vaccinations, counties and providers must track the number of vaccinations being given out, who is getting them and when, and demographic details to ensure equitable distribution. Local systems then must interface successfully with those of the state and federal governments. In reality, “there are multiple computer systems involved and they don’t talk to each other,” said Knaus.

Another frustration, he said, is the difficulty counties have getting full data back from states and the federal government after it has been collected. This is an important concern given counties’ traditional role in public health.

New York was among the states that aggressively took control over who could provide the vaccine and to whom it could be given. At the earliest stages of the state’s rollout, counties were directed to focus on inoculating public sector employers such as police officers and teachers. Other groups that were eligible to receive the vaccine—including people over 65 and health care workers—were directed to state sites, pharmacies, hospitals and health care centers. Up until the first week of March 2021, counties still were not allowed to vaccinate people 65 and older, except for individuals with co-morbidities.

Centralization of vaccine administration has many advantages during an emergency, but the restrictions on what counties could do and the potential penalties for overstepping those bounds added to resident and provider confusion.

Many county officials also believe their greater involvement would have improved outreach to communities of color and to rural areas where access to mass vaccination sites is limited. “How to make the vaccine accessible to people is a big issue and you can’t do that from a higher level of government. You can only do that from governments that are closest to the people,” said Stephen Acquario, executive director of the New York State Association of Counties. “If we had been involved earlier and given more local discretion, we could have helped in reaching communities of need.” 

Ed Day, county executive in Rockland County, which is just adjacent to New York City, bridles at the lack of notice the county has received when the state has changed vaccination practices. He said too many times he has learned about changes in the state’s vaccination approach from television appearances by the governor, without previous discussions about what was coming. “The governor goes on TV, announces what he’s going to do, and then we get a call,” he said. “This is not the way to do things. We can take direction and respect that, but to not let us know or prepare—that makes no sense.”

Many counties around the country are also concerned at the lack of information on what they are expected to do. “I’m not sure that it was ever clearly delineated what our role would be,” said Lisa Schaefer, executive director of the County Commissioners Association of Pennsylvania.  In multiple leadership meetings with its members, the association has witnessed how frustrating it is for counties that have previously been involved in emergency health care response to not fully know the details of the state’s plan.  “We hear about decisions when they’ve happened. If we could be at the table, we could help build solutions—especially since we have experience on the planning and response level."

Michelle Sager, director of strategic issues at the Government Accountability Office, cites several pain points that typically hamper intergovernmental relations. They’re all loosely tied to the knotty question of communication: who transmits information to whom, how clear the information is and whether it is interpreted as a requirement or as guidance. One common problem for local and state governments is simply knowing who to talk to for authoritative information. “Ideally, strong relationships are built before a crisis,” said Sager.

GAO has analyzed lessons learned from previous epidemics that could help address today’s challenges. These include the importance of clarity in the roles of different levels of government, the need to align available supplies with leadership promises and resident expectations, the complexity of data collection, the importance of selecting priority groups, the need for an equity focus and of “effective coordination and communication among commercial partners, jurisdictions, providers and the public.”

Success can only come with a “whole of government approach from the very smallest county to the federal government,” said Alyssa Hundrup, acting director for health care, public health and private markets at GAO. “If we’re trying to vaccinate the whole country, all of the agencies need to be working together. You can’t execute unless you have coordination at every level, and to have that coordination you need consistent communication.”