This pandemic caught us unprepared and is exposing a lot of the vulnerabilities in America’s uniquely fragmented and abnormally expensive healthcare system – but it also shines light on some real new strengths that have been developing in our system over the past 20 years or so.
I’m talking about the relatively new advocacy organization and healthcare policy-oriented thought leadership, research and statistical capabilities in Connecticut and around the nation that in just weeks have been able to lay bare the racial, ethnic, and income-related inequities inherent in the COVID vaccine rollout’s largely age-based early prioritization categories.
Sure, Connecticut’s policy of prioritizing seniors 75 years and older for first vaccinations after healthcare workers seems a no-brainer, because after all, this disease eats our most experienced residents for lunch – until we remember that folks raised in inner-city Hartford live more than 15 years less than their neighbors four miles away in prosperous West Hartford Center.
So in a very real sense, it is both tragic but profoundly fair to say that 60 years old in Northeast Hartford equals 75 years old in West Hartford Center.
Gov. Ned Lamont and his team, along with healthcare executives, front-line staff, and other public and private leaders all over the state, have delivered a particularly high-performing vaccine rollout to the people of Connecticut. The proof is in the pudding: on a percentage basis, only four states have gotten more first doses into more arms than Connecticut – and all of those states have populations significantly smaller than ours. We need to keep that up: Connecticut crushes COVID.
Gov. Lamont is 100 percent correct that the mortality evidence shows that seniors need to be immunized first, and the CDC-recommended 75-year cut-off is as good as any. But at the same time – 60 in Hartford equals 75 in West Hartford.
Is there a way to keep our vaccination cadence just as high and aggressive as vaccine supply allows, while also coming to grips with the harsh reality that a seemingly fair, even-handed uniform state-wide age limit in fact is perpetuating deep systemic inequities, and in particular is disproportionately disadvantaging Black, Latinx, and other treasured communities in our state?
I think so, at least in a rough-and-ready way. Now, there is no fair way – and probably no either legally or clinically defensible way – to give vaccine priority to members of certain minority or ethnic groups because of their race. And, also, that would be foolish. The CDC, Gov. Lamont, and public health experts are absolutely right that age can and should be the single most important determinant of who gets vaccinated first.
We just need to remember that in terms of life expectancy and health outcomes, 75 does not equal 75 across the state. And of course, there are disparities and pockets of high and low health and opportunity within individual towns, so prioritizing whole towns over others doesn’t feel right. Family income is closely correlated with life expectancy, which itself is a rough proxy for healthcare access and health equity. Family income statistics are readily available not just at the town level, but also at the zip code level. (Remember what I said about our new strength in research and data availability?)
We should keep 75 years as the statewide default cut-off for vaccination in the current first wave of post-healthcare worker vaccinations. But while we hold the default statewide age steady, we should also lower the cut-off age for folks from lower-income zip codes, because 60 in Hartford can and does equal 75 in West Hartford.
This is the middle of a pandemic, and we need to keep the pressure up and vaccinate fast, so we can’t spend a lot of time debating the exact formula for how low the zip code family income cut-off should be, or exactly how much to reduce the cut-off age for those zip codes. And, we can’t add a lot of nuance or complexity to the vaccine eligibility process – the vaccination program is already an administrative challenge and we shouldn’t burden those who run the system with any more categories than needed.
For instance, income statistics are available down to the census tract level, but people signing up for a vaccine know their zip code, not their census tract; so because it’s an emergency and we need to keep the solution simple, let’s use residence zip code income here. For what it’s worth, in terms of keeping it simple but delivering some semblance of equity here, my thought would be to clip 10 years off the 75-year limit for all residents of zip codes in the lower one-third of family income.
We need to act fast here, join hands, and jump together, as a community, accepting that whatever solution we come up with won’t be perfect, and certainly won’t be perfectly fair – but will be a good bit better than where we are now.
Let’s fix this, maybe roughly for now, but quickly and decisively. And, without falling prey to the typical American public policy pearl-clutching pastime of minutely weighing the moral virtue and deservingness of exactly who might benefit from changes to the status quo. First, this is a pandemic, and second, healthcare is a human right, and we all deserve to be vaccinated, in full and as soon as possible, from the wealthiest 75-year old Gold Coaster who is quite reasonably planning twenty more years of retirement, to the hardest case 65-year old living on a grate who equally reasonably knows quite well there’s not so many winters left.
Ted Doolittle is the Connecticut Healthcare Advocate.