We should get people vaccinated against Covid-19

We should get people vaccinated against Covid-19

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The Trump administration left Joe Biden with what was, by all accounts, a shambles of a plan to actually administer vaccines to people. But the combination of time, attention, and professionalism sorted those problems out, and we are now in a situation where anyone who wants a vaccine can get one pretty easily.

Unfortunately, a decent slice of the population seems disinclined to get one.

And doubly unfortunately, the Biden administration seems to me to be taking a somewhat unfocused and scattershot approach to dealing with that reality.

The White House, I think, ought to take a gut check. Do they believe that vaccinating a huge share of Americans to obtain herd immunity and prevent future outbreaks is important? If they don’t, that’s fine. But then I think they owe it to the world to adopt a more GOP-like attitude toward the virus. We can just say, look, people who want a vaccine should take it and people who don’t can do what they want, and either way we’re opening things up. That’s not really what I think, and I don’t think it’s what Team Biden thinks either.

But if they want to get people vaccinated, it’s time for a reboot where we make sure that spurring more vaccinations is the top consideration when any agency is making decisions relevant to Covid. Everyone needs to stop, think about what they’re doing, and ask themselves “does doing it this way get more people or fewer people vaccinated?” Then they need to change what they’re doing to make sure we are getting the “more people” answer.

Increase vaccination payment rates

I got vaccinated by driving to a federally-run mass vaccination site in Baltimore, organized by FEMA and the National Guard, and hosted at the stadium where normally the Ravens play. That’s a great model for a scenario where demand for the vaccine outstrips supply, you want to centralize everything to minimize waste, and you don’t worry have to too much about inconveniencing people.

Now we’ve shifted to more of a retail paradigm where shots are available at pharmacies and other places that are convenient.

The vaccines are free to you, the patient, because they are covered by Medicare and Medicaid, and then Obamacare and the CARES Act mandate that insurers cover vaccines for free. The Centers for Medicare & Medicaid Services seem to have a fair amount of discretion over the payment rates, and set one reimbursement schedule under Trump and then a slightly higher one under Biden. Biden should go back and have them further increase the payment rates to say that administrative reimbursements need to go up to compensate for the higher cost of marketing to the more reluctant population.

Right now, there is technically nothing stopping pharmacies from trying to gouge private insurers who are simply required to pay whatever it is that a vaccination costs. But basic common sense and a desire to avoid scandal and backlash have prevented pharmacies from charging high rates. And indeed, in practice pharmacies got off to a slow start in terms of actually giving out shots. There’s probably no way for the administration to just pay people to get vaccinated.

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But if the White House, HHS, Treasury, and CMS all work together with the pharmacy chains and the insurers, they should be able to create a situation where it’s worth the pharmacy chains’ while to get people their shots. That could involve giving them cash or gift cards. It could also involve things that the federal government just isn’t going to directly do, like paying Donald Trump to do vaccine endorsement ads.

Obviously, insurance companies won’t like any of this. But legally speaking, Biden has the power to make them swallow the costs. And it’s a fight worth having — the substance of vaccination is important and nobody likes insurance companies.

Make the vaccine mandatory

There’s obviously not going to be a national rule that everyone has to get a Covid vaccine.

But the maps of states that require an MMR or DTaP vaccine for kids to go to school are really boring because all 50 states require it.

This is a state rather than a federal issue. But we now have a vaccine authorized for use in kids as young as 12, and Pfizer is talking about getting authorization for kids as young as two by September. Biden’s Education Department can encourage states to add the Covid vaccine to their requirement list, and can also just flip to straightforwardly agreeing with Republicans about school openings, emphasizing that if teachers are worried about Covid, they should get vaccinated.

Over 100 colleges are already requiring Covid vaccinations, and university administrators tend to be the kind of people who care what Democratic Party presidents say, and Biden should encourage more to do that.

Biden can also clarify that while employers need to accommodate people with bona fide religious or medical reasons to avoid vaccination, requiring vaccination as a condition of employment is allowed. My guess is most employers won’t do that, but it’s common for healthcare facilities to require staff to get flu shots, and it would be reasonable to do the same for Covid shots.

“I hate to sound like I don’t care, but I really don’t,” one union rep told The Washington Post.

Well, I care whether cops die on the job and I also care whether they spread illness among the public. The International Association of Police Chiefs says it’s legal for departments to mandate vaccination, and blue states and cities should go forward with that. If the officers that are so brain-poisoned by right-wing politics that they won’t take a vaccine choose to resign, that’s not the worst thing either.

Last but by no means least, the military requires all kinds of vaccinations but has not yet made the Covid vaccine mandatory. I think that was a damaging decision. Vaccine refusal rates in the military appear to be high, and I’m honestly not surprised. Military officers order soldiers to take vaccines all the time. And they also order soldiers to do dangerous things all the time. Given the nature of the military setting, failure to mandate the vaccine signals some kind of profound lack of confidence. And I worry it could emanate out from the service members to their friends and family on the civilian side. If we want people vaccinated, we should require vaccination where plausible.

Substance over process

Now what people say about all this is the military “can’t” mandate a vaccine that’s only available under Emergency Use Authorization from the FDA. I’ve also heard that some public colleges and universities are worried about litigation here, though others say that’s nonsense. Certainly it’s not stopping Rutgers.

Be that as it may, I am not an attorney, so don’t take legal advice from me.

To me, the key thing is that Biden needs to set a substantive goal and then bend the process to that end. If we want people to take the vaccine, then either make exceptions to the rules that require full authorization or else get the full authorization done. It’s a bit absurd that we don’t have a nominee to run the FDA while we’re in the middle of a huge global public health crisis, but this issue is frankly too big to be left up to process-focused career civil servants. I’m not a doctor or a scientist, and neither is Biden.

But at a certain point, Biden needs to decide whether he trusts the scientific and medical advice he is being given. From everything I understand, the vaccines are safe and effective and people should be encouraged to take them. Biden also appears to have been told that and believes that it is true. It’s not his job as President of the United States to make the regulatory agencies believe as if they believe themselves on this subject.

Here’s an example. Remember earlier in the article when I wrote that Obamacare and the CARES Act mandate that insurers cover vaccines for free? Well the way this works is that the Affordable Care Act required private insurance to cover the cost of everything on the CDC’s official vaccination schedule. Now, it might seem to you that given that the CDC website is full of information urging you to get a Covid vaccine, the Covid vaccines would be on that vaccination schedule. But they aren’t! Why not? Don’t ask me, ask the CDC.

The good news is that the authors of the CARES Act were aware that the American public health agencies operate according to their own mysterious purposes and just slapped a “this also applies to Covid vaccines” clause into the relevant statute. That’s political leadership.

Align guidance with goals

Here’s the CDC’s current guidance on which activities are considered safe vs unsafe:

This, to me, is not the guidance that you give people if your policy goal is to encourage vaccinations. I would say that if you’re fully vaccinated, everything is extremely safe. And if you’re partially vaccinated, you should wear a mask and try to stay home as much as possible until you’re fully vaccinated. And if you’re not vaccinated at all, you should get vaccinated.

“How risky is it to get a haircut?” was a great question for October 2020. But if you’re vaccinated, you should get a haircut. If you’re a few weeks away from full vaccination, chill out and get a haircut when you’re vaccinated. If you’re not vaccinated, go get vaccinated. If you’re impatient to get a haircut as soon as possible, go get a J&J shot.

Similarly, this incredibly strict CDC guidance for summer camps is totally misaligned with the goal of encouraging vaccination. The guidelines should be:

Everyone who is age-appropriate and medically eligible should get vaccinated. Everyone younger should be free to play maskless if they wish.

Then let’s have a fun summer, which will be safe because of all the vaccinations.

A setting where everyone over 12 has been vaccinated is extremely unlikely to have any severe Covid cases. And if there are people over 12 who haven’t been vaccinated, the solution is to get them vaccinated, not to walk on eggshells around it.

Vaccinate America’s kids

The New York Times article about likely FDA approval of vaccinating teenagers contained this nugget that I thought was revelatory:

“I do think we need to have a national and global conversation about the ethics of our vaccinating kids, who are low risk for serious complications from the virus, when there aren’t enough vaccines in the world to protect high-risk adults from dying,” said Jennifer B. Nuzzo, an epidemiologist at the Johns Hopkins Center for Health Security.

Now Joe Biden is a politician. And he’s a pretty good one. He didn’t get where he is by telling mothers to deprioritize their children’s health in order to help foreigners. That’s not going to be the policy of his administration, nor would it be the policy of any administration.

He has to be aware, though, that many well-credentialed public health experts think that’s immoral. But those experts are conversely aware, of course, that “no American teens can get vaccinated until we’ve hit every person in the developing world over 50” is not a rule that will fly in the basic American political context. The experts will look at me ranting and raving about how the only CDC guidance about summer camps should be vaccinate the older kids and the staff and they’ll say “well, it wouldn’t actually be the worst thing in the world if a lot of Republicans decided not to vaccinate their children.”

To some extent they're right — you wouldn’t want to waste shots by mandating them for middle school and high school students next fall when we could be shipping that medicine to Indonesia. The problem is then those same people are going to point to the existence of continued Covid infections and millions of unvaccinated children as the reason various mandates and warnings need to stay in place.

It’s going to take real leadership to say, no, we are not going to do that. We are taking Covid seriously and our strategy to beat it is to vaccinate, and we are going to vaccinate everyone. Give Covax all the money in the world. Global vaccination should absolutely be the Biden administration’s number two priority — but that means pursuing it primarily by trying to boost vaccine production. The number one priority has to be pulling every lever possible to vaccinate as many Americans as possible.