In summary

Pressure has been building for California to vaccinate people faster, especially those most vulnerable to severe COVID-19. Yet ongoing vaccine scarcities are forcing officials to make trade-offs and tough calls.

Melinda McKee is anxious to get her COVID-19 vaccine. The medication she takes for a rare form of arthritis makes her immunocompromised and at high risk of falling severely ill from infections. But she’s only 33, and at the current vaccination rate, it may be months before she can get her shots. 

After filling out a questionnaire from her provider, McKee learned she likely would fall in Phase 1C of the state’s vaccination plan, alongside millions of other Californians with underlying medical conditions. It’s not certain, though, because the state has yet to define  which conditions would be included in this phase. It would put her ahead of the healthy general population, but behind seniors, millions of essential workers, the homeless, and incarcerated people.

“It’s unfortunate that immunocompromised people have to wait this long. I think we’re just as vulnerable, if not more, than a healthy 65-year-old,” McKee, of Los Angeles, said. 

With more than 37,000 deaths from COVID-19, pressure has been building for the state to vaccinate people more quickly, especially those most vulnerable to a severe form of the disease. But ongoing limits on the supply of doses are instead forcing the state’s top public health officials to make tradeoffs and tough calls. They say the overarching question behind their decisions is this: How can they save the most lives? 

As the virus evolves and vaccine supply fluctuates, the only thing for certain is that their plans have to be flexible. That proved true today with an announcement from Gov. Gavin Newsom that the state will change its vaccine eligibility to an age-based system after it completes its current phase. More details will be released on Tuesday.

“It’s heartbreaking for all of us every day. And the challenge we have is that we don’t have enough vaccines.”

Dr. Nadine Burke Harris, state surgeon general

“We’re between a rock and a hard place,” Dr. Nadine Burke Harris, the state’s surgeon general, said during last week’s vaccine advisory committee meeting, where health, senior, and disability advocates, union representatives, and community groups had sometimes heated and impassioned discussions about the state’s proposals and slow progress. 

“It’s heartbreaking for all of us every day. And the challenge we have is that we don’t have enough vaccines,” Burke Harris said. 

About 12 million people are eligible for a vaccine now, under the state’s current guidelines. The state has received nearly 5 million doses and administered about 45% of them as of today. Each person requires two doses. There are close to 30 million adults in the state, and some experts have estimated at least 70% of the population needs to be immunized for widespread protection.  

The vaccine advisory committee doesn’t make the call about who goes next but members are able to advocate for their own constituencies. Some want to keep it simple and distribute vaccines by age. Others argue that wouldn’t be fair for farmworkers and grocery store employees, essential workers who generally are younger but highly exposed. Some members said last week they were concerned about fast vaccine availability in zip codes that are virus hot spots. Others asked about people under age 65 with disabilities and preexisting conditions. 

Earlier this month, following federal guidance, the state announced people aged 65 and over would be eligible to receive a vaccine — although how soon seniors could actually make an appointment varies by county. California’s public health officials said vaccinating that age group will help reduce deaths and take the pressure off strained hospitals. Those seniors make up about 11% of cases, but almost three quarters of deaths in the state. 

While the federal guidance also encouraged states to start vaccinating people under age 65 with certain documented medical conditions, California’s public health officials decided supply was too limited to include them. It would take potentially tens of millions of additional doses to vaccinate that group.

For example, expanding eligibility to people with diabetes would add millions to California’s immediate rollout; about 3 million adults are diabetic in California, including those over age 65. Diabetics have a higher risk of becoming severely ill from COVID-19, according to the U.S. Centers for Disease Control and Prevention. Other conditions that make people high risk include cancers, heart conditions, chronic obstructive pulmonary disease, obesity, and sickle cell disease.

Yet decisions on eligibility could be modified at any time, depending on the state’s supply of the vaccine. Public health officials heed advice about the phased rollout from a panel of medical experts that includes Dr. Mike Witte, chief medical officer of the California Primary Care Association. “Epidemiologists know how many people are in each of those tiers… so they can cross that with how many vaccines are being allocated,” Witte said. 

The state is receiving anywhere between 300,000 to 500,000 vaccine doses a week. To date, it is unclear whether President Joe Biden’s goal to vaccinate 100 million people in 100 days would boost California’s supply. But at its current rate, the state wouldn’t finish immunizing those aged 65 and over until June, Dr. Erica Pan, the state’s top epidemiologist, said during last week’s vaccine advisory meeting

In addition to supply issues, some experts have also blamed California’s inefficient system, in which rules vary by county and health system, for the slow vaccination rollout. With it comes confusion about who is eligible to be vaccinated, and when. 

About 12 million people are eligible for a vaccine now, under the state’s current guidelines. The state has received nearly 5 million doses and administered about 45% of them as of today.

Anthony Wright, director of Health Access and a member of the vaccine advisory committee, said an effective vaccine plan needs to be easy to understand. “I find age compelling because of the simplicity and clarity in being able to communicate that to the public; it’s very simple to know when you’re eligible based on your age,” he said. 

While it’s worth considering faster immunizations for people with certain medical conditions, Wright said that would require the state to define the comorbidities and be able to verify them. If California took that route, it likely would need to create more subsections in its vaccine tiers, further complicating an already complex system, he said.

“You could imagine a formula that took health conditions, age, your work, your level of exposure, and other factors as well, in creating some sort of score,” Wright said, explaining the difficulty. “We’re hoping this moment of scarcity won’t be for very long.”

State health officials hope other manufacturers will soon hop in line and increase supply — especially with potential vaccines that only require one dose like the Johnson & Johnson vaccine that is nearing the end of its trial.  

In the meantime, counties fear running out of doses, noting they have no choice but to take it week by week, making planning extremely difficult. 

“We were honestly afraid we were going to run out this week, and then the state came through with an extra 5,100 doses… which we think will allow us to continue until our next allocation next week,” Dr. Rais Vohra, Fresno County’s health officer said last week. The county has built a system to vaccinate many more people if only the doses were available, he said.  

Amid the slow rollout, Dr. Otto Yang, an infectious disease expert at UCLA Medical Center, said he is concerned many high-risk individuals might have to wait several more months to be vaccinated because they don’t meet a certain age requirement. 

“A healthy 65-year-old and 60-year-old with a list of comorbidities are not the same in terms of risk,” Yang said. “It seems a little arbitrary, but I understand you need a cutoff.” 

CalMatters COVID-19 coverage, translation and distribution is supported by generous grants from the Penner Family Foundation, Blue Shield of California Foundation, the California Wellness Foundation and the California Health Care Foundation.

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Ana covers health policy and the COVID-19 pandemic. She joined CalMatters in 2020 after four years at Kaiser Health News. She started her reporting career at McClatchy’s Merced Sun-Star. Her work has...