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Maryland Vaccination Honor System a ‘Double-Edged Sword’

Maryland relies on an “honor system” at its mass vaccination sites where those who show up for their shots without proof of eligibility or photo identification are asked to sign affidavits attesting to their credentials.

by Alex Mann, The Baltimore Sun / March 1, 2021
Cars line up at the mass vaccine site at Six Flags America amusement park in Bowie. TNS
(TNS) - People who show up to Maryland’s mass coronavirus vaccination clinics will not be turned away for lack of documentation or proof of eligibility — a possible benefit for some of the state’s most at-risk residents, but also for those exploiting the system, medical ethicists, logistics experts and lawmakers say.
 
Like other states, Maryland relies on an “honor system” at its mass vaccination sites, where those who show up for their shots without proof of eligibility or photo identification are asked to sign affidavits attesting to their credentials before getting immunized, according to Dennis R. Schrader, the state’s acting health secretary.
 
But that leaves open the possibility of scarce vaccine doses falling into the hands of the wrong people, some say.
 
“Our approach to making sure shots get into the right arms is ‘trust, but not verify,’ " state Sen. Mary Washington, a Democrat who represents Baltimore, told Schrader at a recent vaccine oversight committee hearing.
 
That can mean residents are getting shortchanged.
 
Republican state Sen. Addie Eckardt said the Walmart in Denton had been administering vaccines to people from out of state at the expense of some of her more vulnerable constituents in the Eastern Shore.
 
“We’re in the middle of a pandemic: We’re not out of a crisis,” Eckardt said in an interview. “Everyone wants to get it over with. And one of the ways to get it over with is getting vaccinated.”
 
At the same Senate meeting where lawmakers raised concerns, Schrader said the Maryland Department of Health provides little oversight of whether vaccination sites, such as pharmacies and hospitals, are following eligibility guidelines. He expressed confidence that they were, saying health officials had heard as much “anecdotally.”
 
But, he said, “we’re not going out and sending secret shoppers out to look to see if they’re doing it.”
 
Charles Gischlar, a health department spokesman, said there is no data that backs up the senator’s assertion about Walmart. He said the state agency provides specific guidance to all COVID-19 vaccinators about which priority groups are eligible.
 
“Most providers are diligent in following the state’s guidance,” Gischlar said in an email. “An affidavit is available at state-run vaccination sites for individuals who are eligible but cannot provide supporting documentation, and it has the force of law.”
 
The debate about eligibility requirements, and how rigid or loose they should be, comes amid a fierce scramble for doses among Maryland residents who qualify for COVID-19 immunization. Many people have bemoaned the process of scheduling appointments, calling it overly cumbersome and disadvantageous for people without computers or digital skills.
 
Constrained by national supply shortages and logistical hurdles, state vaccinators have administered at least 474,011 second doses as of Monday, representing a small fraction of the more than 2 million people who qualify under the current guidelines.
 
Maryland has said it receives approximately 12,000 shots a day from the federal government. At that pace, it would take about five months to vaccinate everyone eligible in the first phase. However, the state is set to receive 49,600 doses of the newly approved Johnson & Johnson vaccine this week.
 
The pressure on states and private partners to quickly administer doses has mounted as more people continue to die from COVID-19 complications and as new, potentially more contagious variants circulate in the United States and elsewhere. As of Monday, about 513,000 Americans — and nearly 7,700 Marylanders — have died due to the virus since March.
 
Some say having extensive checks in place at the mass vaccination sites, some of which are designed to accommodate thousands of appointments a day, minimizes the vaccine rollout’s efficiency.
 
“They’re setting up these large vaccination programs because they are more efficient — you can get a lot more people through them than the smaller sites, and you can maximize your resources that way,” said Diane Hoffmann, a professor of health law at the University of Maryland Carey School of Law. “There’s this trade-off in however you set up the system; the more you put on people administratively, that takes time, and is less efficient.”
 
Schrader said the goals of the vaccination campaign were to ensure efficiency and equity as well as collaborate with local health departments.
 
Critics of the rollout say those goals are often at odds with one another, especially as the county health departments see their weekly allotment numbers shrink or plateau while the state-run mass sites scale up.
 
Dr. Michelle LaRue, senior manager of health and social services at CASA, an advocacy group for Latino and immigrant people, said not having to provide documentation serves as a “double-edged sword” for those who might benefit most from that policy.
 
“It does allow for people to skirt the system,” LaRue said. “Really, those who are hardest hit should be prioritized, and we’re not seeing that in the vaccine data.”
 
More people under the age of 60 are fully vaccinated in Maryland than those older, even though the virus has killed 7.5 times more people 60 and older than those younger. This may be attributable to the state’s prioritization of health care workers and first responders in the first weeks of the vaccine rollout.
 
And white Maryland residents have received more than four times as many doses of coronavirus vaccine as Black residents, state data shows. Through Monday, about 64% of first doses where the recipient’s race was known were given to white residents, compared with about 17% for Black Marylanders. The latter group has been disproportionately hurt by the virus; 31% of Maryland’s population is Black, according to U.S. census data, but the community accounts for 33% of the state’s confirmed infections and 34% of the deaths.
 
Meanwhile, Latino residents, 11% of the population, have received 4.1% of vaccine doses, yet 19% of the infected and 9% of the victims have been part of that group.
 
LaRue said more will have to be done to ensure that the Latino and immigrant community can get vaccinated, aside from eliminating documentation requirements. Many do not have internet or transportation access, or might work front-line jobs that offer few, if any, paid days off. There also might be language barriers.
 
A shortage of clear information also may be inspiring some people to try to cut the line, said Jeffrey Kahn, director of the Johns Hopkins Berman Institute of Bioethics.
 
“When people are confused or don’t have confidence in what they’re being told, they will have more of a tendency to act in their own interests, especially if they see others doing so,” Kahn said in an email. “To me, the clear answer is messaging and clarity about the vaccine rollout and when it will be your turn, how the process will work, etc.”
 
Elected officials, lawmakers and public health experts have criticized Maryland’s rollout as overly balkanized, as it often relies on eligible individuals to preregister at multiple sites and with many providers until securing an appointment. Facebook groups dedicated to helping people find appointments have amassed tens of thousands of followers.
 
Schrader and Maryland Gov. Larry Hogan have defended the system, arguing that it offers a breadth of choices and successfully gets shots into arms, even though Maryland lags behind many other states. Up to 80% of the country will need to be inoculated to end the coronavirus pandemic, scientists and researchers say, making mass vaccination sites all the more beneficial.
 
Tinglong Dai, associate professor of operations management and business analytics at the Johns Hopkins University Carey Business School, said most states had implemented honor codes to speed up the process.
 
With demand as high as it is — and with the pressure mounting to not let a single dose of vaccine go to waste — it can be nearly impossible to enforce eligibility, Dai said. But an audit, or random checks at high-volume clinics, could keep efficiency levels high without being too disruptive, he said.
 
“Vaccine tourism is real,” Dai said about the phenomenon of people traveling in and out of their home states to find vaccination appointments. “It’s affecting accessibility for groups who are eligible.
 
“I wouldn’t verify everyone’s eligibility; I would prefer random checks, or making it simpler from the beginning.”
 
Washington, the Maryland state senator, said eligibility concerns underscore the need to make more vaccines available to people who are most at risk and might have more barriers to access than others, such as the Latino and immigrant community, people who are homeless and older adults.
 
“Because there is a limited supply, the priority list has to be adhered to with more fidelity than we would with, say, public education or health care at an emergency room,” Washington said. “If people had confidence that there was diligence, that someone at the top was making sure things were fair and equitable, they’d say, ‘I’ll wait my turn.’ "
 
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