The priority order for scarce Covid-19 vaccines has received considerable debate. Should the elderly be ahead of essential workers? Where do teachers stand in line? What doesn’t seem to receive much attention is the basic model for a priority system. The assumption is that there will be a line. First will be the group with the highest-priority characteristic, then those with the next-highest priority characteristic, and so on.
An oddity of this approach is that a member of two high-priority groups receives the vaccine no earlier than a member of the higher priority of these groups. The current priority list has health care workers at the front, then nursing homes, then first responders, then those with health risks, then elderly, then essential workers, then teachers, and so on. But what about a teacher who is elderly and faces serious health risks? There might be an argument that this person should be ahead of first responders—or at the very least, at the front of the line among the many who have health risks. But the proposed system treats each person based on the single characteristic that moves the person as close to the front of the line as possible.
It is a univariate system for a multivariate world. Forget about interaction effects. But couldn’t we even consider a points system?
Each characteristic in such a system would correspond to some specified number of points, and the points would then be summed to produce a total score, which in turn would determine someone’s place in line. Our elderly teacher with health risks would be closer to the front of the line than someone with just one or two of these three characteristics. A points system also could allow for more distinctions within each category. Instead of treating all elderly as an undifferentiated group, the system could assign different points values for different ages. A 64-year-old would not be treated exactly the same as a 30-year-old, and a person who is extremely obese might be treated differently from one who is just marginally obese. People with some health conditions are more vulnerable than others, and that should be reflected in their place in line.
A point system would yield a more granular ranking. A priority system that may place many millions of people at the same point in line leaves unanswered the question of how health care providers should prioritize within each group. Telling ten million people who want the vaccine that it’s their turn when there is only enough vaccine for half of them will predictably result in an avalanche of phone calls, attempts at influence, and anger. There will inevitably be some uncertainty about just when it’s anyone’s turn, given the lack of clarity about how many people exist in each category and how many will want to be vaccinated, but a points system would at least give local vaccine providers a metric that orders patients.
So far as I have found, no one has recommended a points system. Why?
Twenty-dollar bill. Maybe this is the proverbial $20 bill on the sidewalk, and I am the first to invent the idea of a points system for vaccine priority. Much as I would like to pat myself on the back, I don’t think so. There are many rankings that do rely on points systems of one kind or another. (Consider, for example, U.S. News and World Report rankings.) The officials creating the priority system might not have discussed a points system, maybe even didn’t consciously think about it, but that just invites the next question of why they implicitly rejected it.
Complexity for patients. The most obvious answer is that a points system would be too complex for people. But it’s not hard to add up a few numbers. Online calculators could make this easy, and health-care providers could tell people without online access their scores. This isn’t nearly as complicated as filing taxes.
Complexity for committees. The priority list is the result of a complex negotiation involving the CDC, the Advisory Committee on Immunization Practices, and the Administration, and no doubt others. It may be easier to develop a simple framework than a more complex one. The last thing we’d want is for the vaccine to be delayed because we can’t agree on how to allocate points. And so the decision-makers assign themselves a simpler task. This seems more plausible, but it’s not entirely satisfying. Legislative bodies, after all, often produce rules far more complex than a simple points system. Moreover, a points system creates the possibility of compromise. One reason that juries hang on a criminal sentence or damages much less often than on guilt or liability is that compromises are easier.
Complexity for vaccine providers. Vaccine providers may need to perform at least some minimal verification of patients’ entitlement to receive a vaccine at a particular time. For example, they might ask for a paystub to prove that a patient is an essential worker. With just one group at a time, there is only one piece of information that they will need to verify. With a multivariate points system, they may need to verify a patient’s ranking in each category. But this is not an elaborate system of adjudication. Much of the verification is likely to be cursory anyway, and some variables (weight and age) are easily (if occasionally imperfectly) verified.
Legitimacy. A points system cries out for some underlying methodology. That requires a theory of the relative importance of different goals, such as vaccinating those who have the greatest risk of dying if they contract Covid, vaccinating those who are most likely to spread Covid, encouraging economic activity, and compensating for social disparities. Any priority system reflects some weighting of these goals, but less transparently. It’s easier to say “we’re letting the elderly go ahead of essential workers” than to say that someone’s status as elderly counts 1.3 times as much as someone’s status as essential. Why that number? But pseudoscientific precision might lend more apparent legitimacy to the project rather than less. Moreover, a simple line is also arbitrary. It may not feature arbitrary numbers, but it will include somewhat arbitrary decisions about which group is first.
Irrelevance. It’s not just that we don’t have a good political methodology for weighting different goals. We have no shared comprehensive economic or moral theory that even in principle would allow us to make the relevant trade-offs. The moral dilemmas are legion. Is an elderly life worth less than a younger life, either because the elderly have fewer years remaining or because they are less likely to be working? Should groups that have acted relatively irresponsibly (say, young adults) receive the benefit of the vaccine early to protect others? What is the appropriate trade-off between economic activity and life? Add to these a myriad of scientific and economic questions, and serious doubts about our ability to get the priorities right arise. That doesn’t mean we should give up altogether, the theory goes, but there’s no point in worrying about second-order issues when we are probably wrong on some of the biggest questions. But here the second-order issues are easier than the first-order issues. We are pretty sure that age is relevant and so is being an essential worker. Given these very mild assumptions, shouldn’t an elderly essential worker be ahead of someone in just one of those two categories? Surely, that will produce at least some benefit in health or wealth.
Federalism. The federal priority list is just a recommendation to state officials. Presumably, state officials may change priorities or develop subpriorities, and these will be akin to a points system. But if so, the recommendations really ought to be at a higher level of generality, indicating the characteristics that should generally move people up in line and perhaps their relative importance. A points system is not an elaboration of but a change from the recommendations being developed. If the ultimate goal is for the states to create or consider points systems, the recommendations should say so. Many states are likely to follow the federal guidance because it allows them to avoid making hard choices that are sure to anger some constituents. Thus, the federal guidance either should make clear that states have more decisions should make or should provide good default rules.
Most people, I suspect, will prefer the existing approach to a points system. They value simplicity and fear technocracy. In my judgment, if the government is going to make value choices, it ought not make them crudely. 64-year-olds and 30-year-olds should not be at the same place in line. One might reasonably question whether the government should be setting priorities at all, and perhaps the crudeness of the government’s approach is all the more support for private ordering. But vaccines have positive externalities, so there is a case for at least some government involvement. And if the government is going to set priorities, it ought to do it right.
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