Tracking the Vaccine Rollout: Federal and State Efforts to Achieve Speed and Equity

After a dismal federal COVID-19 pandemic response in 2020, the United States is betting it can turn the tide of hospitalizations and deaths by vaccinating more than 100 million people by the end of April 2021. But vaccinating high numbers of adults in the U.S. has never been easy. Our highly decentralized vaccination system is built on state and territorial autonomy, with further delegation to counties, clinics, and pharmacies. In the face of a scarce vaccine supply, the absence of strong federal support and coordination left states on their own to allocate vaccine to local hospitals, clinics, pharmacies, vaccination sites, and mobile units, and to acquire supplies, hire personnel, and ensure that vaccine doses are administered efficiently and equitably. And now, even as supply increases, states are confronting new and more contagious viral variants that may require booster shots.

The Biden administration has taken an active role, increasing the vaccine supply to more than 13 million doses per week, giving states advance warning about expected shipments, and helping states plan by defining priority populations. It set a goal of 100 million additional doses administered by the end of April. This target may be exceeded.

Vaccination Is Progressing and Accelerating

The first dose of COVID-19 vaccine in the U.S. was administered on December 14, 2020. By January 20, 2021, when the goal of 100 million doses was set, an estimated 35 million vaccines had been distributed to states and 16 million doses had been administered, mostly to frontline heath care workers and select groups of high-risk Americans.

Progress has accelerated. An additional 45.8 million vaccine doses have been administered as of February 20, a pace that exceeds what is needed to reach 100 million additional doses by the end of April (i.e., the orange target line in the exhibit). Delivered doses are increasing. With luck, the gap between doses delivered to the states and administered to people will narrow as states get better at administering their supply quickly while keeping a cushion for unexpected supply disruptions like weather.

Comparing State Progress Toward the Goal

Each state contributes to the national goal by administering the vaccine doses it receives from the federal government. For expediency, vaccine doses were initially allocated proportional to the size of each state’s adult population, regardless of differences in COVID-19 risk factors or burden. The number of doses supplied to states differs based on population size, but the number of vaccine doses distributed per capita should be similar for every state. So far, that mostly appears to be the case.

However, the pace of vaccination has varied substantially among states for several reasons. One may be the choices states have made to either reserve vaccine doses to deliver second shots or to rely on future supply for second doses. Focusing on the number of shots administered (rather than the number of people who received two shots to complete a vaccination), Alaska, West Virginia, New Mexico, and North Dakota have the highest per capita vaccine administration rates, as of February 20. Despite state differences in vaccine administration rates, all states have seen the pace pick up in the past four weeks.

Some states have administered larger portions of their distributed doses than others. West Virginia, New Mexico, and North Dakota have each administered around 90 percent or more of their allocated doses, compared to a lower portion in other states. States with lower percentages of administered doses may be reserving vaccine to ensure that second doses are available within the three-to-four-week timeframe.

Early Data Show Emerging Racial and Ethnic Vaccination Inequities

The virus has caused disproportionate death and suffering among people of color, making an attention to equity imperative. But recently released federal reports show large disparities in vaccination rates for Black and Latino populations even though collection of race and ethnicity data is incomplete. In the states that collect and report data on race and ethnicity, there are emerging inequities. As illustrated in the exhibit, Black and Latino adults in many states are much less likely to have received the vaccine compared to their share of the state’s adult population. White adults are more likely to have received the vaccine.

These inequities may be a result of which health care facilities have received vaccine supply, structural barriers including differential access to providers and scheduling appointments, and concerns about vaccine safety.

So far, many states appear to have erred on the side of speed over equity; some localities have run into obstacles trying to target hard-hit communities. Disparities could grow as states prioritize adults age 65 and older — baby boomers are a large group and less racially diverse than the overall U.S. population.

Looking Forward

With a coordinated federal strategy and average daily doses nearing 2 million, there is reason for optimism. FDA authorization of a third vaccine for emergency use also could produce a welcome supply boost this spring, and the U.S. may be poised to reach a more ambitious goal of 150 million doses by the end of April. But still, states have significant and variable challenges as they scale efforts, and early inequities demand immediate attention from state and federal agencies, including improved data on the race and ethnicity of those receiving vaccine.