vaccine
Vaccine Watch

With California’s huge COVID-19 vaccine expansion relying on trust, will people do the right thing?

California on Monday began a new phase of its COVID-19 vaccine rollout, making nearly half of all residents eligible for a shot — and relying more than ever on public trust and honesty to make sure the doses get to those who need them most.

The changes add to the eligibility list more than 4 million people, most notably those 16 and older who have disabilities and underlying health conditions.

Previous eligibility tiers focused on certain jobs and age groups — factors that are easily verifiable to determine whether those seeking the vaccine are entitled to it under state guidelines.

But there will be a much looser verification system for this new group due to issues of privacy and access. And despite eligibility lists provided by the state, there is still confusion about which health conditions are covered, so the true size of the new group is unclear.

The ambiguities raise new ethical and logistical challenges.

“I think we’ve seen throughout the rollout that there is a big hunger to get people vaccinated,” said Dr. Kirsten Bibbins-Domingo, chair of the epidemiology and biostatistics department at the UC San Francisco School of Medicine. “What I hope is that we trust our fellow Californians to basically rely on the honor system.”

There is certainly potential for fraud, as people are being asked to self-attest as to their eligibility. Line-cutting has already been a major issue in California, particularly in cases in which access codes meant for members of underrepresented communities have gotten into the hands of more affluent residents.

But advocates, health experts and public health officials are optimistic that most residents won’t take advantage of a system that relies on trust, though they admit that it would not be hard to do so.

A more immediate concern is that vaccine supply is still limited. That puts this new group in direct competition for appointments with previously eligible groups, including residents 65 and older, healthcare workers and a variety of essential workers.

As more people vie for the vaccine, advocates have championed a system that would not create unnecessary barriers to obtaining shots, following situations in which people have forged documents and abused the access codes intended for high-risk communities. Public health officials have implored people not to take advantage of the lax regulations.

Dr. Aaron Kheriaty, director of the medical ethics program at UC Irvine and a member of the vaccine task force in Orange County, said implementing stricter requirements like doctors’ notes would have overwhelmed medical offices and, more significantly, left large swaths of people out in the cold.

“The challenge is, if we make the verification criteria too strict, it becomes too onerous and cumbersome to actually implement on the ground, and people are really bogged down in all kinds of red tape,” he said.

For example, a person with a cellphone and a concierge medical service might easily secure a doctor’s note within a day, while a person who is uninsured or underinsured, or doesn’t have a regular healthcare provider, could be left without the needed documentation.

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Tory Cross, a 27-year-old with severe asthma and Ehlers-Danlos syndrome, said the lack of verification requirements is in fact crucial to California’s commitment to vaccine equity.

“It’s really important for people to be able to self-attest,” she said, noting that many lost their healthcare during the pandemic and might not have easy access to a doctor. “Additionally, so many disabled people I know who have disabilities that are invisible [like asthma] were really worried that we would have to argue with vaccine providers to get them to believe that we’re high risk.”

When Cross secured an upcoming appointment at Safeway, she “sobbed like a baby” from relief, she said Monday.

Others haven’t been so lucky. Already, some people, including asthmatics, have expressed confusion on social media as to whether they qualify for vaccination under the latest expansion. Some complained that appointments were already booked when they tried to obtain a slot and wished the state had opened the process sooner.

Under the current guidelines, Californians do not have to disclose what condition they have, only that they are eligible — a decision experts chalked up to health privacy laws, noting that not all people involved in vaccine administration, including volunteers at county sites, are bound by doctor-patient confidentiality.

In Los Angeles County, public health officials estimate that 1.5 million to 2 million residents qualify under the new eligibility list and have reserved roughly 19% of allocated 181,560 first vaccine doses this week for those with underlying conditions.

“We don’t really have a definitive number ... of how many people are eligible under the current new eligibility guidelines that were issued by the state,” L.A. County Public Health Director Barbara Ferrer said Monday. “The bigger unknown is how many people have a disability, or a condition that puts them at grave risk, that wasn’t on that list.”

The state offers a list of 10 general conditions that qualify one for vaccination but also includes a nonspecific category of “individuals who are likely to develop severe life-threatening illness or death from COVID,” which is meant to allow local health providers to use their clinical judgment.

Some people may suffer from ailments they feel make them high risk; others have rare conditions for which there are little to no state data. Ferrer said people who are uncertain about their eligibility should check with their doctor or provider.

In guidance released Thursday, the state offered examples of who might qualify for the vaccine under categories not clearly listed, including those who receive in-home services or obtain care from an independent living center.

“California has gone from being middle-of-the road on priority eligibility with the vaccine to being the best in the country,” said Andy Imparato, executive director of Disability Rights California and a member of President Biden’s COVID-19 health equity task force.

Other states have also implemented an honor system by not requiring extensive verification. The belief is that the elimination of hurdles to getting the vaccine will benefit those who are most at-risk and will help to ensure equity.

“Some might argue, '[California] opened up the floodgates, aren’t you worried?’ My answer is unequivocally no. I think anything the state did to try not to open the floodgates would have created barriers,” Imparato said.

It’s possible that some jurisdictions could implement a stricter verification process beyond the state’s guidance. But for now, experts are optimistic that the rollout will not be overrun by fraudulent behavior.

“I think the bulk of society in a situation like this is interested in fair play,” said Dr. Jeffrey Luther, a member of the state’s vaccine advisory committee and a board member of the California Academy of Family Physicians. “You start thinking there’s mad scramble for vaccines and no one can be trusted — I don’t think that’s true.”

Luther had previously fielded questions from patients about when they would qualify and how they could get a shot. Over the weekend, he said, questions instead were from people asking whether their condition meets the eligibility requirements.

While vaccinations are increasing, the state has a long way to go. As businesses and schools begin to reopen, many Californians are still waiting for their turn to get vaccinated. And all the while, coronavirus variants have been on the rise.

But the latest vaccine expansion is a notable sign of progress, Bibbins-Domingo said. “I think things are moving in the right direction,” she said.

Although the system does allow for some fraud, many are accepting of that if it means more high-risk people can get doses.

“I’d much rather know that someone lied in order to get vaccinated than know they’re not getting it at all,” said Emma Alvarez-Gibson, 45, who is diabetic and has been in quarantine for a year. “The goal is for everyone to be vaccinated.”

Experts said some degree if fraud is inevitable when you’re dealing with a state of nearly 40 million people.

“Public policy cannot force people to be good,” Kheriaty said, noting that the system can only “nudge or dissuade” people from making the wrong choices.

“For society to function, especially in circumstances like this,” he added, “you have to try to trust that most people, much of the time, are going to behave in ways that are trustworthy and upright.”

This story originally appeared in Los Angeles Times.