COVID-19 vaccines have finally arrived, but for most Americans they remain hopelessly out of reach. Over the past week, thousands saw their vaccine appointments abruptly canceled as local health departments received far fewer doses from state officials than expected. In other parts of the country, thousands of doses linger on freezer shelves as under-resourced and underfunded local authorities struggle to cobble together the infrastructure and legions of personnel needed to turn vaccines into vaccinations. While the Trump administration invested considerable resources into vaccine development, it left the details of distribution almost entirely in the hands of state and local authorities.
This strategy, intended to allow local policymakers to craft unique distribution approaches suited to their population’s circumstances, has instead laid bare the weaknesses of America’s fragmented health care system. Inconsistent communication and coordination across county public health departments, state policymakers, and federal agencies has given way to a widening chasm in state vaccine distribution performance. For example, California, which holds nearly 2 million unused doses scattered across 61 different city and local health departments, has one of the lowest rates of vaccine administration in the country.
Successful vaccine rollouts use integrated health care systems. West Virginia has one of the highest vaccination rates nationwide. In contrast to California, the state relies on a centralized process for vaccine deployment rather than tasking local counties and municipalities with coordinating among themselves. Globally, Israel leads the way in vaccines distributed per 1,000 people. The nation’s digitally integrated, community-based health systems and centralized government have been essential in their execution of an effective and efficient vaccination campaign. In ramping up America’s vaccination efforts, the Biden administration needs to do more than pledge additional doses; it needs to make it easier to distribute those doses in a coordinated way. While America cannot overhaul a fragmented strategy overnight, the new administration can activate a national, if niche, health care system to aid in vaccination and replicate some of the success seen elsewhere around the globe. To boost America’s vaccine rollout, the Biden administration should consider leveraging the Department of Veterans Affairs.
The VA is the largest integrated health care system in the United States. Its primary purpose is to provide health care services to over 9 million veterans in every state. Lesser known is the agency’s fourth mission, established by the VA/Department of Defense Health Resources Sharing and Emergency Operation Act of 1982, tasking the agency’s 1,255 health care facilities with reinforcing America’s preparedness for and response to war, terrorism, national emergencies, and natural disasters. This means that the government could ask it to serve as a network of national stockpile sites and distribution centers, not just for veterans but for all Americans. Unlike state and county efforts to distribute vaccines, the VA could centralize accounting of both local and national medical supply levels, meaning it can mobilize supply across VA medical centers to accurately match demand. The agency has already proved this capability by successfully routing masks, ventilators, hospital beds, and other critical care equipment to community hospitals facing shortages in the early days of the pandemic. The VA’s centralized mechanism for communication with patients, including a central COVID-19 vaccination page, could also help resolve the confusion surrounding varying information and prioritization of vaccine distribution among public health departments, health systems, and pharmacies. The VA should establish a standardized sign-up and walk-in protocol communicated broadly through the Centers for Disease Control and Prevention to allow Americans across the country to follow a simplified, standardized approach to receiving the vaccine.
The VA is best poised to address the vast swaths of rural America with few vaccination touch points. Pharmacy chains and city stadiums will play important roles in the vaccination campaigns, particularly within urban and suburban centers. But vaccinating rural Americans poses a daunting challenge to an already stumbling rollout. The VA offers a surge capacity of physical infrastructure, personnel, and equipment that could be used in regions plagued with delays and disorder, particularly those that are difficult to reach. Given the agency’s experience caring for the 2.8 million rural veterans who rely on its health services, the VA has already begun to tackle the “last mile” distribution problem to mobilize vaccines from traditional storage and distribution sites to veterans in remote areas, all while keeping them cold enough to remain stable. While the VA’s efforts have focused on veterans to date, through its fourth mission and additional resources, the agency could play a much broader role in vaccinating Americans. VA facilities regularly care for large rural catchment areas where physicians and nurses visit remote sites and conduct home visits with patients. Relying on this operational expertise will be necessary to vaccinate the 60 million individuals living in rural America, veterans and civilians alike.
To be sure, the VA is far from perfect. In 2014, the Veterans Health Administration was widely criticized for delayed access to care, preventable deaths, and falsification of records, which eroded public trust in the institution. By mid-2020, however, veteran trust in the VA reached an all-time high. The administration’s digital infrastructure has also become outdated. Once cutting-edge, the Veterans Health Information Systems and Technology Architecture, or VISTA, electronic health record has languished under a lack of investment, and clinicians have found it cumbersome compared with commercial systems. These outdated systems and clinical inefficiencies don’t matter as much to the goal of administering vaccines, which require limited clinical knowledge and care coordination. Congressional investment in the Veterans Health Administration can help overcome many of the resource challenges the system has faced for years. The VA’s logistics and operational expertise, coupled with its nationwide reach, should make the agency an important partner alongside local health departments, the Federal Emergency Management Agency, and the National Guard in the race against the pandemic. Furthermore, it is simpler for the VA, a federal agency, to directly infuse federal funds to scale its response.
Calling on the VA may help us settle a long-standing political science debate in the limelight over the last 12 months: Amid a chaotic national health emergency, how do we best allocate responsibility between the federal government and the states? States and municipalities should absolutely be empowered to customize responses for their unique situations, as they know their citizens best. However, throughout most of the pandemic, the federal government minimized its responsibility and overburdened localities already facing economic catastrophe for a public health effort that required centralized resource management and financing. Funding and leveraging our country’s existing nationalized health infrastructure, with provision of care tailored to the needs of regional populations, could be exactly what we need to achieve an effective and efficient national vaccination campaign and make our nation’s largest integrated health system stronger for the decades to come.