Whom to Inoculate?

I’m honestly not sure what the editors of the LA Times are arguing in favor of in their latest editorial. I do know what they’re arguing against: inoculating the rich first. They say they want to prioritize “by need” and here’s their conclusion:

Any healthcare rationing decision is going to be politically fraught, especially when the government is playing a role in the decision-making. The best approach is to ensure that emergency triage, and leaving some people to die in this pandemic, remains a hard-fought but strictly theoretical matter.

If we can’t do that by rapidly increasing our supply and distribution of medical equipment, emergency physicians and specialists, then we do it by holding down the surge. That’s why Americans can tolerate a temporary infringement on personal liberty. That’s why we stay at home instead of going to the movies or to the beach, and why owners of restaurants, bars and other retail businesses have closed their doors: to prevent hospitals from being overwhelmed by critically ill patients, and to not have to take a ventilator away from a patient whose life could be saved.

The economic and social costs are huge. But we pay them in order to reject the process of assigning a different value to different human beings, and to reject the affront to human dignity that such calculations entail.

Before that there’s a lot of hand-wringing about the poor, disenfranchised, and people of color being short-changed.

An old client of mine used to talk about “too many oars in the water” by which he meant trying to accomplish too many conflicting goals at the same time. I think the LA Times has too many oars in the water. Let’s just give one example. A bit fewer than half of all practicing physicians, that’s a half million people, earn enough to put them among the top 1% of income earners, a category referred to as “the rich” by some. Said another way you can’t prioritize health care workers without prioritizing the rich at the same time.

My own view is that the highest priority for using the limited supplies of vaccine should be with those for whom it will do the most good. That means the first priority should be given to frontline health care workers. I also think that, for example, the State of Florida, has erred in prioritizing the elderly. Although they’re more at risk of dying from COVID-19 should they contract it IMO there are just too many of them to prioritize and there are other ways open to reduce the likelihood of contracting the virus than using the limited supplies of vaccine on them. I would inoculate people who work in long-term care facilities (who are disproportionately “people of color” by the way) and shut those facilities as tight as a drum. We don’t even have enough vaccine at this point to inoculate all the health care workers and people who work in long-term care facilities. We can talk about other priorities later. By the way, the elderly have higher wealth than the non-elderly as well. You can’t prioritize the elderly without prioritizing the rich.

I hate to advocate sticks before carrots but it should be made clear to frontline health care workers and people who work in long-term care facilities that they are free to accept or reject inoculation but they’re not free to keep their jobs unless they’re either already contracted COVID-19 and recovered or been inoculated.

Ideas for carrots, anyone?

Meanwhile, complicated rules are just plain foolish. The simpler the better. Setting up elaborate point systems borders on the insane.

17 comments… add one
  • steve Link

    “free to accept or reject inoculation but they’re not free to keep their jobs unless they’re either already contracted COVID-19 and recovered or been inoculated.”

    Where do you plan to get all of the replacement workers? (I just love it when other people make decisions that will result in doubling my workload.)


  • Well, it wouldn’t be me who would be “increasing your workload”. It would be your colleagues. I’m not sure how to motivate a group, among the most highly compensated in the country, who can’t be motivated by peer pressure or public spiritedness.

    I’m open to alternate priorities and plans. If you don’t think inoculating frontline health care workers is a priority, that’s interesting. What penalties or rewards would you suggest to ensure compliance?

  • steve Link

    I wouldnt force anyone to have this vaccine. In the context of my already having both my shots let me note that we have no idea of the long term effects of this vaccine. I have looked a t a lot of the data and more importantly talked with people who do are even better at interpreting this stuff re: vaccines. In my particular case I have decided that the risks outweigh the benefits.

    I would further note these are the same people who took care of Covid pts, often with inadequate or just barely adequate, PPE so I dont think this is a matter of people being rationally frightened. I also know our own data (very well) and have seen recent data on iatrogenic Covid and it is very, very low. The biggest risk is actually that we give it to each other.

    So I have no problem requiring people take a proven vaccine like the flu vaccine. I dont have any problems requiring hospital workers wear masks at all time as they are quite effective in the hospital setting (multiple studies). And maybe next year when we have at least a Year’s experience maybe we start making it mandatory.

    Otherwise we rely upon persuasion and hope that good data continues to come out. I have never had trouble getting people to implement new treatments/therapies even when they are a lot of work or dont pay well when there is good evidence support them.

    BTW, where do yogurt your data on physician incomes. Not being in the 1% I cant afford to subscribe to some of the better sources I would like to have.


  • Basically, MedScape. They say the the present income for GPs is around $250,000 and for specialists around $350,000. Add a little statistics and that puts a lot of physicians among the top 1% of income earners.

  • steve Link

    It is hard to find data that makes me completely happy about incomes for docs and I have multiple sources. About 1/3 are in primary care and your numbers are about what I generally see for them. Your numbers (salary) arent too far off of what I think they are but it is hard to find a median which I would like. I let my Health Affairs subscription elapse alas. Too busy to read it much. Anyway, Would guess about 1/3 of docs would be in the 1% with some specialties like ortho earning in the $800k range. Of course that is just for clinical work and a lot of docs make money from their surgicenter investments and there is always drug and device money. Still shocks me when I think abut the guy we got rid of because he was taking close to a million a year from some device maker and was hiding and lying about it. Maybe the fact that his MAGA hat was made out of silk should have been a clue?


  • steve Link

    BTW, assuming that things beside Covid and Trump become important again, link goes to an important health care article. I find it risible that they thought they were going to have a big impact on health care costs.



  • bob sykes Link

    NYS is throwing away most of their vaccine allotment. Wouldn’t it be better to dose on a first come first serve basis?

  • Jeff Link

    “The first thing we do, let’s kill all the lawyers.” W. Shakespeare, Henry VI, Part 2, Act 4. Are we agreed that lawyers should be the last to get the vaccine? Many of them are rich and most people regard them as non-essential. As a disproportionate share of lawyers are elected officials who failed to govern us through this pandemic, so much the better.

    Of course, physicians constitute a comparatively modest percentage of all health care workers and not all of those physicians are frontline dealing with COVID patients. Hospital workers (nurses, techs, janitors, and hospital based physicians) should be highest on the list for obvious reason. While I appreciate the KISS principle of keeping it simple, I believe the vaccine priority should be focused on those communities and places where new infections are the greatest. If the objective is to reduce spread of the virus, it makes sense to target the neighborhoods with the highest number of cases per 100,000 to get the vaccine sooner. In California, that would include poorer areas with a predominantly Hispanic population. Even if the vaccine does not reduce virus transmission, it will bend the curve to reduce hospital admissions.

  • Grey Shambler Link

    Big money has an effect on people.
    Musk has plans to colonize Mars, and I don’t hear anyone laughing.

    Patient compliance is where I see a need for improvement but imagine trying to do healthcare in a room with children playing and scrapping and running away with your instruments.
    And even with perfect compliance you’d have better outcomes and maybe extended lifespans and yet no reduction in overall cost.
    It appears we’re headed for some kind of Medicaid/Medicare if not for all, then for more and more until we end up with a two tier system.
    One with government controlled cost and procedure approval and the other concierge.
    I guess I’m not sure what role that leaves for insurance companies and my own personal experience leaves me thinking more and more that they are a con and a scheme and in most instances just an expensive savings account that most of us should be able to do without if we were better financial planners. Rambling….

  • At this point I think the preponderance of the evidence suggests that New York’s political leadership is incompetent.

  • steve Link

    I hire people out of NYC. Mostly critical care docs but also others. The word they have is that most vaccine is not being tossed. What has happened is that because of the storage requirements they take out to thaw the number of expected doses based omg the number of appointments. If people dont show the have leftovers. Those dont keep. Everyone is afraid to give it to someone not on the “list” so they toss it.

    You certainly could free up things so that the leftovers could be given to whoever is available so they are not wasted. This does leave things open to obvious gaming so you do need to decide your priorities.


  • PD Shaw Link

    @Jeff, lawyers are essential workers pursuant to CDC guidelines, who should be vaccinated in the first phase (Phase 1C), so they don’t agree with you.

    One way to look at these definitions is that “essential worker” lists appear to have been formulated before this pandemic in the case of a zombie apocalypses. If we need to reconstitute society, what would be important? It turns out almost every employment sector is important, or at least integrated with what is important, or has skills that could be used to rebuild society.

  • PD, let me introduce you to Jeff. He’s a lawyer. Jeff, PD is a lawyer in Springfield, Illinois.

  • Andy Link

    “Where do you plan to get all of the replacement workers? (I just love it when other people make decisions that will result in doubling my workload.)”

    I go back and forth on requiring the vaccine. If a worker who refuses to get vaccinated infects a bunch of people, you’re losing out on workers as well. There are definitely tradeoffs.

    I’ve mentioned before that I’m the legal guardian for my sister who has dementia and lives in a memory care facility. One or possibly two asymptomatic workers brought covid into the facility in late November or early December, causing an outbreak which is still ongoing. 53 total cases so far and 12 deaths. 40% of the residents who got covid have died so far. I’m lucky my sister was asymptomatic and is doing fine (she’s physically healthy for her age).

    Yes, the vaccine may have unknown long-term effects. But not vaccinating can have very devastating shorter-term effects. There are tradeoffs for sure, but I think the tradeoff’s support mandatory vaccination for certain categories of workers, particularly those who have regular contact with vulnerable populations.

  • PD Shaw Link

    Locally, there was an outbreak in a residential facility for developmentally disabled men, and staff started quitting. My initial reaction was outrage, but then I don’t know how many of those quitting had significant medical risks or lived with someone who did. I think this is what steve is getting at, a mandate might encourage staff to quit without ready replacements available.

    There were also issues when they vaccinated the residents and staff at all of the veteran’s homes. 74% of residents and 40% of staff were vaccinated last month, which drew a lot of outrage. The union pushed back that staff was informed on Christmas Eve that the vaccine would be available the next 24 hours (btw/ there was a large distribution nationally right around Christmas) and at least at one location, they ran out. I would also add that the home with the worst participation rate is in the middle of large outbreak, I think a quarter of residents died in December. I don’t know how many people at that home were infected. At this point, I don’t consider the vaccine widely available to front-line workers, though its close.

    At the local hospitals the largest group not getting vaccinated are women of child-bearing age believed to be concerned about something they read on-line about potential impacts on fertility. I guess the hospital is doing reach-out, thought I don’t know what they are going to say, but there are some healthcare workers who were not in a hurry who will get vaccinated at some point. One carrot is having that option available at the workplace, as opposed to waiting in make shift garages or in long lines in abandoned malls with the masses.

  • Andy Link

    “I think this is what steve is getting at, a mandate might encourage staff to quit without ready replacements available.”

    That might happen and I admit that reduced care from too few employees is difficult to balance compared to the potential of people dying.

    Perhaps splitting the baby would mean that those who refuse to get vaccinated have to get daily tests, and moved to positions where their contact with vulnerable populations is limited.

  • PD Shaw Link

    I don’t have a problem with mandating the vaccine, might be a little early because there is probably still upward movement for voluntary vaccinations right now. If there is a mandate, employers will have to pay attention to Americans with Disabilities Act requirements and evaluate reasonable accommodations.

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