The rollout of the COVID-19 vaccine has been accompanied by reports of line-jumping as people farther down the list attempt to get ahead of those deemed higher priority.
In late February, for example, one health provider, One Medical, was stripped of its vaccine allocation after allegedly allowing people connected to the company and those paying for its “concierge medical service” to have the shots – despite not being eligible. Likewise in January, hospitals in Washington state and South Florida faced criticism for offering invitation-only vaccine slots to private donors. More recently, Texas has come under scrutiny for allowing people to be vaccinated without proving eligibility.
The resulting unfairness of practices such as these has compounded other inequalities highlighted by the pandemic. As a law scholar who has studied queuing, I consider building trust in the fairness of the line, alongside trust in the vaccine itself, to be important for the success of the immunization program. Those who skip the line not only displace those waiting behind them, they flout the informal rules of fair play that, with appropriate priority rules, make the rollout fairer than any market or lottery-based alternatives.
First come, first served
Historically, first come, first served has often been the default when it comes to queuing. The “first-in-time, first-in-right” principle goes at least as far back as the 17th century, when it served to settle property disputes in English common law. In wartime Europe, first come, first served was used to allocate rationed goods. And the bread lines in communist Eastern Europe became a symbol of the erosion of trust when systems fail to match supply and demand.
Nowadays, first come, first served is often replaced by scheduling algorithms that can triage priority. And waiting lists differ in other respects. Sometimes the lines are winner-take-all, in which one’s position can determine whether or not one gets the goods or services. Other times, placement determines only your wait time.
The COVID-19 vaccine phased allocation falls somewhere in between the two – not quite winner-take-all, but a little more than affecting
just wait time, given the stakes of COVID-19 infection.
Because demand for COVID-19 vaccines has outstripped supply, there has had to be a rationing of supplies. In determining who is eligible for a vaccine and when, a series of ethical principles have been drawn up to help determine priority, alongside considerations of epidemiology and ease of implementation.
These ethical goals include reducing deaths and hospitalizations among high-risk groups, as well as promoting solidarity and protecting against systemic unfairness disadvantaging vulnerable populations.
As the COVID-19 vaccine has rolled out across America, each state has established its own priority lists and timelines. As a general rule of priority – endorsed by the Centers for Disease Control and Prevention – health care workers and long-term care residents have been given the highest priority, followed by those age 75 and over and front-line essential workers, with people at high risk of serious COVID-19 illness next in line.
Many states have added groups or tweaked the list. Sixteen states now give priority to smokers, for example, and 44 have moved to provide teachers with early eligibility. With so much variety and changeability in vaccine priority, and the different speed of each state’s rollout, some people might question whether the line deserves adherence.
Skipping the line
Each state has also made various official exceptions that allow people to jump the queue. Permission to skip the line has been given in cases of expiring doses, where vaccines would have to be disposed of if not injected into people’s arms.
In Los Angeles, expiring doses have been opened up to so-called “vaccine chasers,” who wait at clinics or vaccination sites and receive end-of-day shots. Meanwhile in Massachusetts, doses have been reserved for “companions” who accompany persons age 75 and over to a mass vaccination site.
But there have also been, as the One Medical case has shown, scandals involving line-cutting by the wealthy or politically connected. This is not restricted to the U.S. Several politicians in Peru, Argentina and Ecuador have been forced to resign after getting vaccines for friends and family, and scandals involving both the wealthy and the politically connected have been reported in Brazil, Canada and the U.K. This compounds the inequality of vaccine access between, as well as within, countries.
Cases of people jumping the line are entirely predictable; the special treatment of the rich and powerful has a long history when it comes to queuing. And line-jumping may be more frequent in already unequal societies, scholars have suggested.
This imbalance affects both the number of lines people have to join and the length of time they wait.
America’s poor often encounter more unavoidable lines for basic services, and can spend days, weeks, months or even years waiting for housing, schools, health care or immigration services.
Lines are prolific for specific vulnerable populations, such as those within the U.S.‘s extensive prison system, welfare recipients or people caught up in an extreme weather disasters. This results in a cost to those affected in their time, but also in other ways. Studies have shown that an uncertain delay – one in which you are not sure how long you will be waiting for a service – can reinforce subordination and political resignation on the part of those already vulnerable.
Wealthier Americans do not have to encounter many of these lines. And in the ones they do join, they are more likely to be able to skip to the front. Common examples can be seen in air travel, where VIP lanes are opened for those who can afford them, or recreational goods – such as for sports games or theme parks, where you can pay more to bypass those lining up.
But the ability to pay to line-jump also extends to more basic goods, including health care.
Concierge medicine services – such as the ones that have allowed some people to get illegitimate early access to vaccines – allow paying patients the first access to a suite of time-sensitive resources, ranging from priority scheduling to eliminating waiting rooms.
They have been increasingly prevalent in the U.S. and are presented both as a workaround for wealthy patients and a way for doctors experiencing burnout to practice outside an overburdened primary care system.
Such practices have been justified by their supporters as a way to cut wait times. In reality, such VIP lines in health care can make health care more inaccessible. Given the overall scarcity of primary doctors, and the premiums demanded for such services, such systems can displace lower-income, minority and Medicaid patients.
They also inject market forces into a sphere generally governed by other ethical principles, such as the rights of all patients to health care. Skipping the line undermines this commitment. It also exposes line-jumping to be both a symptom and a cause of inequality.
This is the concern when it comes to the rollout of the COVID-19 vaccine. The CDC and the different states’ phased allocations have prioritized equality and mutual responsibility. Illegitimate line-jumping is a direct threat to these principles and works more insidiously to undermine them.