Bill Lang didn’t get much of a break over Thanksgiving. Almost every day last week, the medical director at a high-end concierge medical practice, WorldClinic, heard from clients asking when a Covid-19 vaccine would be available.
Two patients even texted on Thanksgiving day. “Since then, I’ve had at least three texts or calls every day just asking, ‘When do you think I can get a vaccine?’” said Lang, who is based in Washington, but also speaks with patients across the U.S. and internationally.
Athletes, politicians, and other wealthy or well-connected people have managed to get special treatment throughout the pandemic, including preferential access to testing and unapproved therapies. Early access to coronavirus vaccines is likely to be no different, medical experts and ethicists told STAT. It could happen in any number of ways, they said: fudging the definition of “essential workers” or “high-risk” conditions, lobbying by influential industries, physicians caving to pressure to keep their patients happy, and even through outright bribery or theft.
The worst attempts to nefariously procure a vaccine may come a few months into distribution, once vaccines are available that don’t require ultra-cold storage and local pharmacies and physician practices get allotments. “There absolutely will be a black market,” said bioethicist Arthur Caplan of New York University. “Anything that’s seen as lifesaving, life-preserving, and that’s in short supply creates black markets.”
At WorldClinic, which charges members $10,000 to $250,000 a year for 24/7 care, no patients have asked for special treatment and the clinic would not undermine its integrity by trying to secure vaccines unethically, said Lang, who was a White House physician during both the Bush and Clinton administrations. “The optics of trying to jump the line would be so bad, they don’t want to do that.” But within the broader system, he added, some people will inevitably cut in line.
“Essential workers” are expected to receive early access to the vaccine, and the definition of this category is open to interpretation by state health departments, creating a means for influential industries to lobby for priority. “The devil’s going to be in the details of how the state runs their program,” Lang said he tells his patients.
Members of the Advisory Committee on Immunization Practices (ACIP), the federal panel recommending how to distribute the vaccines, want to prioritize essential workers to help ensure people of color, who are often the hardest hit by the virus, get early access. But the predominantly white workers in the financial services industry are also considered essential, according to guidance from the Cybersecurity and Infrastructure Security Agency, which was referenced by ACIP, as well as executive orders from several states including New York, Illinois, Colorado, and California. Public-facing bank tellers face contagion risks in their work, but aren’t the only financial services employees included.
“It was left a little bit nebulous but basically covered people who oil the movement of money, so exchanges, trading floors, trading operations, and people who keep money moving at the retail [banking] level,” said Lang. “They’re defined very broadly in New York and Illinois, because that’s where so many of our financial services industries are based.”
The concept of “essential workers” has already been tested during the pandemic, when Florida declared that World Wrestling Entertainment (WWE) met the definition and could remain open during lockdown. The chairman of WWE, Vince McMahon, is friends with President Trump, while his wife, Linda McMahon, served in the administration and is chair of a pro-Trump super PAC. Neither WWE nor Florida’s health department responded to requests for comment about whether WWE would be considered essential for the vaccine rollout.
Other powerful industries might be tempted to follow this example. The potential of industry lobbyists “redefining what an essential worker is is a very strong possibility,” said Glenn Ellis, a visiting scholar at the National Center for Bioethics in Research and Health care at Tuskegee University and a narrative bioethics fellow at Harvard Medical School.
Prioritizing essential workers is intended to give early vaccine access to those who provide a critical societal function and cannot socially distance easily, the Colorado health department said in a statement that acknowledged it can be difficult to write airtight rules. “Given the thousands of different job descriptions in the state, it is impossible to come up with a complete list for every occupation for a specific vaccine phase. Vaccine providers will need to use their best judgment about which patients may qualify for vaccination during this phase.”
The California health department confirmed financial services employees, including those needed to “maintain orderly market operations,” will have early access to the vaccine as essential workers, as will people in the news media, such as reporters. State health departments in New York and Illinois did not respond to requests for comment about whether those in financial services would receive a vaccine early.
Another opening that could be exploited to skip the line involves high-risk medical conditions that warrant early access to the vaccine. Smokers are within this group, according to ACIP, and people with conditions such as moderate-to-severe asthma and high blood pressure could also be included.
This leaves room for a doctor to, for example, portray a patient’s mild asthma as severe enough to justify early access to a vaccine, said Jonathan Cushing, head of major projects of the health initiative at Transparency International, a nonprofit focused on global corruption. The profit motives within U.S. health care make it particularly susceptible to such distortions, he said: “It’s a market-based economy. You as a doctor want to keep your clients coming back.”
Given the need to protect patient privacy, Lang said he doesn’t expect immunization sites to demand documentation of health risk factors. Instead, they will likely either ask patients to state that they have one of the relevant conditions, without disclosing details, or require physician certification, he said: “A lot of that is left to a doctor’s judgment.”
Exaggerating sickness is not a new phenomenon in the U.S. medical system. Insurance companies have portrayed Medicare patients as sicker than they really are, so as to receive higher government payouts. Similarly, physicians to wealthy patients could “make sure they’re among the first to get the vaccines by fudging it in a way that would enable their clients to cut in line” said Wendell Potter, former head of corporate communications at Cigna and current head of the nonprofit Center for Health and Democracy.
The U.S. health care system is generally designed to give preferential treatment to those with wealth and connections, ethicists said. “When we talk about the concept of individuals being able to get to the front of the line, that’s not difficult, because our system is designed to advantage those people with means like that,” said Tuskegee’s Ellis. “They don’t have to really do anything sinister. All they have to do is access the system that they are a part of.”
Powerful companies can leverage their connections with insurance companies to get access to shots quickly, for example. “Some of the richest investment firms have their own mini health systems, so they can run vaccines through those doctors that give the physicals and maintain the health of the executives in the company,” said NYU’s Caplan.
GPS tracking on vaccine shipments will make it harder to pilfer shots en route, though not impossible. “I have a lot of respect for the creativity of criminals,” said Alison Bateman-House, a bioethicist at New York University Grossman School of Medicine. “If someone can see a way to make good money off of driving a pallet of vaccines off in a forklift, I’m sure somebody will figure out how to do it.”
But bioethicists believe pharmacies, urgent care clinics, and doctors’ offices are among the most vulnerable points along the distribution chain. The state-line divides within the health care system make it especially vulnerable to abuse. “There’s far less scrutiny of state legislative and regulatory bodies than at the federal level,” said Potter. “The fragmentation makes gaming the system easier and more likely.”
Vaccine administration sites are subject to less scrutiny than vaccine shipments, agreed Hani Mahmassani, the director of the Northwestern University Transportation Center. “Once this product is in the hands of the entities that are responsible for vaccination, and that’s going to be your, sort of, your local entities, really, anything could happen.” Vaccine administrators who accept bribes could face serious deterrents potentially including prosecution, he said, but the possibility can’t be ruled out.
The supply of a high-demand, life-altering vaccine will never be completely protected from abuse.
“Will there be people who do break the line? Yes,” said Lang. “Will family members of Congress somehow get immunized a little bit early? Who knows.”
At a certain point, though, vigilance brings its own risks. “If you add too many inefficiencies of checking and double-checking everyone, then you put so much bureaucracy into the program, you slow things down,” he added.
The public shame of being caught should act as a deterrent, especially if the backlash is akin to what several Hollywood celebrities and wealthy parents faced following the 2019 college admissions bribing and cheating scandal, said Bateman-House.
“I can promise you, no CEO wants to be on the front page of the newspaper for giving preferential access to his college roommate,” she said. “I think a few public naming and shamings would probably tamp down some activity.”
Instilling a sense of public responsibility and solidarity is another way to deter malfeasance, said Cushing, though this is easier in theory than practice. Otherwise, he said, vaccine delivery should be clearly and transparently tracked, and there should be reporting mechanisms to flag abuse, ideally with state hotlines specifically focused on vaccine line-cutting.
Several bioethicists warned that the number of high-profile politicians, including President Trump, Chris Christie, and Ben Carson, who received early access to experimental Covid-19 treatments set a dangerous precedent. When that occurred, the general consensus, Caplan said, was a wink and a blink and a, “Well, that’s the way it is.”
Following the vaccine rollout, the response to the wealthy and powerful cutting the line needs to be different and fierce, he said. “Everybody has to condemn them: the media, your neighbor, your boss, everybody.”