Why D.C. Is Failing at the Vaccination Game

Washington’s effort to quickly vaccinate the population against COVID-19 is a success just about everywhere except its own backyard.

President Joe Biden pledged to administer 100 million vaccine doses within his first 100 days. After surpassing that goal with 41 days to spare, Biden doubled his pledge to 200 million doses. The CDC projects that 70 percent of the U.S. population will be vaccinated by summer, probably the minimum threshold to achieve herd immunity. The process is going so well that the Biden administration has started fretting about what to do with an anticipated vaccine glut. That’s the best possible problem to have.

But in Washington, D.C., where the key national policy makers work and often live, vaccination has been a fiasco. Software for a same-day registration system—immediately likened universally to The Hunger Games—spat out so many error messages that the city had to find a new vendor. The new Microsoft system, which went online in early March, worked better and allowed preregistration, but for people without qualifying medical conditions or work circumstances, the District continues to restrict availability to people age 65 and up, even as well over half the states (including neighboring Maryland) have lowered their age thresholds. In New York the age threshold has fallen to 30. That is a sore point for your correspondent, age 63.

[Read: The vaccine line is an illusion]

D.C. vaccinations may have reached their nadir on March 24, when an irate Tyler Longpine, the political director for the Teamsters, reported on Twitter that about 100 people who had shown up for previously scheduled morning appointments at Lamond Recreation Center in Northeast Washington, including Longpine’s child-care provider, were told at 11:45 a.m. that vaccinations would be halted until 1 p.m. while the staff went on lunch break.

An appalled city-council member, Christina Henderson, brought the matter up at that afternoon’s council meeting. “When our neighbors arrive for a scheduled appointment,” she later told me, “they deserve to be met with a safe, organized, and professional process.” A D.C. health-department official immediately pledged to get to the bottom of it, but Longpine, who confirmed his tweeted account to me by phone, said no one from that department ever contacted him. My own repeated requests to speak to the D.C. health official investigating the matter, or otherwise get the city’s side of Longpine’s story, went ignored.

Vaccinations ought to be easy in the District. It has about 700,000 people; among the states, only Wyoming and Vermont have smaller populations. And, unlike Wyoming and Vermont, D.C. concentrates its population within a very compact 69 square miles. But as of yesterday, CDC data compiled by The New York Times showed that only 26 percent of District residents had received their first shot, placing D.C. in the bottom quarter of the states, on par with Louisiana and Arkansas. The national first-dose figure was 29 percent. The percentage of people in D.C. who were fully vaccinated—13 percent—placed D.C. two rungs up from dead last, on par with Alabama, Tennessee, and Texas, and two percentage points behind Mississippi, the poorest state in the union. The national percentage of fully vaccinated people was 16 percent.

On the key efficiency metric of “doses used,” D.C. had delivered 72 percent of its doses into people’s arms, ahead of only Alaska, Wyoming, Louisiana, Arkansas, Mississippi, Georgia, and Alabama. The national efficiency rate was 78 percent.

The vaccination fiasco has taken District residents by surprise because until the vaccine rollout, D.C.’s handling of the pandemic was going quite well. Mayor Muriel Bowser was admirably cautious in her approach, resisting pressure to open restaurants and other businesses too early. She didn’t commit any hypocritical gestures like California Governor Gavin Newsom, who attended a crowded indoor November birthday dinner at the French Laundry restaurant in Napa Valley, or New York Governor Andrew Cuomo, who gave family members and associates preferential treatment for coronavirus tests. And you can’t accuse Bowser of living comfortably removed from the hardships that constituents are suffering; her sister, Mercia Bowser, died of COVID-19 in February.

Case numbers in D.C. never spun out of control to overwhelm medical facilities, as they did in New York City and Los Angeles. A field hospital set up in D.C.’s Walter E. Washington Convention Center never had to be used. “We didn’t have refrigerator trucks in the back of hospitals,” notes Andrew Lightman, the managing editor of Capital Community News, which publishes community newspapers in D.C.

[Read: The fourth surge is upon us. This time, it’s different.]

Getting people to shelter in place and maintain social distance is hard, and D.C. managed that part extremely well. Vaccinating people would seem, by comparison, pretty easy. But that part has gone poorly in Washington. Why?

The U.S. Department of Health and Human Services bears much of the blame, and by extension the Trump administration, which made a bad decision about the District’s vaccine allocation, and the Biden administration, which has failed to correct that decision.

HHS decided early on that vaccine doses would be distributed to states and territories based on population. For most jurisdictions, that made sense. For D.C., it made no sense at all. That’s because D.C. must vaccinate a huge number of people who live in other states.

Three-quarters of all the people who work in D.C. live in Maryland or Virginia, mostly because housing in the District is too expensive. The capital’s so-called daytime population, which includes people who come into the city every day to work, is nearly double the nighttime population of about 700,000. Many of these people are essential workers who can’t work from home and therefore must be vaccinated to do their jobs—hospital workers, police officers, firefighters, teachers, grocery workers.

Washington is a major health-care hub for the mid-Atlantic region, employing 85,000 health-care workers (nearly 6,000 of them at MedStar Washington Hospital Center alone). “Private hospitals are our biggest private-sector employers in this city,” the city-council member Elissa Silverman told me. Those 85,000 health-care workers, she said, require about 120,000 vaccine doses.

Ultimately, about one-third of all vaccine doses administered thus far within the District—more than 94,000—have gone to out-of-staters. Another wrinkle is that vaccine allocations for the roughly 141,000 people who work at the federal agencies within D.C.’s borders come out of the District’s population-based ration, even though the District doesn’t administer those doses. The upshot is that D.C.’s population-based vaccine allotment—44,440 this week, the third-smallest allocation in the country, after Wyoming and Vermont—likely falls short by one-third to one-half. How could that happen?

Because D.C. isn’t a state. If a federal agency isn’t serving a state well, it can expect to hear complaints from that state’s congressional delegation. But D.C. doesn’t have a congressional delegation. It has one delegate to the House of Representatives, Eleanor Holmes Norton, who is one of the very best members of Congress—but who is not permitted to vote on the House floor. Norton can vote in committee, but she doesn’t sit on the House Appropriations Committee, so she can’t bring HHS to heel by threatening to cut its budget. No D.C. delegate has ever sat on Appropriations. Were Norton to chair some other House committee, she might have the means to intimidate HHS, but no D.C. delegate has ever held a full committee chair, either. When District residents complain of “taxation without representation,” this is what they’re talking about.

[Read: D.C. statehood is more urgent than ever]

Blame HHS for the fact that the District has inoculated so few of its residents; the department is not giving the District enough vaccine doses. Blame Congress for resisting D.C.’s demands for statehood, which would give the capital more clout in such situations. As for D.C.’s poor efficiency record at delivering the few doses in its possession, the city government’s performance may not be quite as bad as it looks.

Ankoor Shah, who’s leading the vaccination program in the District’s health department, believes that the CDC’s 72 percent efficiency statistic is just wrong. Here’s how Shah explained the problem to me: The doses allotted for D.C. are deposited into three buckets.

Bucket 1 is the D.C. health department. “D.C. has complete control over that,” Shah said.

Bucket 2 consists of community health centers and pharmacies that have partnered with the federal government through two programs managed by the CDC and the Health Resources and Services Administration, a unit of HHS. The District has a supervisory role here, but in practice, Shah, told me, “it’s more a collaboration, because we can’t make those strategic decisions for them about how to order doses.”

Bucket 3 consists of federal agencies located inside the District. These agencies receive vaccines for employees who work in the city. The District has no supervisory role here at all, and Shah told me he’s been unable to glean from the CDC any information about how many doses are being assigned to these agencies and how many are being used. “That’s a black box,” he said. (For what it’s worth, the federal agencies’ vaccination performance across all 50 states is a respectable 79 percent.)

The reason the CDC’s efficiency score for the District is so dismal, Shah said, is that the CDC includes all three buckets in the denominator (total vaccine doses delivered in D.C.) but only Bucket 1 and Bucket 2 in the numerator (total vaccine doses injected into arms). I asked the CDC press office to confirm this assertion, and to clarify, percentage-wise, how D.C.’s vaccine allocation is divided among the three buckets, and what proportion of each bucket gets used. This query, made by email and in repeated telephone calls, went unanswered over three business days.

The District finally addressed the garbage-data problem on Monday, by releasing a breakdown of Bucket 1 and Bucket 2. Bucket 3 remained a black box, but for the first time it was possible to assess what was going on in the first two buckets. The District’s overall efficiency was, by this reckoning, a still underwhelming 76 percent, putting it in the bottom third among the states.

But the D.C. health department’s own vaccinations—Bucket 1—are efficient. The health department has gotten 85.3 percent of the doses it’s received into people’s arms. That’s better than California and New York (78 percent), better than the adjacent states of Maryland and Virginia (78 percent and 82 percent, respectively), and better than the national average (78 percent).

D.C.’s overall efficiency is poor because of Bucket 2. The community health centers and pharmacies that partner with the federal government have received 17 percent of the District’s allocation (not counting the opaque Bucket 3), but they’ve failed to administer most of these. When I say “most,” I mean quite literally “the large majority.” Bucket 2’s efficiency rate is a dismal 21 percent.

Clearly, these D.C. facilities received more vaccine doses than they knew what to do with, perhaps because so few of them are participating. According to the Health Resources and Services Administration website, only seven D.C. community health centers, all of them very small, are participating or have been invited to participate in its COVID-19 vaccine program. (The two best-known are Bread for the City and Community of Hope.) According to the CDC website, only four corporations are signed up for the pharmacy program in D.C. Most of the participating stores aren’t pharmacies at all, but rather supermarkets that house small pharmacy sections.

One of the participating supermarket chains is Safeway. I live two blocks from the Safeway in D.C.’s Chevy Chase neighborhood. I do most of my family’s food shopping, so I go there a lot. In the tiny pharmacy area, six or seven folding chairs are set aside for vaccinations. Sometimes I dream that one day I’ll receive my shot there. Then I wake up and remember that I’ve never seen anybody receive a shot there.

[Read: Random people are lining up to get vaccinated in D.C. grocery stores]

The largest pharmacy chain in the U.S. is CVS, which in the 1990s purchased D.C.’s once-dominant Peoples Drug chain and became the biggest player in the D.C. market. Yet CVS hasn’t joined the CDC partnership in the city (though it just started helping the District inoculate frontline workers and people over 65). To have a pharmacy vaccination program in the District that doesn’t include CVS is like throwing a royal wedding in Westminster Abbey to which the Queen sends her regrets.

Nationally, the retail-pharmacy program is such a blazing success that, according to Politico’s Erin Banco, the Biden administration is focusing its efforts there more and more. Over a five-day period, March 11 to 15, Banco reported, the federal retail-pharmacy program delivered nearly 6 million doses nationwide. But the magic isn’t happening in Washington, D.C., where the Biden administration is actually situated.

I asked Shah what the D.C. government can do to push Bucket 2’s efficiency rate above 21 percent. “DC Health does not have control over [its] orders,” he reminded me via email. But he also sounded a hopeful note: “Now that we know more about these doses and orders over the past 1–2 weeks, we are providing technical assistance and resources to get those doses into arms quickly. DC Health is currently helping scale up our community health center and pharmacy vaccinations.”

Help is on the way. Things will get better. I actually believe this, because they couldn’t get much worse. In the meantime, some D.C. residents are giving up on their city altogether and crossing into Maryland, where more groups have become eligible for vaccination and residency is not always required. The state isn’t exactly advertising this fact, but word is slipping out. It beats waiting.