California's new vaccine rollout program through Blue Shield is threatening to derail efforts to equitably distribute doses in Santa Clara and San Mateo counties, county health leaders told their respective boards of supervisors on Tuesday.
The state is directing 40% of vaccines for low-income and minority groups in more than 400 ZIP codes, but none of those will be going to either county's most vulnerable communities, county officials said.
Concern over the diminishing number of vaccine doses has both counties looking at ways they might opt out of the state system. Santa Clara County is planning to write state officials a letter regarding their concerns and is likely to request a withdrawal; and San Mateo County health officials are also exploring how it can leave the system run by Blue Shield.
The state's new vaccination network, which launched on March 1, contracts with the Oakland-based health insurance company to distribute the vaccines and create an online central site, myturn.ca.gov, for residents to book vaccination appointments. Blue Shield also advises the state on how the vaccines would be apportioned to target areas in the state that are most heavily affected by COVID-19. Counties would also be required to follow state guidelines for vaccine eligibility rather than make their own decisions on whether to follow the state's phase system.
County officials said the state's use of ZIP codes to determine which communities are in highest need — communities that rank poorly on the state's Healthy Places Index, which measures socioeconomic disparities — is flawed because many large metropolitan regions ZIP codes are often shared by wealthy and economically disadvantaged communities. Because of that association, areas highly affected by COVID-19 are not on the list of 400 ZIP codes the state is targeting to reduce the disparity.
"This week, the vaccine situation has gotten precipitously worse," said Dr. Marty Fenstersheib, Santa Clara County's COVID-19 testing and vaccine program officer.
While the state's overall vaccine allocations rose this week for Pfizer-BioNTech and Moderna doses, Santa Clara County saw a drop in its vaccine allocation by more than 4,800 doses from both manufacturers. The total number of doses the county received did increase by about 3,000 due to the addition of the single-shot Johnson & Johnson vaccines (the county received 7,500 doses), but the shortage of the two-dose vaccines from Pfizer and Moderna caused the county to scramble to find vaccines for people who were due for their second dose, which is must be given roughly three to four weeks after the first injection for full immunity, Fenstersheib said.
"We needed second doses, especially Moderna. We had to work hard on the second doses and to make up for it, we had to cancel first doses and not take any more appointments," he said.
County Executive Jeff Smith said officials have "significant concerns about this process. It's a significant risk to the health and welfare of residents in our county because it's adding another layer of administration between their opportunity to get vaccinated and our opportunity to give them vaccinations," he said.
The third-party agreement between California and Blue Shield also forces the county into a new appointment system and a new way of accessing appointments through the state that would leave the county without any control, he said. Having a private insurance company collect private health data for all residents who are vaccinated is also problematic, he said.
"It's a significant problem with confidentiality and trust because many of our residents do not trust the government to treat their information with care and security. It eliminates local control, puts our local equity efforts at risk. It means that we would not be able to operate as many small pop-ups and focused sites on particular communities," Smith said.
The county has the infrastructure in place to make it easy for residents to search its website for data on its daily updated data dashboards and to sign up for vaccines, he said. The Blue Shield contract adds layers of bureaucracy and puts "statewide priorities over local needs," he said.
Santa Clara County has a robust system for operating vaccination sites, which it would still control under the state plan, but vaccine supply has been, and continues to be, hampering their efforts.
"With respect to Santa Clara County, our impediment and our issue is purely one of vaccine supply," he said. There's no indication that in any way that (the) supply issue is addressed through the third-party administrator, Blue Shield, he said.
County Health Officer Dr. Sara Cody said she remains concerned about the vaccine shortage. Without a rapid deployment of doses, the circulating virus has more chances to mutate into more dangerous variants that could make the vaccines less effective or ineffective.
"I am quite concerned. I'm trying not to go over the top expressing it to you all, but we really are in a race between emergence of these variants and our ability to get our population vaccinated. And, as you know, we do not have control over the vaccine supply," she said.
The Board of Supervisors directed county staff to draft a letter regarding their objections, particularly the allocation by ZIP codes issue and opting out of the Blue Shield program, to be signed by the board.
County Counsel James Williams said the option to not participate in California's vaccination system is unclear and has heard different information from the state. There is hope that California will exercise its discretion to allow counties flexibility in using their own programs that are working, he said.
Williams also noted there could be a conflict of interest by contracting a core state function to a private entity, in particular to a private health insurance company that is otherwise responsible for paying claims on a vaccine that it is now determining how to distribute.
Supervisor Cindy Chavez said the state's plan impacts the county's ability to be flexible and its work with entities it has been partnering with since earlier this month. The state program would require private health providers such as Palo Alto Medical Foundation, which is part of the Sutter Health network, to use the Blue Shield distribution framework, staff also noted.
San Mateo County officials are also examining ways to potentially exit from the Blue Shield program. On Tuesday, county Chief of Health Louise Rogers noted that none of the county's ZIP codes are in the state's 40% vaccine supply distribution to the lowest Healthy Places Index.
"We will not be receiving more supply as a result of this state policy change. Although our lowest Healthy Places Index census tracts do experience disparities, they are not in the lowest 25% of census tracts statewide. In fact, there are only 10 Bay Area ZIP codes on the list: four in Solano, three in Alameda, two in San Francisco and one in Contra Costa," she said. If California doesn't increase its stockpile of vaccines, it will result in a flattening of the supply, which is already insufficient to meet the local demand.
County health officers and legal counsel are contemplating the ramifications of possibly turning down the Blue Shield partnership, Rogers said. They are working to understand the positions of other counties including Los Angeles and Ventura, which have petitioned the state to be removed from the Blue Shield program. They cite the insurance giant's lack of on-the-ground understanding of their counties' diverse populations and needs, according to multiple news sources.
Rogers indicated the county is treading cautiously.
"Our goal is to ensure the maximum supply of the vaccine to our county" with minimal disruption, she said.
Find comprehensive coverage on the Midpeninsula's response to the new coronavirus by Palo Alto Online, the Mountain View Voice and the Almanac here.