The COVID-19 vaccine: What can states learn from each other?

Area school staff members receive a COVID-19 vaccination Friday at the Mid-Ohio Education Service Center .Dsc 9625

The American states have been called “laboratories of democracy,” because they have a fair degree of autonomy and are able to do things differently from one other. Often the states lead the way for the federal government, as they have on issues such as legalized marijuana and gay marriage. While the lack of a uniform policy can be frustrating at times, the advantage of the federal system is that states can learn from one another, and so can the federal government. But they cannot do so unless they can determine which state experiments are succeeding and which are not. This is even more important when getting it right is a matter of life and death, as it is with the management of the COVID-19 pandemic.

The distribution of effective vaccines offers the best hope for halting the pandemic, reopening the economy, and restoring normal social life. Which states seem to be doing the best job of doing this, and how can we know?

In this blog we’ll look at several metrics on which to compare states. Table 1 compares state performance along two dimensions—the percentage of state residents who have received at least one vaccination and the percentage who have received both, as of February 15. They are ranked from 1 to 51 (including the District of Columbia) based on the share of state residents with at least one shot.

Table 1: Aggregate performance

State Percentage receiving at least one shot Percentage receiving both shots
1.Alaska 18.2 8.9
2. Connecticut 14.7 6.5
3. New Mexico 14.6 6.9
4. West Virginia 14.2 8.3
5. North Dakota 13.7 6.6
6. Massachusetts 13.2 4.4
7. South Dakota 13.2 6.2
8. Wisconsin 13.1 4.6
9. Maine 13.0 4.9
10. Wyoming 13.0 5.2
11. Montana 12.8 5.0
12. Vermont 12.8 6.2
13. Virginia 12.6 4.6
14. Washington DC 12.6 5.9
15. Colorado 12.6 5.6
16. Arizona 12.6 3.9
17. Delaware 12.5 3.9
18. New Jersey 12.4 4.9
19. Minnesota 12.4 4.6
20. Oklahoma 12.3 5.3
21. California 12.4 4.0
22. Hawaii 12.3 5.2
23. Illinois 12.2 3.5
24. Washington 12.0 4.3
25. Iowa 12.0 3.9
26. Indiana 11.9 4.8
27. Florida 11.9 5.7
28. North Carolina 11.8 5.2
29. Oregon 11.8 5.0
30. Kentucky 11.6 4.6
31. Michigan 11.6 5.5
32. New Hampshire 11.6 5.1
33. Pennsylvania 11.5 4.0
34. Ohio 11.5 4.4
35. Arkansas 11.5 4.7
36. Louisiana 11.5 5.6
37. Nevada 11.3 3.8
38. New York 11.2 5.1
39. Maryland 11.0 4.4
40. Idaho 10.9 4.0
41. South Carolina 10.9 3.9
42. Nebraska 10.7 5.0
43. Mississippi 10.7 4.0
44. Texas 106 4.3
45. Missouri 10.5 4.2
46. Kansas 10.4 3.9
47. Alabama 10.3 3.4
48. Rhode Island 10.2 4.9
49. Tennessee 10.1 4.7
50. Georgia 10.1 4.4
51. Utah 10.1 3.9
United States 12.0 4.9

Sources: CDC data tracker as of 2/19/21 and authors’ calculations

Including the second measure—percentage of residents receiving both shots—enables us to test one of the several plausible hypotheses: some states may be doing worse on the first measure because they have given a higher priority to stockpiling doses for second shots. Table 1 challenges this hypothesis, however. Eight of the ten states doing the best on the first measure are also performing at or above the national average on the second, and 10 of the 13 doing the worst on the first measure are performing poorly on the second as well.

Going on to another important measure of state performance, we look at efficiency, defined as the percentage of doses each state receives from the federal government that have been delivered into people’s arms. The results of this measure are displayed in Table 2.

Table 2: Efficiency

State Vaccinations as a percentage of doses received
1. New Mexico 100
2. North Dakota 96
3. West Virginia 91
4. Montana 91
5. Utah 89
6. Virginia 88
7. South Dakota 87
8. New Jersey 86
9. Arizona 86
10. Oklahoma 86
11. Louisiana 86
12. Delaware 85
13. North Carolina 84
14. Washington 84
15. Wisconsin 84
16. Connecticut 83
17. Wyoming 83
18. South Carolina 83
19. Idaho 83
20. Texas 82
21. Colorado 82
22. Florida 81
23. New York 81
24. Oregon 81
25. Missouri 80
26. Minnesota 80
27. Massachusetts 80
28. Michigan 79
29. Nevada 79
30. Iowa 78
31. Vermont 78
32. Indiana 77
33. Ohio 77
34. Hawaii 77
35. Kentucky 76
36. Maine 75
37. Illinois 75
38. California 74
39. Maryland 74
40. Arkansas 74
41. Alaska 73
42. Pennsylvania 73
43. Georgia 73
44. Tennessee 72
45. Kansas 72
46. Nebraska 71
47. Mississippi 71
48. New Hampshire 71
49. Rhode Island 68
50. Washington DC 67
51. Alabama 65
United States 80

Source: CDC Tracker as of 2/19/21.

Comparing Tables 1 and 2 helps us determine whether states that have inoculated high percentages of their population have done so because of high efficiency in their vaccinations, or because for some reason they have received above-average shares of doses from the federal government. Of the 10 states that ranked at the top in their share of population receiving at least one dose, 8 are well above the national average for efficiency as well, and Maine and Alaska are below average.

Alaska is the principal outlier, and it’s not hard to see why. While the average state has received 22.3 doses per hundred population, Alaska has received 37.1. The state’s unusual topography and demography may help explain this anomaly.

Previous articles in this series have explored some tentative explanations for differences in performance among states. Another possibility is that there is a relationship between a state’s population and its performance. Of the 10 jurisdictions ranked at the top in vaccinations per capita, all but one—Massachusetts—have populations below the national mean state population (about 6.5 million) and below the median state (Kentucky, with 4.5 million) as well. Is there a small-state advantage, even though many of them are sparsely populated, with long driving times to even small population centers? If so, why?

One possibility is that high-performing states have more vaccination sites than other states—making it easier for people to reach the sites and increasing the chances that citizens feel more comfortable and more trusting at a local drug store or health center. In the graph below we researched the number of sites per state and then, to control for the size of the state we converted those numbers into the number of sites per 100,000 population.[1] We then plotted that number against the percentage of vaccine doses administered. Across the country, the average number of vaccine sites per 100,000 population is 6.18. Of the top ten states in terms of sites per capita, 3 are firmly in the middle of the states in performance—Iowa, Missouri and Minnesota have 28, 30 and 23 sites per 100,000 population. West Virginia, the state that has consistently out-performed other states in terms of vaccinations administered has 13.9 sites per 100,000 residents but Utah, also a high performer, administers vaccines through 47 pharmacies and 13 local health departments, which means it only has 1.87 sites per 100,000 population. The relationship between number of sites and vaccines administered does not seem to be robust.

Chart comparing sites per capita with vaccines administered, showing no relationship.

Sources: U.S. Census, State departments of health.

Finally, we have hypothesized in the past that in some places, vaccines may have been reserved for two groups which were high on the priority list—residents and workers in nursing homes—but which didn’t end up using them. Last year the CDC allotted doses based on the number of beds—not the number of patients in beds. As more and more information has come out it is clear that too many vaccines have been held on shelves by the pharmacy companies charged with delivering the vaccines. 

While states were holding onto vaccines for nursing home residents, the number of these residents nationally plummeted in 2020. The following graph using data from the Centers for Medicare and Medicaid Services shows the number of vacancies in nursing homes by state. A quick glance shows that in a majority of states, 25% to 45% of nursing home beds are vacant. This shouldn’t surprise anyone; nursing homes have been the site of many heartbreaking COVID deaths—especially early  in the pandemic. People who may have put their elderly in a nursing home in normal times are understandably reluctant to do so now. Some states have already begun to distribute doses reserved for nursing homes to the larger population of seniors.

Chart showing vacancy rates by state, with most states above 25%.

Source: Centers for Medicare and Medicaid Services

But problems in nursing homes go beyond relying on the number of beds as a proxy for the number of residents. A recent CDC report found that workers in nursing homes “had a median vaccination rate of 37% for staff during the first month of the federal vaccination effort; by comparison, a median 77.8% of nursing home residents received the vaccine.” The low take-up rate among nursing home workers and other health care workers surprised officials. It has taken longer to get these groups vaccinated than anticipated, although public education programs appear to be helping.

Clearly, we need to dig deeper into the variation in performance of states. There are no simple explanations for why poor states like West Virginia which is not known for the quality of its health care should do so much better than rich states like Massachusetts—famous for the quality of its health care. Indeed, our research shows that there is no relationship between states’ median household incomes and their performance in COVID-19 vaccinations.

Chart comparing vaccination to median income, with no discernible relationship.

There’s a lot we don’t know at this point. It may be that these first three months of vaccines are suffering from the same technological failures that plagued the Obamacare rollout in 2013—when the websites built for people to sign up for health care were overwhelmed and crashed. In Massachusetts, the governor opened up vaccines to people 65 and older and the system crashed on the first morning. A national system that was outsourced to Deloitte for development has been plagued with problems and states have been developing their own systems, many of which have also had problems. (Deloitte officials cite complex and shifting state requirements as the principal cause of problems with their system.)

Newspapers and television and radio news around the country are replete with stories of frustrated citizens trying to navigate an impossible digital maze. Like the Obamacare websites these sites will eventually be fixed but in the meantime the pandemic rages on and the virus mutates.

Figuring out what works has never been more important and studying the states can help government at every level to deliver vaccines faster and save more lives.

[1] One caveat: we were only able to find data on number of vaccination sites for 39 out of the 51 (including the District of Columbia) jurisdictions. And some states are listing sites but don’t yet have enough vaccines for all the sites.