How to stretch our Covid relief dollars with smarter booster campaigns in the future.
Timing Boosters: Part II. Rapidly boosting at-risk people during surges would save lives and be more cost effective than annual "boosters-for-all" campaigns. It's time for insurers to do their part.
Yesterday, I wrote about how timing boosters to waves by waiting for surges before rolling them out en masse would likely save more lives than one-size-fits-all booster campaigns every fall. To work, though, a timed/rapid booster rollout would have to be done properly and would take great effort and coordination. The problem is logistics—and convincing the old guard that we have the tools to do this (and to some extent, making those experts actually run the numbers.)
Another problem is money and a lack of comfort around such uncertainty that public health officials would have with such plans. To be sure, a general cattlecall to “get boosted this fall” won’t take much hustle. It would just be another page out of our old annual flu vaccine playbook: Healthcare providing entities will get shipments of the annual booster, and People Will Come™️. (At least, some will.) But if we waited until a big surge comes and only then unleashed a 2021-style mass vaccination campaign, we could save many more lives. This was the crux of yesterday’s Inside Medicine.
Admittedly, a last-minute scramble to vaccinate the most at-risk 25% of the US population during a bad surge would be expensive and a little nerve-wracking for officials who like to have solid plans. And, what about the expense? Is there even money for a last-minute rapidly-deployed booster campaign with a goal of bringing millions of at-risk Americans up-to-date within just a few weeks?
Yes. Doing this will require a major paradigm shift in who is paying for at least part of the pandemic response, though. To be clear, I am not in favor of privatizing all Covid-19 expenses, like tests, treatments, and related care. But mostly privatizing Covid vaccines/boosters could be a good idea whose time has come.
I’m suggesting that money in our future Covid rescue packages mostly not be used to pay for all boosters. Before you cancel me, let me say the following: If the funding is there for everything else we need, sure Covid rescue packages should pay for all boosters. But if not, we should start to redistribute the increasingly small Covid budget and be smarter about how we are spending. Here’s how we can do this, reach the most at-risk people, and not fall further behind on equity (and maybe even improve on that).
Medicare and Medicaid should be required to cover Covid vaccine boosters. Private insurers should also be required to cover their customers’ boosters, with no copays. (In a world in which Covid boosters were not paid for by the government, insurers would be foolish not to cover these anyway, actuarily speaking). This could reduce the amount of money any future Covid rescue package needed to devote to vaccines by 91%. To reach the remaining 9% of US residents who do not have health insurance, strategically placed free vaccination sites (some mobile), could be deployed to areas with high rates of poverty/low rates of insurance, and other underserved communities. Those doses should would be free and targeted to those who do not have insurance; those doses should be the only ones paid for by the Covid relief package funds at that point. Sure, some insured people might inappropriately use such vaccination sites—meaning the perhaps instead of 9% of the current funding, we’d have to overbuy by a factor of 2, to the tune of, say, 18%. But people with insurance are unlikely to use these sites much. The one thing that people don’t take extra of when it’s being offered for free? Healthcare.
So instead of ransacking future Covid relief funds for $171m on boosters as we did this last time, a modernized program could spend just 18% of that, on doses specifically meant to reach underserved, uninsured people. We could then apply the $140m saved by letting insurance providers do their jobs and—perish the thought, cover preventive care—spend it on the infrastructure and human resources needed for the rapid deployment of boosters to the high-risk groups who would need added protection during bad surges.
We have done this before, logistically. We did it in the winter of 2021. We vaccinated millions of people per day. Even this fall, we boosted around 25%-30% of seniors in just about two months—and we did very little work to proactively bring the vaccine to people. In addition, the fall was not a period where Covid was running wild. Uptake would certainly have been higher if we’d been in a bad wave. I’m optimistic that we can reach the most at-risk people extremely quickly. There’s no reason to think that we can’t boost >75% of seniors in just several weeks, with the right plan in place.
To do this though, given anticipated budget constraints, we’ll need to spend our money wisely. Transitioning booster expenditures to private insurers and existing public programs like Medicare and Medicaid—but, again, still paying for boosters for the uninsured—will free up the money needed to deploy a plan like this.
But money is not the only barrier. We also have to be willing to think beyond our comfort zones. Even though Covid mortality rates have fallen dramatically, Covid is not yet anything like the flu. We can’t pretend we are in a phase in which things are more predictable than they are. The virus has proven nimble. While it may turn out to have important seasonality (i.e., worse in winter), it’s too soon to settle into complacency and assume that is guaranteed. The virus is not endemic—by which I mean stable and predictable. When it is, we can treat it more like the flu. Until then, we have to be smart enough to keep up. I firmly believe that we have the brainpower to do better in the next phases. So let’s do it.
If only...
As a high risk person, I'm dismayed by the FDA annual shot proposal when we continue to have waves that are not seasonal.
While I agree hypothetically with your proposal, I think it involves collaboration, innovation and is just beyond the scope of realistic expectations. I wish it was possible.
At this point, I'd just appreciate the option for a second bivalent booster--and as data on waves is nearly impossible to find--and I track hospitalizations, cases, waste water--I just have no faith in the the local or federal public health response to be nimble enough to track waves and act on them.
My northeast county went red recently and absolutely nothing happened.
What would you think about assigning people to "boarding groups"?
Those patients at highest risk (for whatever reasons) would be assigned to "Group A", those with somewhat elevated risk "Group B", most people "Group C", and those for whom there are concerns about the risks of the vaccine itself (e.g., younger males) "Group D".
With such a system, we could not only say that Group A gets boosted more frequently than the others, but perhaps there might be lower threshold for community spread that would get the relevant authorities to say "If you are in Group A or Group B, now is the time to get boosted; Groups C and D should hold off for now."
It's a coarse-grained method of trying to address both the population-level and individual outcomes.