### The Volokh Conspiracy

Mostly law professors | Sometimes contrarian | Often libertarian | Always independent

# A Point System for the Vaccine Line

|

The priority order for scarce Covid-19 vaccines has received considerable debate. Should the elderly be ahead of essential workers? Where do teachers stand in line? What doesn't seem to receive much attention is the basic model for a priority system. The assumption is that there will be a line. First will be the group with the highest-priority characteristic, then those with the next-highest priority characteristic, and so on.

An oddity of this approach is that a member of two high-priority groups receives the vaccine no earlier than a member of the higher priority of these groups. The current priority list has health care workers at the front, then nursing homes, then first responders, then those with health risks, then elderly, then essential workers, then teachers, and so on. But what about a teacher who is elderly and faces serious health risks? There might be an argument that this person should be ahead of first responders -- or at the very least, at the front of the line among the many who have health risks. But the proposed system treats each person based on the single characteristic that moves the person as close to the front of the line as possible.

It is a univariate system for a multivariate world. Forget about interaction effects. But couldn't we even consider a points system?

Each characteristic in such a system would correspond to some specified number of points, and the points would then be summed to produce a total score, which in turn would determine someone's place in line. Our elderly teacher with health risks would be closer to the front of the line than someone with just one or two of these three characteristics. A points system also could allow for more distinctions within each category. Instead of treating all elderly as an undifferentiated group, the system could assign different points values for different ages. A 64-year-old would not be treated exactly the same as a 30-year-old, and a person who is extremely obese might be treated differently from one who is just marginally obese. People with some health conditions are more vulnerable than others, and that should be reflected in their place in line.

A point system would yield a more granular ranking. A priority system that may place many millions of people at the same point in line leaves unanswered the question of how health care providers should prioritize within each group. Telling ten million people who want the vaccine that it's their turn when there is only enough vaccine for half of them will predictably result in an avalanche of phone calls, attempts at influence, and anger. There will inevitably be some uncertainty about just when it's anyone's turn, given the lack of clarity about how many people exist in each category and how many will want to be vaccinated, but a points system would at least give local vaccine providers a metric that orders patients.

So far as I have found, no one has recommended a points system. Why?

Twenty-dollar bill. Maybe this is the proverbial \$20 bill on the sidewalk, and I am the first to invent the idea of a points system for vaccine priority. Much as I would like to pat myself on the back, I don't think so. There are many rankings that do rely on points systems of one kind or another. (Consider, for example, U.S. News and World Report rankings.) The officials creating the priority system might not have discussed a points system, maybe even didn't consciously think about it, but that just invites the next question of why they implicitly rejected it.

Complexity for patients. The most obvious answer is that a points system would be too complex for people. But it's not hard to add up a few numbers. Online calculators could make this easy, and health-care providers could tell people without online access their scores. This isn't nearly as complicated as filing taxes.

Complexity for committees. The priority list is the result of a complex negotiation involving the CDC, the Advisory Committee on Immunization Practices, and the Administration, and no doubt others. It may be easier to develop a simple framework than a more complex one. The last thing we'd want is for the vaccine to be delayed because we can't agree on how to allocate points. And so the decision-makers assign themselves a simpler task. This seems more plausible, but it's not entirely satisfying. Legislative bodies, after all, often produce rules far more complex than a simple points system. Moreover, a points system creates the possibility of compromise. One reason that juries hang on a criminal sentence or damages much less often than on guilt or liability is that compromises are easier.

Complexity for vaccine providers. Vaccine providers may need to perform at least some minimal verification of patients' entitlement to receive a vaccine at a particular time. For example, they might ask for a paystub to prove that a patient is an essential worker. With just one group at a time, there is only one piece of information that they will need to verify. With a multivariate points system, they may need to verify a patient's ranking in each category. But this is not an elaborate system of adjudication. Much of the verification is likely to be cursory anyway, and some variables (weight and age) are easily (if occasionally imperfectly) verified.

Legitimacy. A points system cries out for some underlying methodology. That requires a theory of the relative importance of different goals, such as vaccinating those who have the greatest risk of dying if they contract Covid, vaccinating those who are most likely to spread Covid, encouraging economic activity, and compensating for social disparities. Any priority system reflects some weighting of these goals, but less transparently. It's easier to say "we're letting the elderly go ahead of essential workers" than to say that someone's status as elderly counts 1.3 times as much as someone's status as essential. Why that number? But pseudoscientific precision might lend more apparent legitimacy to the project rather than less. Moreover, a simple line is also arbitrary. It may not feature arbitrary numbers, but it will include somewhat arbitrary decisions about which group is first.

Irrelevance. It's not just that we don't have a good political methodology for weighting different goals. We have no shared comprehensive economic or moral theory that even in principle would allow us to make the relevant trade-offs. The moral dilemmas are legion. Is an elderly life worth less than a younger life, either because the elderly have fewer years remaining or because they are less likely to be working? Should groups that have acted relatively irresponsibly (say, young adults) receive the benefit of the vaccine early to protect others? What is the appropriate trade-off between economic activity and life? Add to these a myriad of scientific and economic questions, and serious doubts about our ability to get the priorities right arise. That doesn't mean we should give up altogether, the theory goes, but there's no point in worrying about second-order issues when we are probably wrong on some of the biggest questions. But here the second-order issues are easier than the first-order issues. We are pretty sure that age is relevant and so is being an essential worker. Given these very mild assumptions, shouldn't an elderly essential worker be ahead of someone in just one of those two categories? Surely, that will produce at least some benefit in health or wealth.

Federalism. The federal priority list is just a recommendation to state officials. Presumably, state officials may change priorities or develop subpriorities, and these will be akin to a points system. But if so, the recommendations really ought to be at a higher level of generality, indicating the characteristics that should generally move people up in line and perhaps their relative importance. A points system is not an elaboration of but a change from the recommendations being developed. If the ultimate goal is for the states to create or consider points systems, the recommendations should say so. Many states are likely to follow the federal guidance because it allows them to avoid making hard choices that are sure to anger some constituents. Thus, the federal guidance either should make clear that states have more decisions should make or should provide good default rules.

Most people, I suspect, will prefer the existing approach to a points system. They value simplicity and fear technocracy. In my judgment, if the government is going to make value choices, it ought not make them crudely. 64-year-olds and 30-year-olds should not be at the same place in line. One might reasonably question whether the government should be setting priorities at all, and perhaps the crudeness of the government's approach is all the more support for private ordering. But vaccines have positive externalities, so there is a case for at least some government involvement. And if the government is going to set priorities, it ought to do it right.

Editor's Note: We invite comments and request that they be civil and on-topic. We do not moderate or assume any responsibility for comments, which are owned by the readers who post them. Comments do not represent the views of Reason.com or Reason Foundation. We reserve the right to delete any comment for any reason at any time. Report abuses.

1. Maybe educated, modern, civic-minded Americans should reject pointers on government from people who revile, sabotage, and subvert our government?

1. You clever Dick, you.

2. people who revile, sabotage, and subvert our government?

Like the people who decided the FDA should take a four day weekend for Thanksgiving?

3. Gor tired of haikus? Back to the ad hominem attacks? The last refuge of someone who has nothing substantive to say.

4. Meaningless blather abound from you regardless how much a post might stimulate rational discussion

2. I suspect demand for the vaccine from the general public will be minimal enough that no triage is necessary, though the first doses are already going to high risk occupations or individuals, as initial quantities will be limited due to production.

1. Preparing excuses for Trump's failure to order enough doses?

1. Bernard,
I don't see that comment as making any excuses.
Far more does will be needed than can be provided within the next half year. Mr. Biden will face this same problem. And why assume that America is at the front of the line until it is done with vaccinating.

2. Well let's review how many doses have been secured by signed contracts with the manufacturer. Doses in millions and cost in billions, but keep in mind that probably 2 doses will be need for full immunity:

AstraZeneca 300m \$1.2b
Novavax 100m 1.6b
Pfizer 100m 1.95b
Johnson and Johnson 100m 1b
GlaxoSmithKline 100m 2b
Moderna 100m 1.5b

AstraZeneca, Pfizer, and Moderna are all in the late stage of testing and approval, and that's half a billion doses right there, enough for 250 million people, even if the other vaccines don't pan out. And from what I'm seeing in the polls 250m doses will exceed the demand, unless they make the vaccine mandatory.

2. Oh I think there will be substantial demand, mainly because there are lots of activities that maybe restricted if you are not vaccinated. For instance usually I like to winter in SE Asia, this year I can't, at least not without onerous testing and quarantine requirements. I hope next year with a vaccine certificate, then I can travel without restrictions.

I can also see bars and restaurants be required to have their employees vaccinated inorder to reopen fully. Or teachers too, because they are so specially vulnerable.

3. Whatever the priority system, leave it up to the states since they know better the conditions in their states (e.g. a state with an older population [FLA?], would prioritize nursing homes where a state with a younger population [Colorado?], might prioritize first responders), and keep feds out.

The feds can prioritize their own agencies (e.g DoD over State?).

1. Agreed.

2. Also agreed, but perhaps with explicitly non-enforceable guidance? You hit on a distribution method; I can say that State emergency planners will, or have been working on this already.

4. An actual point system would likely not prioritize health professionals as there is little evidence they are loci of spreading. Given nursing home populations leading to majorities/pluralities of deaths, that population is arguably a favorable choice.

But after that, a well-designed point system would end up being INCREDIBLY controversial. It would basically be a system of evaluating, "who is an agent of chaos?" And then you end up "rewarding" said agent of chaos with a vaccine. Who would these people be? Well you got your party-goers, the restaurant-addicted (see urban politicians), the travel-addicted, etc. So, to maximize your vaccine's effectiveness, you must, eventually, validate those behaviors!

1. Any point system would likely just replicate the existing priority: 10 points for being a healthcare worker, 9 points for being a nursing home resident, 8 points for being a first responder, 7 points for health risks, 6 points for being elderly, etc etc down the line. It would just bump people up for matching multiple groups

The problem is a system like that would require computers to manage, and even though the government has plenty of computing power they still manage data like they're working out of a giant binder full of names

1. That point system has the virtue of being a point system, and no other virtue. It doesn't increase the speed that the country decreases its transmission rate.

2. Already health professionals are being prioritize withing their respective hospitals and medical groups. For example, The hospital in which my daughter is a physician will start vaccinating next week and is unlikely to be finished with its staff until sometime in March

5. How about prices? The more you pay, the sooner you get the vaccine?

1. No, that's not socialist enough, we don't want manufacturing vaccines to be profitable without subsidies!

2. Interesting concept.

3. Already addressed in the last paragraph, although not in a lot of depth. But markets don't do a great job when there's externalities (positive or negative) involved.

And given that the government already pays for health care for the elderly and many other at-risk populations, it's going to be playing a large role in deciding how vaccines get distributed no matter what.

1. It's alluded to in the final paragraph, but in a way that contradicts the rest of the post.

Any positive externalities associated with COVID vaccination argue for vaccinating the most likely spreaders - ie those who are the most socially contagious - the gregarious young. Who are the people least at risk themselves.

So for a points system, we're going to need extra points - arbitrarily chosen - for those most at risk; and extra points - arbitrarily chosen - for those least at risk. Good luck with that.

Rationing by price, however wicked and capitalistic, does have the tried and trusted benefit of raising the maximum amount of money, without recourse to tax, to defray the costs of development, distribution etc. As well as having the equally valuable benefit of avoiding the need to devise and implement a bureaucratic rationing system. Not only saving yet more money, but also temporarily retarding the tendency of petty bureaucrats to megalomania, and so bolstering their mental heath.

6. The myth/joke about the \$20 reminds me of a crazy event that happened to me once. First of all, here is the joke as quoted from the link:

There is a well-worn joke in the economics profession that involves two economists – one young and one old – walking down the street together:
The young economist looks down and sees a \$20 bill on the street and says, “Hey, look a twenty-dollar bill!”

Without even looking, his older and wiser colleague replies, “Nonsense. If there had been a twenty-dollar lying on the street, someone would have already picked it up by now.”

My wife and I were taking a walk in April 2017 at the campus of the University of the Virgin Islands on St. Thomas. It was a few hours after the Jouvert parade during Carnival...a time of wild abandon. As we were walking, we saw a young couple across the street replacing a flat tire on their car. They were having some trouble. As we were continuing to walk, I looked down and saw a \$20 bill. Wow...someone was unlucky at Jouvert. That probably caused some real hurt feelings. I picked up the \$20 bill and we continued walking. We reached the end point and turned around to head back to our car. As we were closing in on the couple with the flat tire, I mentioned to my wife that the couple probably needed that \$20 bill more than we did and that I should give it to them. She agreed. So as we walked close to the couple, I went over and gave them the \$20 bill.
We walked on another minute or so and, low and behold, on the sidewalk in front of me was another \$20 bill. I picked it up and I turned to go back and give it to the couple. Then I stopped. I had the feeling that the Universe wanted to give me a \$20 bill. It gave me the first one and I gave it away. So the Universe gave me the second \$20 bill...as if it was saying, "We REALLY want you to have this \$20."

1. I picked \$50 off the pavement, once. But it was in the parking lot of a grocery store, so over my wife's half hearted objection, I took it in and dropped it off at the service counter.

I hadn't even made it to the door when a desperate housewife with child in tow came in looking for it.

Fate did not deign to throw another one my way, though.

2. Stepped out of a diner once a windy day and \$20 bills were blowing by on the sidewalk, saw at least half a dozen go by. The guy I'd been eating with with managed to grab three of them. I was too fat and slow.

1. I was too fat and slow.

Congratulations. You may be ahead of me in the vaccine line.

That is unless my current strategy of eating 6000 calories a day to get me to "obese enough" to get a vaccine earlier is more successful than the math seems to suggest.

3. There is a (very) old Irish joke which, being of Irish ancestry, I am allowed to tell, and you are not.

There's this fellah named Liam who has moved to Liverpool, who goes back to visit his home village in the County Kerry. He gets talking in the pub about how great the opportunities are in Liverpool - sure and the streets are paved with gold, so they are. You can literally walk along and pick up money off the streets, so you can.

Much impressed by this, Seamus - one of the listeners - decides to take the first ferry to Liverpool. He has barely stepped off the ferry when walking down the street, what does he see but a crisp five pound note there on the street, right there before his very eyes. He stoops down and picks it up, muttering thanks to good old Liam for the tip, and puts it in his pocket.

He takes a pace or two further, then stops and frowns. He takes out the five pound note, smoothes it out, and lays in back on the street.

No, says Seamus to himself, I'll start work tomorrow.

7. The first question to ask is whether a point system would be more accurate, assuming you even know what you are measuring.

I doubt it.

First, the interactions you talk about are not, in general, additive. If you give say, ten points for being 70 years old, and ten for being diabetic, that doesn't imply you should give twenty for being a 70-year-old diabetic.

Then, they are somewhat correlated. Obese people are more likely to have a variety of ailments. You don't want to give points for all these things.

What you would need is a way to measure the marginal impact of a variety of characteristics on whatever metric you decide is appropriate.

Talk about complexity, arguments, incomprehensibility, arbitrariness.

Best to leave that \$20 bill right there. It's counterfeit, so if you pick it up and try to spend it you're asking for trouble.

1. Bernard,
Excellent point. Moreover, many of the potential co-morbidities have actually had very low correlation with actual fatalities. The largest except at a level of 30% correlation is chronic kidney disease.
https://medrxiv.org/cgi/content/short/2020.09.30.20204990v1

8. "Thus, the federal guidance either should make clear that states have more decisions should make or should provide good default rules."

Huh?

9. I think a complex point system would result in more jockeying for power, not less. Beyond that, your discussion of points to be allocated leaves out a factor that is very important vis-a-vis the Pfizer vaccine: logistics. Logistically, it will be better to have a process that involves the least possible shipment of containers. It will easier to deploy that vaccine at large centers with very good cold storage capability. Prioritizing people who can and will return twice to a central facility would be useful from that point of view.
My general view is that there are too many factors go create a good model that actually predicts the lowest rate of excess deaths. Even worse, trying to calculate "fairness" is impossible, as some of that is a value judgement. I think as a matter of fairness those working in food processing should get it before teachers. They've been in more direct danger longer with no break. But most conversations bring up teachers as a group in need of protection and forget about those working blue collar jobs in food processing.

1. As a point of reference, when the oral polio vaccine was introduced in the early 1960's., it was typically done in mass at a large central building in town, in my case, the town's high school.

Vastly more efficient, for mass vaccination.

2. Too much effort to implement a point system from the top down. And no true libertarian would consider such a proposal to be managed by government.

-Scarcity is not all that much of a problem. Between the first dose administered, and the end of scarcity in the Spring when anyone will be able to access the vaccine at will, an additional 0.03% of the general US population will die of Covid. (100,000 out of 350 million). In that same 6 month time, typical US deaths would be 1.5 million. An allocation scheme might only trivially alter the rate of pandemic resolution.
-Economic, social, and QUALY considerations could reasonably be factored in. Teachers as a group are low risk/low yield population to vaccinate from a mortality perspective (especially if they take vaccine from the elderly or medically compromised), but if it shuts up their political demands while they hold schools, children, and families with children hostage, then send them to the front of the line.
-People have alternatives while waiting for vaccine, such as decreasing personal exposures. Even within health care I see many examples among my peers of sloppy/infrequent use of PPE, as well as excessive personal time risks taken.
-Covid is just not that lethal. My 80 y/o parents got it, were quite able to stay at home, and the roughest patch was dealing with the side effects of the steroids (poor sleep, texting in all caps at all hours of the night...). It ain't Ebola.

10. I don't tend to like quantifying moral calculus.

1. A transparent quantification of risk, published clearly and done reasonably would appeal to many people.

E.g.:
Age: 0 - 12: 0 points
12 - 30: 1 point, ....
75+: 10 points

Pre-existing risk of COPD, diabetes, and a small list of known risk factors for Covid death: 10 points
Any other pre-existing health condition: 5 points

Occupational risk:
Health care: 10 points
First responders: 10 points
Essential service workers: 7 points

The alternative is the usual Game of Pull, where favored persons and constituencies jockey for vaccine behind the scenes. And then take private jets to Mexico to celebrate.

Maybe you're right and morality should be quantified to best be operationalized.

But I think it's reductive. And I don't think you're going to bring many with you.

1. So you prefer the Game of Pull, then? It has warmth to it for sure, as long as you're in the inside lane.

1. It's not one or the other. Plenty of examples of morally founded programs, public and private, that don't use a points system and also are not super corrupt.

1. S0,
Yet in some way, organizations need to make some calculus of priority. That also happens within organizations that have a ranking system for employees.
What is missing in KevinP's system pf measures is any real measure of uncertainty that tells us that in reality 17 points is not distinguishable from 15 points, but it is distinguishable from 5 points.

2. Good but what conclusion do you draw from that?

Do you let people make their own moral calculations privately?

Or do you still favor some men in government dictating the decisions for others, only in a more non-quantifiable way?

3. But in fact hospitals must and are doing that, like it or not.

4. But what's the alternative? You could rely on the market, but that just results in its own price-based quantification. The tiering that the government does now doesn't apply scores like those proposed here, but at a high level is doing the same thing by assigning a number to different classes of people and only providing the vaccine according to that classification. Unless we were just to fallback on a lottery, we're necessarily instantiating the moral calculus in some sort of real-world classification system.

1. You could rely on the market, but that just results in its own price-based quantification.

Not 'just".

It also results in money departing from pocket A and arriving in pocket B. The market isn't just a scoring system it's an actual performance. If pocket B belongs to someone who has made a better mousetrap than other folk, success is reinforced rather than damped.

If pocket B belongs to the government, which would otherwise have to fund the vaccine from more taxes, or scrimp on other spending, then the market allows the money to be raised from volunteers instead.

You do not get this effect with ration cards.

1. It also means that the poorest folks just aren't going to get it.

So simply put, if you want to ever go into a grocery store again without a mask on, you want those minimum wage workers to get vaccinated. Which means that yeah, a purely capitalist system of distribution will fail you.

5. I don't like it either, Sarcastr0. But it is reality that people will choose to do so (quantify the moral calculus). If you miss the cutoff score by a point and then die later of covid-19...Ay yi yi.

Because I am a capitalist and libertarian in outlook, my first questions will be: Can I pay to jump the line, and if so, what is that cost?

11. Angels on the head of a pin.

30 days from now, the 10% of Americans most at risk from Covid will have been vaccinated, including every front-line health care worker and every home-bound elderly person who wants it.

By the end of January it will look more like 25%, and cases and deaths will be dropping like a rock-- down 90% and falling.

No point system needed-- just move that stuff as fast as logistics will allow.

We all have had Covid fatigue so badly for so long that we can't see what's about to happen.

In a few *weeks*, this is going to be all over, except for the tar and feathering of the political tyrants.

1. That is just pollyanna optimism

12. The case fatality rate for individuals below the age of 60 was less than 1%.

In other words, the body's immune system is 99+% effective

What is the vaccine really accomplishing if it effective rate is 95% which is less than the effective rate of the human immune system?

1. I hear that some people are above the age of 60.

1. The case fatality rate for ages 60-69 ranges around 2%-3%

2. Taking your numbers at face value, if the body's immune system is 99% effective at recovery, then you still have two shots at the virus with a vaccine in place.

First the virus would have to pass unrecognized by the vaccinated body with a 5% rate, and then your immune system would attempt to recover with a 1% failure rate. So you would have a 1% of 5%, or .05%, chance of dying as opposed to the 1% without a vaccine.

Certainly this is oversimplified, but the math is pretty clear given the numbers you have provided.

13. There are rumors that at least two of the tested vaccines make you somewhat sick when you get them. For seniors it may not be worth the risk.

In my case I would want to first see the numbers for both vaccine risks and disease risks without the vaccine. I also intend to wait for millions of others to take it first and be my guinea pigs, especially since Congress has given the makers liability for any side effects including death.

As for point systems, any such system would sound to most of us just like China's evil social credit score. And the public is right about that.

1. If the demand for the vaccine outstrips the supply, then you have to have some fair and reasonable method to allocate it. This could be:

1) A simple waiting list with no exceptions.
2) A point system of some kind.
3) Influence and pull.

What do you prefer?

2. "There are rumors that at least two of the tested vaccines make you somewhat sick when you get them. For seniors it may not be worth the risk."

That is true for a lot of vaccines. As mentioned above, for healthy individuals, the case fatality rate is less than 1% - ie the natural immune system is 99+% effective, so why take a vaccine that is less effective than the natural immune system

3. JDG,
By the end of January. we all will have real data addressing all of your concern

14. There is, however, some focus on the prioritization of who gets to not take vaccines.

Cornell offers 'person of color' exemption for flu vaccine requirement

https://www.campusreform.org/article?id=16344

1. I never heard that POC didn't like vaccine
I have heard some states are planning to give them priority for vaccinations

2. "Cornell offers ‘person of color’ exemption for flu vaccine requirement "
Complete racist stupidity.

15. I think that left-handed seniors who are red-green colorblind and their families should be first.

16. The point system is too complicated, and too specific to our current crisis. It doesn't prepare us for the next one.

Why don't we just divide everyone into Essential Persons and Non-Essential Persons, and make it a permanent part of our identity documents.

In addition to solving the vaccine problem it would make a lot of future decisions easier as well.

1. Just let people self identify as essential and non-essential. The past 8 months has created incredible clarity within many work places as to who is essential.

17. Shirley Jackson wrote about a fair method of selection, although is is entirely (?) random. I like KevinP's exposure risk rating, but think many would have an issue putting others first, if the shitty behavior of the last year is any indicator.

18. A "point system" is just taking a more granular approach to a priority system.

And I'm not sure what it accomplishes. Fact is, the way it'll probably break down is that --depending on locality-- the local hospital will advertise that the first month or so will be group A, then group B, then group C and so-on. If you're a member of that group, then you call and make an appointment. The broad but discreet categories will make it hard to game and largely unnecessary to verify.

What would a point system improve over this? Assuming that it's still a "if you're in this range, call and make an appointment", then it'll be the same thing, but with narrower ranges. So it'll be something like "41-45 points get week 1, 36-40 points get week 2, [...]" and so-on. So... largely the same, but doing smaller time slices.

Fact is, a granular and nuanced system only helps if you're doing mandatory door-to-door vaccinations, and not just making them available to prioritized groups ahead of the masses. And I just don't see door-to-door vaccinations in most parts of the country. Maybe in a few big cities, towards the end, they'll start sweeping neighborhoods trying to catch any and all that didn't make an appointment, but since you'll need the booster shot that seems far-fetched.

And that last comment is weird. CDC guidance is obviously just CDC guidance. The states all know that coming up with an actual plan is their responsibility. Don't project your ignorance onto them.

1. A point system can take aggregated risk into account.

For example, a 75-year old doctor or nurse who suffers from diabetes is likely at some higher aggregate risk than individuals who are in only one category.

Is there any hard data to support this? No, not that I am aware of.

Is it an unreasonable hypothesis? Also No.

1. I don't think anyone is contesting the hypothesis.

What folks --including myself-- are contesting is the notion that (A) a proposed "point system" offers any meaningful improvements over the broad priority guidance the CDC has already issued, and (B) that the CDC should be issuing granular guidance on this topic.

2. Think of the point system as similar to airlines boarding by seat row number, where there are no special categories.

First to board / get the vaccine: Those with 25 points or more.
Next week: Those with 22 points or more.
Third week: We'll announce the point threshold next week after monitoring demand vs. supply.

This kind of point threshold is done routinely in many settings. In US immigration, for instance, many immigration quotas are backlogged. Every month, USCIS announces that those who filed their papers after a certain date may now proceed to processing.

1. Unless states send out draft vaccination notices with "you shall appear" dates/times on them, I don't see how voluntary vaccination is comparable to your examples.

The simple fact is, once you acknowledge that most vaccinations are going to be of the "call in to make an appointment sometime in the next two weeks" variety, the ability to enforce such fine detail vanishes.

1. "the ability to enforce such fine detail vanishes."

How? When you make the appointment, you provide your score. If your score is above the threshold, you can make the appointment. If it isn't, you are asked to try again the next week.

19. IIRC the military used a point system for discharging soldiers at the end of WWII, extra credits for medals, etc.

1. Yup, I had an old neighbor who was a Sergeant in the Air Force, who explained it to me once. It wasn't just medals, you could get points for all sorts of fairly mundane things. My neighbor, who was a very sharp cookie, as soon as he heard of the schem, read up all the rules and worked out how to maximise his points without doing any extra work - just by making sure he only did work that qualified for points.

I think he said there was a maximum you could earn for different things, so once he'd hit his maximum for one category, he's stop doing that and flip to the next category. He got the maximum points and was discharged very quickly.

As he said - fortune favors the smart.

From: The Grumpy Economist
Free Market Vaccines

Posted: 08 Dec 2020 07:29 AM PST

Part 1: Who should get the vaccine first? Sell to the highest bidder. The disease and recession go away faster.

Part 2: The cost of perfection. The vaccine was invented in a weekend, available in February. In free market land, we would not have had a pandemic, or a recession. 284 thousand people would be alive today. That is the cost of FDA "protection."

Part 1: Who should get the vaccine first?

Absolutely nobody has mentioned in public the free market answer: Sell to the highest bidder.

It's not as dumb as it sounds. Sure, there is an externality. A good vaccine policy might be to give it to those most likely to spread it to others, with the goal of swiftly reducing the prevalence of the disease. That argues for giving the vaccine in bars.

That is not our public policy. The entire discussion centers around who should be protected first, from a disease whose prevalence is taken as given. Old people, nursing homes, health care workers, essential workers -- the argument is not the externality. The argument is entirely who should get the individual benefit of protection from the vaccine. Just why "to the highest bidder" is wrong is then much less clear.

The case is stronger than usual, for there is a second way to avoid infection: Stay home. Social distance. Wear protective gear. So the question is not, really, "Who should be protected from the virus?" The question is, really, "Who should get a treatment that allows them to be out and about, risking contact with the virus, rather than protect themselves by traditional means?" It is really mainly an economic benefit, avoidance of the cost of other measures to stay healthy. There is an economic answer: people should be out and about first who generate the most economic benefit from being out. And, therefore, are willing to pay the most to get the vaccine.

To say nothing of the incentives. If vaccine companies can charge what they want to first adopters, and the cost to the rest of us is to stay home for a few more months, they can make boodles and boodles of money, incentivizing new vaccines even better. The government does not decide who gets the iPhone 12 first.

"But the rich will be able to afford it first," I hear you complain. Yes indeed. Principle one of economics, don't mess with the price system to transfer incomes. "But we won't make the income transfers, so we have to control prices and ration" I hear you complain. So, here we are in the midst of a pandemic, in the midst of an incredibly dangerous economic situation, with \$5 trillion of federal debt in the rear view window, the main point of fixing prices and rationing vaccines is... to transfer incomes.

If it goes to the highest bidder, then the highest value activities, that benefit most from reduction in social distancing, come back faster. I don't know what those are, but pretty much by definition, the economy recovers faster. That brings back jobs a lot faster than stimulus checks. Heck tax it and transfer the money to people who choose to stay home.

I'll stretch free market nirvana this far: If the government wants to hand out vaccines to whoever it thinks should go first, ok, let it buy the vaccine on the free market, on budget, paid by visible taxes, and hand it out. But it should not forbid anyone who wants it from paying for it, nor forbid vaccine makers from selling to whoever wants it, to artificially keep the price down and hide the immense transfer in its actions. Looked at for what it is -- only and entirely a ban on private transactions -- it is amazing that we meekly put up with such wholesale trampling of our rights to transact, to property, and to pursue our own health. In the most important market in the world right now, vaccine producers may only sell to governments.

No, it's not as dumb as it sounds. At least economics should start with "to the highest bidder," and come up with some well documented market failure, and a public allocation system that mimics the highest bidder allocation. That nobody dares say this in public, not even my favorite libertarians (that I have seen -- send links to anyone else nuts enough to say this in public!) is a little surprising.

Instead... Well, here is (second hand and I may get this wrong, corrections welcome) how Stanford is going to do it. Our first allocation goes to health care. OK, that is a likely answer to "if Stanford had to bid for it, what is our highest value use." The hospital system, however, can't figure out who within health care should get it. Is it "fair" for doctors to get it first, but not custodial workers? The crack team of medical ethicists couldn't come up with an answer. So they're going to do it randomly. I don't have to tell you in the middle of a pandemic who gets it first under the discipline of actually having to bid a market clearing price to get it first. Watch the normally crystal clear Scott Gottlieb run around in circles on the pages of the Wall Street Journal trying to figure out who should get the vaccine when. Well, without a guiding principle, there is no where to go but circles.

In India, meanwhile, that bastion of... informal.. if not free markets, it appears you can sign up to buy the vaccine, for about \$8. Markets in everything, as Marginal Revolution says documenting the story, but not here.

Part 2: The cost of perfection

We had the vaccine the whole time, documents David Wallace-Wells in New York's intelligencer, documenting and popularizing a known but overlooked fact.

Moderna’s mRNA-1273, which reported a 94.5 percent efficacy rate on November 16, had been designed by January 13. This was just two days after the genetic sequence had been made public

the Moderna vaccine design took all of one weekend. It was completed before China had even acknowledged that the disease could be transmitted from human to human, more than a week before the first confirmed coronavirus case in the United States. By the time the first American death was announced a month later, the vaccine had already been manufactured and shipped to the National Institutes of Health for the beginning of its Phase I clinical trial.

Even under operation Warp Speed -- a truly commendable accomplishment of the Trump Administration that, maybe a year or so from now the TDS crowd might acknowledge -- the only thing we have been waiting for is FDA certification: Randomized clinical trials to prove safety and efficacy, before anyone is allowed to take the vaccine.

What's the free-market way? A drug company can sell a vaccine on January 14, and you can buy it, without fear of going to jail.

Sure, there is an FDA, and a Federal Trade Commission which monitors drug labeling. The vaccine has to say "this is totally untested, and has not been proven safe or effective in clinical trials" and offer a stack of paper about known risks. You sign a stack of consent forms. If you take it, you're enrolled in our big national database -- you just volunteered for the national non-random clinical trial. (We don't collect much data on drugs that are out there). The FDA rapidly collects information. At the same time, randomized clinical trials are going on. Drugs can give more and more hopeful labels as the results roll in. At some point after Phase III and FDA review, a drug can get the official FDA seal of approval. No, insurance and medicare don't pay for non-approved stuff. This is free-market nirvana, you pay for unapproved medicines if you want them (see part 1). There is an FTC and a tort system. Drug companies that sell things they know are unsafe or ineffective pay billions.

What happens in free market nirvana? Yes, there are quite a few more cases of people who are hurt by side effects. Not that many actually, as we are following the early adopters carefully and broadcasting data as it comes out. Quite a few useless drugs get tried a bit more widely.

But, going on the current assumptions that these made in a weekend vaccines work, we would not have had a pandemic at all. Every job lost, every business closed, all 284 thousand US deaths, \$5 trillion of federal spending, the biggest (though mercifully short) recession in US history, would not have happened. All of this cost stems from one thing -- the ban on using any medicine before the FDA approves it.

The benefits of FDA protection -- the prohibition of selling drugs before full randomized clinical trials have been run and then painstakingly reviewed -- are not zero. They are the people who are not hurt by the slightly larger (than in clinical trials) experimentation with new drugs.

The costs of this FDA "protection" are immense.

In the free-market world, we would not have had a pandemic.

Maybe free markets aren't so dumb after all.

(We also would have had home tests months ago, which at zero side effect to anyone would have slowed if not stopped the pandemic. But you all know that story.)

Wallace-Wells:

our approach to the pandemic here raises questions, too, about the strange, complicated, often contradictory ways we approach matters of risk and uncertainty during a pandemic — and how, perhaps, we might think about doing things differently next time. That a vaccine was available for the entire brutal duration may be, to future generations trying to draw lessons from our death and suffering, the most tragic, and ironic, feature of this plague.

Indeed.