How a lottery can bring equity to the COVID vaccination process

The rollout of the COVID-19 vaccine across America has been incredibly confusing, disorganized and very user-unfriendly. Now is not the time to point fingers about why leaders wasted crucial time getting organized. Now is the time to focus on best practices that deliver the vaccine in a fair, simple, efficient way that protects hundreds of thousands of lives. 

It is troubling to see how consistently unfair the current vaccine rollout is in some places. Conversations with neighbors and friends leave an indelible impression that those getting vaccinated early are the clever and aggressive ones. Those blessed with internet and phone skills. Those lucky enough to have flexibility in their schedules. In other words, those who can win the “first to call” game.

It should not be this way. We need a system where an isolated 77-year-old widow has the same chance of getting an early vaccination as a 77-year-old couple who is active, has lots of friends, and can keep up with the rules of the “first to call” game. Likewise, the system should not penalize a 35-year-old mom who works two jobs and juggles family responsibilities if she doesn’t have time to play the “first to call” game.

There is a fair and ethical strategy that some local authorities have already implemented to create more equity in allocating the timing of vaccinations. It involves two key rules: 

• Rule 1: Every person in a specific age or risk group who fills out a simple form providing contact information and stating they want the vaccine has an equal chance at securing an early appointment. Priority should be given to those most at risk, such as older adults and those from communities of color, and the criteria should be flexible enough to account for specific zip codes where the vaccination need is greater.
• Rule 2: State and local authorities should be responsible for setting up appointments. If you assign this to individuals, there will be no equity in who gets the vaccine when. The process must be transparent and free of political considerations. 

One increasingly popular method is to use a randomized lottery approach. Once a person fills out a form requesting a vaccine appointment, their name is entered into the lottery. When their name is chosen, the relevant state or local authority schedules their appointment. Appointment locations take into account ease of access and other potential logistics barriers.

The District of Columbia, Minnesota, Idaho, Iowa and Tennessee are already using some form of lottery to randomly assign vaccination appointments precisely because they wished to address issues of fairness in vaccine distribution. Weighted lotteries can further balance the equity scale in favor of those who most need it by including additional risk criteria to benefit populations and locations disproportionately impacted by the pandemic. 

Scientists, medical ethicists, economists and other experts at institutions such as MIT, Boston College, Johns Hopkins Medical Center and Harvard Medical School have designed lottery and random selection models that work very well. One such approach has been used to determine which patients received remdesivir, a life-saving antiviral COVID-19 medication in short supply. Patients accepted the results, even when they didn’t win, because they saw the system as being fair and transparent.

Implementing a random selection lottery system at the local level is just one of the tools that needs to be considered to ensure fairness in a live-saving process that affects all Americans. Equity needs to be the guiding principle in the strategies and tactics implemented to defeat this pandemic. This requires reaffirming our societal commitment to fairness which is, after all, what America has strived to embody for more than two centuries.

Ramsey Alwin is the president and CEO of the National Council on Aging. James Knickman is chair of the Board, National Council on Aging.