By Elisabeth Buchwald
Economists hold that a good is most efficiently allocated when it goes to the people who value it the most and hence are willing to pay the most for it.
It’s for that very reason that bioethicists and infectious-disease doctors worry that initial doses of a coronavirus vaccine, once granted an emergency-use authorization, will make its way into the arms of wealthier Americans first.
The Food and Drug Administration in December granted emergency-use authorization to vaccines from Pfizer PFE and its German partner, BioNTech BNTX , and Moderna MRNA . The Centers for Disease Control and Prevention have recommended that that states prioritize access for health-care workers and long-term-care facility residents while supply is limited.
Health-care workers and nursing-home residents should be the first to get vaccinated, the Centers for Disease Control and Prevention’s Advisory Committee on Immunization Practices, or ACIP, recommended on Dec. 1.
States aren’t required to follow the committee’s recommendations, but health experts are urging governors to stick to ACIP’s recommendations going forward because it gives them a science-based framework to follow that can ultimately help end the pandemic more swiftly.
That said, wealthy Americans who are accustomed to flying in private jets and can afford to pay steep annual fees for personalized care through concierge medical practices aren’t too keen on waiting in line for a vaccine.
Speaking to Stat News, bioethicist Arthur Caplan of New York University did not hold back his feelings on how individuals with money and/or connections may try to skip the line for a vaccine.
“There absolutely will be a black market. Anything that’s seen as lifesaving, life-preserving and that’s in short supply creates black markets,” he said.
Dr. Ehsan Ali of Beverly Hills Concierge Doctor Inc. said he has been receiving phone calls and texts from patients “all day long” inquiring about when they can get the vaccine. His practice, unlike many other concierge practices, accepts some insurance plans.
Andrew Olanow, co-founder of the concierge service Sollis Health, which serves patients in Beverly Hills, Manhattan and the Hamptons, said he started fielding questions from patients as to when they can get a coronavirus vaccine as soon as the pandemic took off in early March.
His practice charges $3,000 a year for adults under the age of 45, plus $2,000 a year for each additional adult. For people above 45 years of age, the membership fees start at $5,000 a year plus $3,000 for each additional adult above 45.
“Once you started seeing trial data become available, particularly from Pfizer /zigman2/quotes/202877789/composite PFE +0.95% , that’s when we started getting much more pointed questions from patients,” Olanow said. They want to know exactly when there will be a vaccine, he said.
He tends to respond to these types of questions by assuring patients that he and his staff are taking all the appropriate steps now, such as procuring ultralow-temperature freezers to store the Pfizer vaccine, so that if/when it’s approved, Sollis Health be ready to get its patients vaccinated.
“We’ll be working hard to get access to the vaccine for the members of our practice when it becomes available to a certain risk profile,” Olanow told MarketWatch. “My guess is that we, as members of the private sector, will be able to move quicker than the public sector.”
As Gillian Tett wrote in the Financial Times: “Definitions of ‘pre-existing conditions’ may vary. As could the concept of ‘essential worker.’ In states such as New York and Illinois, for example, financiers and bankers were defined as essential workers during COVID-19 (which gave them the right to go into the office). So were journalists.
“The net result, then, will be numerous loopholes which could be exploited — or, to use the language of Wall Street, be prone to arbitrage.”
Ideally, the distribution of a coronavirus vaccine would follow the same principles and framework that informs organ-donation registries, said Govind Persad, a professor of health law and bioethics at the University of Denver.
At the United Network for Organ Sharing (UNOS), that framework is based on “medical utility” and “justice,” said Joel Newman, who has served as a staff liaison on the ethics committee at UNOS, a private nonprofit organization that manages the nation’s organ-transplant system under contract with the federal government.
Justice, he said, refers to fairness, while medical utility refers to “all the evidence-based criteria that we know would point to good treatment outcome.”
“The key in our experience is to strike a balance between these factors,” he said.
If medical utility were the only factor determining who receives an organ transplant , that could “mean that we treat more people who may be relatively healthy and who haven’t been waiting as long,” he said.
In contrast, “overemphasizing justice would mean that we treat many very sick patients, but many may die soon afterward or need a repeat transplant, thus removing the chance for better-matching people to get a successful transplant.”
To overcome these challenges, UNOS relies on a computerized matching system that scores an individual and takes into account other factors including the location of the donor and blood type.
However, an individual’s financial or social status is never taken into account, Newman, a senior spokesman for UNOS, told MarketWatch. Not only would that be illegal; it would also go against UNOS’s ethical code of conduct.
That said, wealthier people who may require an organ transplant are more likely to expedite the waiting process compared to lower-income people, Persad said.
Affluent patients can sometimes do this by getting on multiple organ waitlists in multiple facilities or multiple states, traveling to a foreign country, or convincing a doctor to “misstate exactly how at risk somebody is to move them up in line.”
Well-resourced Americans could potentially use those same strategies to receive some of the earliest doses of a coronavirus vaccine, said Persad, who co-wrote a paper titled “Fairly Prioritizing Groups for Access to COVID-19 Vaccines” with Dr. Ezekiel Emanuel, a member of President-elect Joe Biden’s coronavirus task force, and Dr. Monica Peek, a professor at the University of Chicago’s medical school.
For instance, because different states likely will follow different allocation models after health-care workers and long-term-care residents are inoculated, it could create an opportunity for arbitrage “where they’ll go where they think they have the best chance.”
Having some kind of residency requirement could make “shopping around” more difficult, he added, but ultimately there need to be vaccine-allocation criteria “that health-care providers internalize as an ethical obligation.”
“Ideally you’d also want to have one that makes sense to people,” he said.
When it comes to college admissions — another area where the wealthy often have the upper hand , for various reasons — one could make the case that an upper-income family donating money to boost their child’s chances of getting accepted indirectly benefits other students by potentially adding funds to scholarship programs, Persad said.
“That likely is not true for COVID-19 vaccines because there are hard short- and medium-term manufacturing constraints — rich people paying Pfizer or some other supply-chain actor more won’t make more vaccines available.”