Florida adds red tape for medically vulnerable while COVID vaccines go unused in Miami

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Ben Conarck, Douglas Hanks
·9 min read
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With 57% of Miami-Dade County’s 65-and-older population having received at least one dose of a COVID vaccine, a newly opened federal vaccination site sat with ample unused supply on Thursday, even as access expanded, albeit slowly, and with shifting but stringent rules.

Public health experts say it’s a sign that the state, and particularly Gov. Ron DeSantis, isn’t moving fast enough to make more people eligible for the vaccine. They also say the governor’s latest executive order requiring medically vulnerable people under the age of 65 to get a physician’s slip prescribing the COVID vaccine adds needless red tape that will keep uninsured and low-income people from their place in line.

The first week of March was marked by slowly expanding eligibility and an emerging trend of vaccine appointments going unused, at least in pockets of the state with less demand for the 65-and-older age bracket.

Meanwhile, demand is much higher in people under 65, including those with underlying medical conditions, but many have complained about onerous paperwork needed to get cleared for a shot.

In Miami-Dade, the county vaccination dashboard showed more than 20,550 first doses on hand on Wednesday, a surge of supply from three days in a row of vaccine deliveries.

Dr. Michael Lauzardo, an infectious disease expert at the University of Florida who has helped to organize vaccination sites, said in discussions with colleagues around the state, he’s heard about “a lot of openings because of challenges around restrictions and because of the gate-keeping process.”

Lauzardo said the age-restricted approach was the right move when DeSantis first made it, but now, with more than half of the state’s seniors vaccinated, there are too many restrictions in place. He believes the vaccine should be open to everyone, or at the very least, everyone over a certain age group, such as 40 and older, or 50 and older.

“The goal should be: Don’t leave an empty slot,” Lauzardo said. “Our enemy is not someone coming on the wrong day. Our enemy is an empty vaccine appointment. That’s the enemy.”

An uphill battle for the uninsured

Abel Iraola, a 29-year-old communications strategist from Hialeah, was lucky enough to score an appointment at a Publix on Wednesday morning, hours after the governor’s new guidelines for the medically vulnerable came out.

But within a few hours, he got a call from Publix telling him he would need to fill out a state-mandated form, which requires a physician to certify him as medically vulnerable.

Iraola, who doesn’t have health insurance, has been scrambling to get a doctor’s note ever since. On Friday, the day of his scheduled appointment, Iraola still hadn’t had any luck. A clinic he had been using occasionally said he would need to come in and get lab work done before they would sign off.

“On the one hand, I get it — it’s been since late 2016 since my records have been updated,” Iraola said. “But at the same time, it’s like ... come on.”

Dr. Rebecca Weintraub, an assistant professor in the Department of Global Health and Social Medicine at Harvard Medical School, said people like Iraola should be taken at their word. With her colleagues, Weintraub has argued for an “honor code” to make sure that people without healthcare access don’t get bumped out of their rightful place in line for a vaccine.

“Many Americans do not have a primary care provider, and many Americans have delayed their preventative screenings during this time,” Weintraub said. “Some of our most vulnerable populations, their co-morbidities have gotten more complex because of the nature of the pandemic and their limited access to food, exercise and just the stress of the pandemic itself.”

A vaccine honor system

Though it may seem counterintuitive, Weintraub said the simple question of “Are you a resident of Florida?” for example, is enough to deter most people who would access the vaccine inappropriately.

For that reason, Weintraub said people should be allowed to “self attest” to their age and medical conditions. She called the doctor’s note requirement an “unfortunate fence that’s gotten built, and that will not actually lead to us having an equitable or effective deployment of the vaccine.”

In addition to discouraging people with less access to healthcare, the policy also discourages low-income people.

“This is a free vaccine,” she said. “We’ve already paid $18 billion to produce the discovery side of mRNA vaccines, for example. And when people have to bring documentation, they’re getting concerned they may also be charged.”

Florida House Rep. Carlos G. Smith, an Orlando Democrat, has spent an inordinate amount of time lately helping people with underlying conditions figure out whether they can get the vaccines.

“It’s just frustrating because Governor DeSantis says that he’s a small government guy who wants to get rid of bureaucracy and red tape,” Smith said. “And yet, in order for the most medically vulnerable Floridians to get access to the COVID vaccine, he’s requiring them to jump through all of this bureaucracy and red tape.”

DeSantis’ office did not return requests for comment on the doctor’s note policy.

Miami-Dade looking at changes

Miami-Dade Commissioner Jean Monestime’s district north of Miami includes neighborhoods with some of Miami-Dade’s highest poverty rates. At a county COVID-19 briefing on Friday, he pressed Jackson Health administrators on how medically vulnerable residents could get vaccines without the uphill challenge of securing a doctor’s written approval.

“It may require them two to three weeks to get that note. For others who may have lost their insurance, they don’t have doctors. Could some of these people bring their prescriptions to show they have those conditions?” he said.

“I’m hearing a lot from my district that some of these people want to get vaccinated but they cannot get the doctor’s appointment in time to do so.”

Dr. Peter Paige, a Jackson administrator who serves as Miami-Dade’s chief medical officer, said prescriptions aren’t always evidence that a person fits the state’s definition of medically vulnerable.

“Your point is very well taken,” he said.

“As we’ve rolled out the process for high-risk conditions, we’ve tried to be liberal about it,” he said. Jackson does not require the state form, but will accept doctor notes as well, Paige said during the video briefing, which was open to the public.

“We’ll continue to discuss opportunities” for vaccinating more high-risk people, he said.

Carlos Migoya, CEO of the county-owned hospital system, said there are doctors available at Jackson clinics for free appointments if people can’t afford care. “You can get them within a two- to three-day notice,” he said.

Mayor Daniella Levine Cava will ask the DeSantis administration to move away from requiring the single-page state form as a requirement for getting vaccinations under medical exemptions at state-supported sites. Those include Marlins Park and Hard Rock Stadium, as well as the federal center at Miami Dade College North, where Florida provides the screeners. (On Friday, MDC North changed course and said it would accept a doctor’s note as an alternative to the state form.)

Levine Cava also said she would make county-run sites at Tropical Park and Zoo Miami as “flexible as we can be” under state rules for medical exemptions.

“It was designed to make it simpler, But it does not make it simpler,” she said of the state form, which requires a physician’s signature. “I agree that other ways we can document the health situation should be available.”

Commissioner Raquel Regalado said she thought Florida’s one-sheet form, which only requires a doctor’s sign-off, made sense as a quick way for a screener to move someone through the vaccination process as a medically vulnerable person. “It doesn’t require you to say why the person has an extreme vulnerability. ... I think the form is a lot easier,” she said.

Time to open up eligibility?

The lack of access to the vaccine is made worse by the Republican-controlled Florida Legislature’s refusal to expand Medicaid under the Affordable Care Act. That decision left an estimated 850,000 Floridians without health insurance in the “coverage gap.”

“Everyone needs to get access to the vaccine eventually,” said Smith, the Orlando Democratic House representative. “There are millions of medically vulnerable people who are trying their best to comply with the governor’s demands for documentation but they can’t because of the healthcare system we have in this state, or lack thereof.”

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In the meantime, figuring out who is eligible for the vaccine and who isn’t is taking away time that could be used to make more appointments and get more people vaccinated, said Lauzardo, the infectious disease expert at UF.

Beyond the medically vulnerable, the confusion has also played out among those who work for K-12 schools and pre-K and child-care centers.

The Biden administration directive said all people who work at pre-kindergarten to K-12 schools, plus daycare, should be vaccinated nationwide. But DeSantis has limited the vaccines only to K-12 school personnel 50 and older, meaning those who don’t fit this requirement can’t get vaccinated at large-scale vaccine sites like Hard Rock Stadium, Marlins Park, Tropical Park and Zoo Miami.

Lauzardo said with cases and hospitalizations still trending down, now is the time to vaccinate everyone, not continue to target the most at-risk for death and disease while slots go unused.

“We’ve got our foot on the throat of the virus right now,” Lauzardo said. “Now is the time to press hard into the source, not just the vulnerable, and the only way to do that is by getting everybody.”