Michigan and Minnesota both had ample opportunities to push out vaccines through professional health care settings and into the arms of patients. They have essentially the same numbers of hospitals, rural clinics and doctors per capita.
But in the race to put shots in arms, Michigan lost. Its vaccination rate lagged Minnesota’s, exacerbating a late-pandemic spike in cases that killed 2,500 people. The vaccination gap between Minnesota and Michigan was particularly high for older people.
An analysis of data from both states – the only two to provide detailed and comparable vaccine records in response to records requests from USA TODAY – reveals key reasons Minnesota moved faster.
Minnesota supercharged its health care system, dispersing doses to a wide network of doctor's offices and hospitals across the state. Michigan, in an effort to equitably distribute vaccines to rich and poor alike, steered doses to public health departments that aimed to entice uninsured residents to mass vaccine events.
Not only did Michigan trail Minnesota’s overall vaccination rate through the end of March, it didn't do any better at vaccinating Black and Latino residents.
Elizabeth Hertel, director of Michigan's Department of Health and Human Services, defended the state's approach when asked about its emphasis on local health departments over hospital systems and clinics.
The choice of who distributes the vaccine "was really a decision based on who is best equipped in certain regions to handle doing that," she said, adding that in some rural areas of the Michigan "there isn't a health system."
"One of the things that we were trying to focus on was the ability to make sure that people had access, and going through the health systems may not have always been the most efficient way to do that," Hertel said.
Hertel's agency said separately, in a written statement, that local health departments "are well suited to reach minority and vulnerable populations."
"We also recognize that these efforts to address equity sometimes do not yield the high numbers" other channels might, the statement said, "but we strongly believe this is an important strategy to address equity."
To be sure, Minnesota had some advantages unrelated to how it handled the vaccine supply. It historically has had a higher percentage of residents who receive flu vaccines, and the typical Minnesota household earns more than Michigan's. States pursued myriad vaccine strategies, and none got it perfect when it came to speedy or equitable distribution.
But decisions about where to channel vaccines in Michigan and Minnesota had important impacts, according to data and interviews with experts and health administrators. The states' divergent experiences in the crucial early months of vaccination offer lessons about what worked and what didn’t.
Few people have studied the differences in state rollout strategies.
Dr. Kirsten Bibbins-Domingo, chair of the department of epidemiology and biostatistics at the University of California, San Francisco, recently examined Minnesota and California. She said Minnesota’s push to vaccinate people easily reached by the established clinical system left people of color behind. But so did Michigan’s approach.
“Those communities weren’t going to be reached by mass vaccination sites,” Bibbins-Domingo said. “They’re not going to be reached by Walgreens and CVS.”
Neither state, she said, came through for its neediest residents.
Inadequate funding for local health departments in Michigan and elsewhere made it hard for them to lead successful immunization campaigns, according to health care executives and public health officials.
Adriane Casalotti, chief of government and public affairs with the National Association of County and City Health Officials, said the enormous strain of the coronavirus on public health continued through the vaccination push this year.
“There was no money,” Casalotti said, “even though the shots were rolling out the door.”
Minnesota chooses hospitals
Minnesota began to pull ahead of Michigan early, according to news reports at the time. By the end of February, a month after older adults had become eligible in both states, 39% of Michigan’s seniors had received at least one dose of a COVID-19 vaccine. In Minnesota, more than 50% of them had received at least one dose.
Delays in the pace of vaccinations in the early months of the rollout no doubt had an effect on hospitalizations and deaths later on, experts said.
"It does look like Michigan’s slower pace in vaccination in February was really crucial,” said Julie Swann, a professor at North Carolina State University who worked with the Centers for Disease Control and Prevention on the response to the H1N1 pandemic. “At least some of those people would have been protected."
The fundamental difference in Minnesota’s approach was its reliance on hospitals, doctor's offices and clinics.
USA TODAY obtained records from each state for every shot given from mid-December through late March, a crucial period of the vaccination effort. The states listed dates, provider organizations, manufacturer names and lot numbers with each record. The news organization’s analysis classified providers into three types: clinics, hospitals and doctor's offices; pharmacies; and local health departments.
The data showed Minnesota health care facilities delivered 27 doses per 100 residents between December and March. Michigan hospitals and clinics administered just 14 doses per 100. (Records don’t indicate whether the dose was a person’s first or second.)
To hit the higher mark, Minnesota enlisted many more of its hospitals and clinics. The data shows twice as many Minnesota health care locations gave at least one shot compared with Michigan – even though Michigan has a much larger health care system.
The numbers don’t surprise Dr. Bryan Jarabek, chief informatics officer at M Health Fairview in Minnesota.
Jarabek led a coalition of 10 health systems that coordinated COVID-19 vaccinations, including M Health Fairview, with 10 hospitals and 60 clinics of its own. At his first strategy meeting with the Minnesota Department of Health and Minnesota Gov. Tim Walz, Jarabek brought a map.
“All the hospitals in the state have clinics surrounding them,” said Jarabek. “The hospitals and clinics are positioned to take care of the whole state. We then showed that to the governor and MDH and said, ‘You can trust us. Give us the vaccines. We will get it to the places that need it.’”
USA TODAY’s analysis found the approach was applied consistently across different types of counties in Minnesota. The average rural county delivered slightly more doses per capita through hospitals, clinics and doctor's offices than the average urban county.
Systems like Sanford Health, which vaccinated people at more than 30 locations across rural Minnesota, were a big part of the rollout. Susan Jarvis, president of Sanford Health of Northern Minnesota, said hospitals, clinics and doctor’s offices have plenty of space, clinical storage and expertise handling vaccines.
“We knew that we had the infrastructure to give the shots,” she said.
Another essential resource among hospital systems: lists of insured patients, including records identifying their age and medical conditions that would put them at risk for the coronavirus. The Mayo Clinic, for example, ramped up a massive phone bank to contact all its patients over age 80.
“We know their medical problems,” said Dr. Melanie Swift, an occupational medicine physician and internist at the Mayo Clinic. “We have enough information to contact them proactively. We know where they live, we have phone numbers and addresses. Public health doesn’t have that.”
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Officials with Minnesota’s local health departments, which typically do not provide direct patient care, recognized this as well. They turned to nonprofit and for-profit hospital systems to take the lead on COVID-19 vaccines.
Graham Briggs, director of Olmsted County’s health department in Rochester, Minnesota, said his team met weekly with leaders from Mayo, Olmsted Medical Center and other health care systems in the area to divvy up doses.
“Public health departments are not doing the majority of the vaccinations,” Briggs said. “Health care providers are doing it because they have the rolls and can identify high-risk patients.”
In Minneapolis, the city and county hired Hennepin HealthCare to deliver COVID-19 vaccines. Danielle Rice, who manages Hennepin’s flu and worksite wellness program, said public health employees handled scheduling and space. Hennepin HealthCare brought nearly 100 nurses who delivered shots to front-line health care workers, first responders, educators and others.
“We were able to respond pretty darn quick,” Rice said.
Michigan calls for equity
The big asset that Minnesota tapped – access to patient rolls through the established health care system – has one downside. It doesn’t do well at reaching people who are uninsured or without a primary care doctor. Michigan chose a different course.
After initially focusing vaccines on hospital systems, Michigan began a marked shift in mid-February.
“I am excited to announce initiatives that will help enhance the state’s equity strategy and allow us to get more vulnerable Michiganders vaccinated,” Dr. Joneigh Khaldun, Michigan’s chief medical executive and chief deputy for health, said at the time.
The state pivoted from primarily supplying health care providers to steering doses into local health departments, the data acquired by USA TODAY shows.
Health systems were taken aback by the shift. Getting fewer doses caused several private health systems to cancel existing vaccine appointments.
“We could have handled more,” said Brian Brasser, chief operating officer of Spectrum Health in the state. “We were ready to handle more.”
Through late March, only about one-third of Michigan’s vaccine doses were administered at clinics, hospitals or doctors' offices, compared with two-thirds in Minnesota. All of those vaccines in Michigan were concentrated on about 400 clinics and offices, compared with about 900 in Minnesota.
Michigan’s vaccines instead coursed into local health departments that were holding large-scale vaccination events.
Days in which a local health department gave out 1,000 or more shots at a time accounted for 500,000 doses administered in Michigan. By contrast, mass vaccination events by public health departments accounted for only 26,000 doses administered in Minnesota. Michigan health departments had 58 mass vaccine days, compared with 14 in Minnesota.
“Vulnerability is what we do,” said Linda Vail, health officer for Ingham County, home to the state capital Lansing. “That is the mission of health departments.”
But when Ingham County opened up online registration for vaccines, people who could afford faster internet connections and who could take time off work and had transportation booked appointments first, Vail said. As a result, those who got vaccinated tended to be wealthier and white.
In Detroit, a mass vaccination site at Ford Field faced similar challenges: Most of the doses went to people who lived outside the majority-Black city.
Vail worked with a medical ethicist to set aside a certain number of appointments for Ingham County's most vulnerable residents.
“But things were happening so fast,” she said, “I don't know how staff implemented it on the ground.”
The nation faced shortages in the months after the first vaccines were delivered in December. In March, supplies ramped up at Ingham County’s public health department, “right when demand dropped off,” Vail said.
The vaccine rollout entered a new phase. Health departments began teaming up with faith leaders and community groups to set up smaller-scale vaccination sites — efforts that require a lot of time, staff and money, said Jimena Loveluck, health officer for Michigan's Washtenaw County.
When the CARES Act came through, promising money for public health, many smaller departments like Loveluck’s didn’t qualify. “We didn’t get any of that money,” she said.
Meanwhile, Michigan’s huge surge in infections in March and April dragged public health departments into contact-tracing investigations. Already short on funding – the state historically has spent less per capita on public health than Minnesota – they now had less time for vaccinating people.
“We are drowning in cases that need to be investigated on top of trying to execute vaccination efforts,” wrote a Bay County official in a late March email that was obtained by the Documenting COVID-19 project at the Brown Institute for Media Innovation.
“I am drowning!!” wrote Tuscola County’s health officer, who had recently announced her retirement, in another email the institute acquired. “All I have left is to keep vaccinating as fast as possible.”
Michigan’s hospitals and clinics were also swamped. Even if they had vaccines on hand, they couldn’t always use them because they were busy treating a flood of patients.
“The surge was hitting us in different parts of the state and at different times,” said Ruthie Sudderth, senior vice president of public affairs for the Michigan Health & Hospital Association. “Some hospitals had the capacity to administer vaccine. Others had very little capacity.”
At the end of the day, health departments in Michigan’s 10 most diverse counties through late March provided no more doses per resident than in the state’s 10 whitest counties, the USA TODAY analysis shows.
Dr. Andrea Wendling, whose practice is in rural northern Michigan, said some patients came to her to be vaccinated in private because they didn’t want neighbors, friends or family to know. “People didn’t want to go to the mass vaccine clinics because they can’t be anonymous,” Wendling said.
Although immunization records fail to consistently identify the race and ethnicity of vaccine recipients, the data indicates Minnesota dramatically outpaced Michigan among white residents.
Meanwhile, despite Michigan’s focus on public health, it did no better than Minnesota’s vaccination rate for Black people. By March 5, Minnesota had at least partially vaccinated around 10% of its Black residents; Michigan had vaccinated 6%.
Comprehensive data isn’t available to show how unusual Michigan’s approach was. But data that USA TODAY obtained from Colorado, Wisconsin and Washington shows those states, like Minnesota, avoided Michigan’s heavy reliance on public health departments in distributing vaccines.
According to other data collected by Bloomberg News, all of those states are also currently ahead of Michigan when it comes to vaccinating Black residents. Michigan lagged all but Colorado for its Latino vaccination rate.
Michigan's health department said in a statement that local health departments received $48 million in new state and federal funding for vaccination outreach in January. The department is devoting another $6.6 million to the effort after local agencies requested additional money.
In the final analysis, Minnesota’s approach may not point toward a solution anymore than Michigan’s.
Bibbins-Domingo, the UC-San Francisco epidemiologist, said poor and vulnerable populations already hit hard by the pandemic should have been the first priority. Big hospital systems, pharmacies and public health departments all failed to deliver for them.
She found in her study of Minnesota and California that both vaccinated older, white residents at the expense of protecting communities of color.
Bibbins-Domingo said the key to vaccinating vulnerable people is places that bridge health care systems and public health: community pharmacies, community clinics, federally qualified health centers that provide primary care to poor and uninsured people, and other trusted community sites.
But in Minnesota as in California, these local approaches were only prioritized late in the process, she said. The two states favored speed over equity, she said, leading disadvantaged people to experience long delays in vaccination.
Michigan did no better because it was slow to get vaccines to low-income clinics. Although Michigan's federally qualified health centers got a bump in vaccines after the state announced its new push for vaccine equity in February, the data shows such clinics ultimately administered only 2.8% of all doses in February and March.
“The problem with doing it late is you have surges in Michigan where people got sick and die because we got there late,” said Bibbins-Domingo.
“We haven't put the equity first,” she said, “and we’ve allowed other messages to take hold.”
Contributing: Kristen Jordan Shamus and Miriam Marini, Detroit Free Press
Aleszu Bajak can be reached by email at firstname.lastname@example.org and on Signal at 646.543.3017.
This article originally appeared on USA TODAY: Michigan COVID-19 vaccine rates trailed Minnesota’s: What went wrong?