Many questions about the pandemic are being discussed. Most of them are about the immediate future or for the next couple months. Other issues are more distant but so troubling that consideration of them should begin. They concern the vaccinations that we all hope will become available. First and foremost, scientists, doctors, politicians, and commentators all seem to be confident that a vaccine or vaccines for coronavirus will be developed, but if that virus regularly mutates, is that confidence overstated?

Who will pay for vaccinations? I assume, but do not know, that Medicare, Medicaid, and private insurers will cover the costs. What kind of burdens will be placed on these systems? We already hear often that the financing of Medicare and Medicaid is precarious. Are all private insurers sound enough to handle the costs?

But what about all the uninsured, a group whose size is no doubt going to increase? Many people get health insurance because of employment. When they lose their job, they lose coverage. Many of them won’t be able to afford insurance on the open market or under Obamacare even if Obamacare is not further gutted under the lawsuits the Republicans are pursuing. Does that group go without vaccinations? Will the government pay for them and get further into the health insurance business?

The initial availability of a vaccine will raise other important and difficult ethical, economic, foreign relations, and governmental questions. The pandemic is a worldwide phenomenon—there are outbreaks on every continent—but every person cannot be vaccinated at once. There won’t instantly be eight billion doses or the distribution networks or people to immediately vaccinate the world’s population. As a vaccine is rolled out, some people will get the vaccine before others, and we have little idea about how long it will be before the last in line gets vaccinated. This will be true for the world, but also true in each country.

How will the vaccine be allocated among nations? Every country will want the number of doses that is necessary to protect its population, which means that countries will compete for the vaccine. The severity of that competition will be affected by whether only one vaccine is found or more than one, but also by whether the vaccines are patented. (Of course, they will be patented, you might think, but Jonas Salk did not patent the polio vaccine he along with others developed.) If something is patented, the patent-holder normally can control who will manufacture the patented product. If the vaccine is patented, not everyone who could make the vaccine will be able legally to produce the drug unless the patent-holder agrees, and the patent-holder can also determine to whom the vaccine will be sold. Should this normal regime for inventions be allowed to operate with this pandemic or should there be legislation requiring the automatic licensing of a patented vaccine? In other words, should the government (gasp—dreaded word) regulate (gasp – another dreaded word) the manufacture and distribution of the vaccines or even seize the patent with something like eminent domain?

Patents grant monopolies. Monopolies increase prices. A lot of money can be made from these vaccines. Should there be (gasp yet again) price controls? At least some of the large vaccine makers have already said that none of their profits will go to their shareholders but will be used to subsidize vaccinations in disadvantaged countries and be used for further research and development. In other words, the companies expect profits—probably massive profits—but the companies promise to use all that money humanely (and, of course, the research and development will have the goal of making other profit-making products from which, no doubt, dividends will flow). Should we just trust the largesse and good will of these multi-national corporations?

There will be strong pressures to impose export controls in the nations where the vaccines are manufactured to make sure that the producing countries will have adequate supplies as quickly as possible. Of course, this raises ethical questions about whether some nations can deprive other populations of immediate access to vaccinations, but it will also present foreign policy concerns. Will there be a new kind of most-favored nation status where vaccination exports are allowed to some countries but not others? If so, who decides and on what criteria? In this country, would it be health officials, and if so, who would they be? Or the State Department? The President? Congress? And will all this be complicated by the fact that vaccine companies are part of multi-national corporations? The largest such one is Sanofi Pasteur. If you have been vaccinated against the flu, the odds are your dose came from Sanofi Pasteur. It has five plants in the United States with its American headquarters in a little town in Pennsylvania, but it is a division of a French corporation. Does the French government have any authority to determine where vaccines made in Swiftwater, Pennsylvania, go?

But let’s assume an effective vaccine is rolled out for use in the United States. Doses for 300 million American will not all be available at once. Who will get them first? Who will get them second? Who will make those decisions? What will the criteria be?

The closest analogy I can think of is the mass polio vaccinations in the 1950s when schoolchildren, including me, stood in line to get a shot. My memory is very incomplete here, but I believe it was the forerunner of the March of Dimes who undertook the project, not the government, but I think there was a widespread consensus that children should be the first ones. The coronavirus will not be as simple.

I would hope that there will be a consensus that the first to be vaccinated will be those on the frontlines—healthcare professionals and first responders with a close second being essential workers like those in grocery and drug stores and delivery people. But beyond that what should be the priorities?

Perhaps epidemiologists should control the schedule aiming for the fastest way to achieve something like herd immunity. On the other hand, since people over 65 are most likely to die from Covid-19, perhaps this group should have priority. Someone like me (I am old) might expect to live ten years more if I don’t get the disease. Giving me the vaccine could be said to save ten life-years discounted by the likelihood that I would get the disease and recover without being vaccinated. Giving the vaccine to a forty-year-old could save 45 life-years discounted by those same factors. Looked at this way, it could be more beneficial to inoculate the younger person first, but who should, or will, make those decisions?

On yet another hand, economists might conclude that the country will benefit most by first vaccinating those who contribute most to the economy, but I am sure that economists (and others) will disagree how to calculate that.

It is not clear who will set the priorities. Nothing I have read in the Constitution gives the President the authority to set them. Perhaps the Constitution can be stretched to say that Congress can set them or delegate this power to the executive branch, but public health matters have traditionally been, and perhaps constitutionally are required to be, under the control of the states. If the states do make the decisions, we can expect to see different priorities in different places, just as lockdown orders and the labeling of essential businesses has not been uniform across the country.

Or, of course, we can adopt the conservative philosophy that market forces should set the priorities. Whoever can pay the most should get the vaccine first. Will this basic tenet of modern conservatism be re-thought?

It would be a waste to give the vaccine to those who do not need it, but we need to know whether those who have recovered from the disease have immunity to it, how strong the immunity is, and for how long, questions that have yet to answered. And then we would have to be able to test widely for the antibodies if they do give an effective immunity. So far, our present system has not performed well on giving widespread tests for the disease, which are necessary to control the present spread of Covid-19. Will our system be any better for antibody testing?

Whatever the priorities, some people lower on the priority rungs waiting for a vaccination after a vaccine is available will die before they are vaccinated. Although we will not call them this, whoever sets the priorities will constitute a death panel. It will be a frightening responsibility.

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