Those that are lucky enough to be near another provider with shots available are relying on neighborly generosity — encouraged but not mandated by the state — to inoculate front-line workers, who are sometimes dealing with overflow patients from urban areas alongside their own coronavirus patients.
But many small, rural providers don’t have neighbors with doses to spare, leaving them waiting or scrambling to find vaccine for their most high-risk front-line health workers, even as other counties have reportedly distributed excess vaccine doses to politicians and healthy members of the public.
The majority of the 157 rural hospitals in Texas will have gotten at least some doses either delivered, shipped or allocated by the end of this week. Those 132 providers have either gotten it shipped directly or, in a handful of cases, distributed to them through their larger health network.
But 25 are still waiting.
Rural health care advocates say they understand that the logistics involved in the largest vaccination program in the nation’s history will involve some unavoidable inequities at first, but they note that many of their communities have been disproportionately ravaged by the pandemic.“There’s no question there are massive inequities in this,” said Don McBeath, director of government relations for the Texas Organization of Rural & Community Hospitals. “While I think [state health officials] have made a concerted effort, and it has gotten better, the bottom line is that we still have nurses and doctors working in some rural communities around sick COVID patients, and they can’t get their hands on vaccines themselves. Something’s wrong.”
Advocates and rural hospital officials say the reasons for the lapse range from approval delays caused by technical issues with the application process to smaller providers’ inability, early on, to use or store the Pfizer vaccine, which initially was the only vaccine available.
The Pfizer vaccine can only be shipped in orders of 975 doses — way more than many small communities needed to vaccinate their front-line workers — and have to be stored in special sub-zero freezers that most rural hospitals don’t have.
The later arrival of the Moderna vaccine, which comes in smaller batches and can be stored in standard refrigerator conditions, helped alleviate some of those challenges, but delays in shipments, combined with the demand overwhelming the supply, has left these hospitals without doses to distribute to their own workers or other eligible residents in their communities.
Roughly 1.4 million doses have been shipped to Texas since mid-December, while more than 8 million people are in the groups that now qualify for the shots. Health care workers and residents of nursing homes and long-term care facilities, a group labeled as 1A, were prioritized for the first round of vaccines. People who are elderly and those with underlying conditions, a group known as 1B, were the next to be listed as eligible. The next group of eligible Texans still has not been announced.
Gov. Greg Abbott and Texas Health Commissioner John Hellerstedt in late December urged health care providers to open up their distribution to more people and keep doses from “sitting on hospital shelves.” Hospital administrators have said doses are being given out as fast as possible and that no doses are being unused.
“The irony of the process is that DSHS is pushing hospitals to get shots into arms, but it’s kind of hard to do so if you don’t have the vaccine,” said Don Bates, CEO of Golden Plains Community Hospital in Borger, north of Amarillo.
Bates’ hospital has received no doses yet, but has relied on the local United Supermarkets Pharmacy for getting shots to about 50 of his front-line health care workers who wanted it.
Hutchinson County, where Golden Plains is located, is home to 21,000 people. Some 1,217 confirmed or probable COVID-19 cases have been reported in the county by state health officials. It borders Hansford County, where 642 cases have been identified as confirmed or probable, in a county of just over 5,000. In nearby Amarillo, hospital capacity is stretched, according to public health officials.
“The state failed to recognize that folks in rural communities travel to the larger communities often for work, shopping, dining, conferences and travel,” Bates said. “Our testing positivity rate has been just as high as some urban areas.”
Bates said he expresses his frustration regularly during calls with the Texas Department of State Health Services.
“I think sometimes the Panhandle of Texas is forgotten,” he said. “We’re treated like the proverbial red-headed stepchild.”
Chris Van Deusen, a DSHS spokesperson, said the agency was working with the rural and community hospital association on problems being experienced “as they arise.”
"I know there are still a number of hospitals working to complete their enrollment as a vaccine provider," he said in an emailed statement. "Rural hospitals serve an important role in providing care in their communities, and we will allocate vaccine to them as they enroll. We will continue to work with [rural and community hospital association] and the facilities directly to help them complete that process."
The state's expert vaccine allocation panel, which makes recommendation to the state on which providers get vaccines shipped to them each week, "routinely" discuss the need for all Texans, regardless of location, to have access to the vaccine, said Carrie Kroll, vice president of advocacy, quality and public health for the Texas Hospital Association and an ad hoc consultant to the panel.
"Ensuring equitable distribution in terms of geography has been a priority, as has the epidemiology of the disease, including which populations are most at risk either because of their age or health status," she said.
Her organization has been advocating that rural hospitals be included, and while they recognize the challenges, they are "very concerned" that some hospitals don't yet have any doses to distribute to their workers."The bottom line is that, first and foremost, all hospitals need to be able to protect and vaccinate their front lines," she said. "We'd like to see doses at every hospital in Texas right now."
Some rural facilities, like Otto Kaiser Memorial Hospital in Karnes County, have been approved providers for weeks but haven’t received any doses to distribute yet. Otto Kaiser was approved by state health services on Dec. 18, but has yet to appear on any list for the first four weeks of the vaccine distribution.
The hospital has instead relied on nearby providers to vaccinate its front-line workers while officials wait their turn on a distribution list.
Facilities that were sent the vaccine are not required to share with the have-nots, but the state has encouraged them to do so in order to keep pushing out the vaccine as fast as possible, said Otto Kaiser CEO David Lee.
Lee said they are are luckier than many to have the local H-E-B pharmacy and hospitals in Cuero and Floresville that were willing to help inoculate a few dozen workers at his hospital.
“That’s kind of been their directive. When you run out of 1A (front-line workers), look in the neighboring county, look at closer facilities that might have some more names” of workers who want the shot, Lee said. “So I think that’s what folks are doing. We’re very grateful for that.”
The lack of vaccine doses also prevents the hospital from being able to share with its members of the community who may be eligible. Some 122 people in Karnes County, southeast of San Antonio, have received the first of the required two doses, according to DSHS. That’s in a county of more than 12,500 people over age 16, where 24 people have died and 1,266 cases have been confirmed, including 45 new cases in the last two weeks.
Cuero Regional Hospital helped vaccinate Lee’s front-line workers after another local facility shared its doses with Cuero Regional — a chain of cooperation that rural communities count on as a matter of culture, with or without state directives.
Citizens Medical Center, about 30 miles away in Victoria, received a large allotment of vaccines before Cuero did, and more than a dozen of Cuero’s health care workers were able to travel there to be vaccinated, said Emily Weatherly, a spokesperson for Cuero Regional.
Then Cuero Regional, which received 200 doses of the Moderna vaccine just before Christmas, administered the vaccine to half a dozen of Lee’s staffers. A hospital in nearby Floresville vaccinated the rest, Lee said.
Weatherly said that although her facility has been able to vaccinate health care workers, the hospital is now “eagerly anticipating” another shipment and has set up an online form where people can sign up for a waiting list.
The facility has been inundated with calls from the public, she said, but everyone is still playing the waiting game for the next round of new doses.
“We are at the mercy of the state,” she said.
Another issue outlined by the hospitals is an array of delays and difficulties in the process to apply and register as a vaccine provider with the state.
The process is no different for the larger or urban hospitals, but it presents a unique challenge to the smaller facilities that don’t have the resources to spend what some executives said could be weeks of follow ups to correct glitches.
In some cases, administrators said their applications were rejected due to technical errors but they were never notified, finding out on their own weeks later that they had to resubmit paperwork.
Some of the problems arose from user error, like missing signatures, but the correction and notification process shouldn’t take weeks in a state where hundreds of people die every day and record numbers of people are hospitalized for COVID, administrators said.
“Suffice it to say that DSHS has made the enrollment process more cumbersome than it needed to be,” Bates said in an email to the Tribune. “The most ridiculous examples were first described to us as an ‘enrollment system error.’ We later found out it was because the hospital was using Internet Explorer instead of Chrome…for real.”
Each time the application is corrected it has to be signed again and then resubmitted, and then is subject to approval and processing times, Bates said.
Lee agreed that the process is rife with opportunities for user error but, more importantly, creates delays for strapped small hospitals trying to wade through the red tape and get their workers and residents vaccinated while also taking care of a surge of COVID-19 patients.
Some application issues in early November delayed Otto Kaiser’s process because “it took the better part of six weeks get it all fixed, in spite of the fact that we were sending frequent emails to check on status and waiting 90 minutes on hold to speak to someone,” Lee said.
“I know that DSHS is slammed and distribution of the vaccine is a huge undertaking,” he said. “But the process and the associated lack of communication is hard to accept, and our health care workers and our community are being delayed access to the vaccine as a result.”
Staff writer Shannon Najmabadi contributed to this report.
Disclosure: H-E-B and Texas Organization of Rural & Community Hospitals (TORCH) have been financial supporters of The Texas Tribune, a nonprofit, nonpartisan news organization that is funded in part by donations from members, foundations and corporate sponsors. Financial supporters play no role in the Tribune's journalism. Find a complete list of them here.Stay on top of San Antonio news and views. Sign up for our Weekly Headlines Newsletter.
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