VAX: So, why is West Virginia kicking other states butts?

And, why aren’t other states imitating WV’s approach?
Originally posted Oct. 10, 2021

Based on all key outcome & efficiency metrics – e.g. percentage of population vaccinated and utilization of available supply —  WV’s performance has been stellar – in absolute terms and relative to other richer and self-proclaimed “smarter” states.

See States’ Performance Ranks

Why is that?

First, let’s stipulate that being a small state has had its advantages:

> Per capita vaccine allocations (from the Feds) have tended to be higher for smaller states – probably a function of logistical rules (think: minimum shipping quantities and critical mass required to “seed” a vaccinator network).

> Smaller states are more accommodative to centralized management. The “sight lines” from the state capitals to the borders are shorter than in large states … i.e. it’s easier to see what’s going on without relying on filtered reports from layers of self-interested politicos and bureaucrats.

> There is less dependency on grandiose scheduling & information systems. Much of business can be transacted via personal relationships using very basic (often manual) legacy processes.


OK, so the degree of difficulty for WV’s dive is lower than the dive in, say, New York, California or Maryland.

But, based on my analyses, those structural advantages don’t come close to explaining WV’s success.

Urban elites may shudder at the thought, but their states were outcoached and outplayed by a team of rural ragamuffins. (Note: I say that out of respect, not disdain!)

So, how did West Virginia do it?


Here’s my take on West Virginia’s key success factors…

Fast start

In mid-2020, “the science” (think Fauci & Friends) were saying that Trump was delusional – that there was no way that a vaccine would be available until mid-2021 at the earlies … and probably not until late 2021 or early 2022.

Many smarty-pants governors (think: leadership icon Cuomo) saluted Fauci’s expert proclamation and put vaccine distribution planning on the backburner (or shoved it completely off the stove).

Rather than doubting, discounting and demeaning Operation Warp Speed, WV Governor Jim Justice adopted a “what if it works?” mindset and laid a foundation so that WV would be ready if the aggressive end of 2020 deadline was achieved.


Clear objectives

Early on, WV articulated a short set of measurable operating objectives.

  • Reduce the rate of hospitalizations
  • Reduce the death rate
  • Protect the most vulnerable
  • Maintain critical care services

Sorry, but WV kept the lid closed on “Pandora’s Box”.  Concerns  — like “essential workers” and “equity” —   didn’t make (and complicate) the otherwise apolitical list of objectives..

Most important, policies and actions were consistently screened for consistency against those explicit objectives.



From the get-go, Gov. Justice accepted responsibility for implementing his state’s vaccination program.

He didn’t spend time whining that it’s the Federal government’s job (not his) and that there wasn’t a turnkey plan provided by the Federal government.

Rather, he and his team accepted ownership of the program and just got to work.

Further, Gov. Justice didn’t cede decision-making to WV’s 55 counties and the state’s bigger cities.

Rather, drawing on a sports analogy: Team Justice developed the game plan and managed the game but relied on the local players to execute the game plan and the plays.

The WSJ has recently noted:

Early evidence suggests that centralizing vaccination policy at the state level works better than devolving it to localities.

Uniform standards can reduce competition among subordinate jurisdictions and confusion among residents.

West Virginia was ahead of the crowd on that realization.


Bold decisions

The WV government wasn’t afraid to make bold decisions that went against the conventional wisdom

For example, WV was the only state that didn’t rely on the Fed-initiated CVS-Walgreen’s “partnership” to vaccinate nursing homes and long-term-care facilities.

Rather, they utilized WV’s established network of local (often non-chain) pharmacies to service the nursing homes and LTC facilities.

That contrarian decision was bold.

Again, to repeat for emphasis, WV was the only state to opt out of the CVS-Walgreen’s program.

And, the decision turned out to be colossally beneficial.

The local pharmacies were efficient at the task.

That’s understandable since since they were already in place with trained employees, they knew their local market and had skin in the game — protecting their families, friends and neighbors.

Equally important, the pharmacies got their needed doses “just-in-time” from the state’s vaccine inventory.

In other states, the Feds shipped large vaccine allotments directly to CVS & Walgreens.

It’s finally being reported that CVS & Walgreens were grossly over-supplied with vaccine that is still largely being held as unutilized inventory.

See Where the hell is the vaccine inventory? and Some of the unused vaccine inventory has been found!

The bold decision to opt out of the CVS-Walgreen’s program meant that WV’s full inventory of Fed-provided vaccine was always “in play” – available to be “shot in arms.”.


KISS: Keeping It Simple

Inspired by CDC guidance, most states have adopted complicated, overly inclusive (often politically induced) vaccinating priorities that largely ignored supply constraints and uncertainties, that weren’t supported by game-ready scheduling systems and that provided a plethora of loopholes for line-cutters.

Not so West Virginia.

Initially, WV dutifully gave top priority to nursing home staffs, frontline medical personnel and 1st responders.

Even then, the eligibility list was restricted.  For example, priority was given to “health care workers in high-risk settings such as COVID units, intensive care units and emergency rooms” …  not to every badged healthcare employee or contractor in the state.

The explicit “tight reins” signaled that the state was serious about getting shots into the right arms.

Once the initial phase was completed, the state adopted an age-based vaccination scheme.

See Start sequencing vaccinations from oldest to youngest … period!

Recognizing that old people are most vulnerable to consequential COVID outcomes (i.e. hospitalization and death), WV started vaccinating the oldest residents (age 80 and over) … and then systematically opened eligibility to younger age groups … 70, then 65.

Adopting the age-based eligibility scheme really simplified the processes.

> First, it was easy to validate a person’s eligibility at the vaccination sites: require a proof of age and proof of state residency.

That eliminated on-site eligibility debates on whether or not the people showing up were “essential” workers or whether their pre-existing conditions were sufficiently severe.

See What do lawyers, prisoners and ‘the media” have in common? and Eat, drink, smoke … and move to the front of the line.

In West Virginia, you’re either old enough to get a shot or you’re not. Period.

> Second, there was no need for sophisticated scheduling systems and algorithms.

Demand could be “throttled” in aggregate and the flow of patients through vaccination sites could be managed simply via the qualifying age.

Note: Even when WV eventually gave eligibility to some essential jobs, there was an age requirement, e.g. only teachers over 50

The plan was brilliant in its simplicity.


Bottom line:

West Virginia managed its way to success by:

  • Hitting the ground running when vaccines became available
  • Accepting the state’s responsibility for managing the vaccination process … and running with it
  • Setting (and adhering to) a short list of apolitical objectives
  • Making bold decisions, notably opting out of the CVS-Walgreens program
  • Keeping things simple by adopting an age-based priority scheme

“Smarter” states could learn from the West Virginia experience … but it doesn’t appear that many are.


Sources: The West Virginia Vaccine Web Site, and a  multitude of articles & interviews that I’ve read or seen … complemented by a heavy dose of my triangulation to  “fill in the blanks” by making reasoned conjectures.

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