Chuck Rich, of Waterboro, is vaccinated by Kennebunk Fire Rescue paramedic David Garriepy during a MaineHealth COVID-19 vaccination clinic in Sanford. Credit: Gregory Rec / Portland Press Herald via AP

Maine is the only U.S. state to establish a coronavirus vaccination plan based solely on age, a system that state officials say will speed the process but some ethicists worry leaves many vulnerable people behind.

The switch to an age-based vaccine plan comes after the state offered vaccines to health care workers, residents of long-term care facilities and certain workers considered integral to the state’s virus response. Gov. Janet Mills and state health officials touted the system — rolled out with support from the state’s medical community on Friday — as the quickest way to distribute vaccines while highlighting age as the most significant single risk factor for severe COVID-19.

There is no consensus among experts about the best way to distribute vaccines, Kaiser Health News noted, with some praising an age-based system as easy to administer and hard to cheat. Vaccine rules should be “open, explicit and verifiable,” said Michael Grodin, director of medical ethics at the Boston University School of Public Health, and the age-only system does that.

But certain disabilities and medical conditions also put younger people at higher risk for severe illness, according to experts and several studies cited by the Maine Center for Disease Control and Prevention. Some ethicists and Mainers with health conditions question whether the state’s system is equitable and accomplishes its stated goal of saving the most lives.

Focusing solely on age is not the most effective way to prevent deaths, said Govind Persad, a law professor at the University of Denver who focuses on medical ethics. The state should account for the risk of severe disease, based on several factors including age, as well as who is most likely to contract the virus, he said.

“Throwing out that risk factor entirely seems like it is both inefficient and not really fair to those people who are in those higher-risk medical groups,” Persad said.

Maine’s age-only system excludes younger Mainers with health conditions and those who work in frontline jobs with higher risk of transmission, such as restaurants or schools. It also disadvantages much of the state’s Black immigrant population, which is younger overall but has seen substantially higher infection rates during the pandemic.

State officials acknowledge those tradeoffs, but point to age as a significant risk factor for severe COVID-19. The state extended eligibility to residents aged 60 and older this week, with a tentative schedule allowing those in their 50s to get vaccinated in April and younger Mainers in the months after that. More than 231,000 Mainers have received at least one vaccine dose.

Mainers aged 50 and older have accounted for 98 percent of deaths, Maine CDC Director Nirav Shah noted on Friday. But risk of death is heavily concentrated on the older side of that large group, with Mainers aged 80 or older about 36 times more likely to have died from the virus than Mainers in their 50s, according to state data.

Several studies cited by Mills and Shah when outlining the state’s policy suggest some health conditions used to grant vaccine eligibility in other states, such as asthma or a history of smoking, may not be linked to severe illness or death.

But those same studies also show a few conditions — including severe obesity, a history of blood cancer or being the recipient of an organ donation — are associated with a higher mortality rate. Being a transplant recipient, one study suggested, increased a person’s risk more than being in their 50s. Down syndrome has also been linked to higher mortality.

AARP Maine and the state’s two largest hospital systems — MaineHealth of Portland and Northern Light Health of Bangor — have backed the plan, but it drew criticism from Kim Moody, executive director of Disability Rights Maine, who said people with disabilities “really had their hopes up” and were upset by the change.

Shah acknowledged there were “always cases on the margin,” noting that, within Maine’s established age categories, the state was allowing providers to target high-risk patients, and had supplied dialysis centers and oncology clinics with vaccines for that purpose.

He added that other state health departments have faced difficult decisions as to how to determine the severity of health conditions eligible and prevent ineligible people from gaming the system. The state has also said Maine’s timeline for vaccinations could speed up if the state’s supply continues to increase.

“While an individual with certain health conditions may be at greater risk of severe illness or death from COVID-19 than a particular older person, this policy protects the greatest number of people as fairly and quickly as possible,” Maine Department of Health and Human Services spokesperson Jackie Farwell said. “And rapidly vaccinating helps all Maine people, including those with medical conditions, by helping keep Maine ahead of the highly contagious variant.”

Streamlining administration to prevent delays is important, said Holly Fernandez Lynch, a professor of medical ethics at the University of Pennsylvania. But she worried Maine’s system was “too streamlined and will further entrench inequity.”

While an on-site verification system could be time consuming, hospitals could use medical records or doctors could refer high-risk patients, Persad suggested. Allowing that could help people like Sarah McQuade of Kittery, who has lupus and has battled pneumonia in the past.

At the advice of doctors, the 43-year-old mother of two has barely left home since March 2020. Her teenage children have done remote school all year to minimize the chance they would infect her. McQuade, who assumed she would be next in line in the state’s rollout, thought she “must be hearing something wrong” when she learned of the change.

McQuade wants to be fully vaccinated in time to watch her 18-year-old son graduate high school in June. But if she does not receive her first dose until May, when Maine’s current schedule suggests people in their 40s will be eligible, she may not be able to attend.

“Sometimes disabled people, we feel like we don’t matter, like people don’t consider our needs,” she said. “We’ve heard so much during this pandemic about how, ‘Well, you know, 99 percent of people are just fine, and it’s only the high-risk people who get sick and die anyway.’ It really feels like you’re being dismissed.”