Although reserve systems have not been part of medical rationing guidelines prior to the Covid-19 pandemic, following the circulation of Pathak, Sönmez, Ünver, and Yenmez (2020) and our subsequent collaboration with various interdisciplinary groups and healthcare officials, they have recently been recommended or adopted in a number of settings.  This page summarizes some examples.  

NASEM Framework for Equitable Vaccine Allocation

July 2020: CDC and NIH commissioned the National Academies of Sciences, Engineering, and Medicine (NASEM) to formulate their recommendations on the equitable allocation of a Covid-19 vaccine. NASEM appoints committee of distinguished experts.


September 2020: A discussion draft of the preliminary Framework for Equitable Allocation of Covid-19 Vaccine is made public and comments from the public are solicited.

  • In his written and oral comments, University of Pennsylvania bioethicist Harald Schmidt inquired about the mechanism to prioritize members of hard-hit communities, bringing our proposed reserve system to the committee’s attention as a possibility.

  •  In response to the NASEM discussion draft, JAMA published the viewpoint “Fairly Prioritizing Groups for Access to COVID-19 Vaccines,” endorsing our proposed reserve system (Persad, Peek & Emanuel 2020):


“Dividing the initial vaccine allotment into priority access categories and using medical criteria to prioritize within each category is a promising approach. For instance, half of the initial allotment might be prioritized for frontline health workers, a quarter for people working or living in high-risk settings, and the remainder for others. Within each category, preference could be given to people with high-risk medical conditions. Such a categorized approach would be preferable to the tiered ordering previously used for influenza vaccines, because it ensures that multiple priority groups will have initial access to vaccines.”


October 2020: NASEM published their final Framework for Equitable Allocation of COVID-19 Vaccine (2020), and formally recommended a 10 percent reserve for people from hard-hit areas:


“The committee does not propose an approach in which, within each phase, all vaccine is first given to people in high SVI areas. Rather the committee proposes that the SVI be used in two ways. First as previously noted, a reserved 10 percent portion of the total federal allocation of Covid-19 vaccine may be reserved to target areas with a high SVI (defined as the top 25 percent of the SVI distribution within the state).”

Tennessee  Covid-19 Vaccine Allocation Plan


October 2020: Tennessee became the first state that has announced its plan to use a reserve system for Covid-19 allocation. The interim plan by the Tennessee Department of Health included the following reserve categories:

  • 5% of the State’s allocation of Covid-19 vaccines will be distributed equitably among all 95 counties

  • 10% of the State’s allocation of Covid-19 vaccines will be reserved by the State for use in targeted areas with high vulnerability to morbidity and mortality from the virus  

  • 85% of the State’s allocation of Covid-19 vaccines will be distributed among all 95 counties based upon their populations

December 2020: Tennessee updated their plan to accommodate ​different vaccines.

Massachusetts Covid-19 Vaccine Allocation Plan

December 2020: Massachusetts became the second state that has announced their plan to use a reserve system for equitable Covid-19 vaccine allocation. 

  • 20% of the vaccines will be reserved (in an over-and-above form) for communities that have experienced disproportionate Covid burden and high social vulnerability.


New Hampshire Covid-19 Vaccine Allocation Plan

January 2021: New Hampshire also announced their plan to use a reserve system for Covid-19 vaccine allocation in an equitable manner.

  • 10% of the vaccines will be reserved for communities that have experienced disproportionate Covid burden and high social vulnerability.


Massachusetts Guidelines for Covid-19 Monoclonal Antibody Therapeutics 


November 2020: For allocation of monoclonal antibody therapeutics, Massachusetts became the first state that has recommended the use of a reserve system. For within hospital allocation,  Massachusetts Department of Public Health Guidance for Allocation of Covid-19 Monoclonal Antibody Therapeutics reccommends 20% reserve for vulnerable populations.  

  • The Department of Public Health assembled a Working Group, comprised of infectious disease specialists, emergency physicians, community health center representatives and ethicists to advise on equitable public health strategies to allocate the doses of Covid-19 therapeutics delivered to Massachusetts in the event that there is not sufficient capacity to respond to demand for this scarce resource. 

  • A member of the Working Group inquired whether our proposed reserve system can be used for equitable allocation of Covid-19 Monoclonal Antibody Therapeutics, and if so how it can be operationalized in practice. 

  • Our group provided the member of the Working Group with a Excel spreadsheet implementation of our proposed reserve system tailored to the specifications for Massachusetts policies.