It was a moment of clarity and common sense, but it contradicted what Maine public health officials were saying during regular press briefings and had posted on the state’s COVID-19 vaccination website.

Responding to a reporter’s question about eligibility guidelines for priority groups waiting to be inoculated, Gov. Janet Mills explained during a Jan. 13 briefing how the state’s phased-in approach to doling out vaccine might work.

“If somebody who’s 71 appears at a clinic to be vaccinated and they bring their spouse who’s 69 and 10 months old, they probably won’t turn that spouse away,” Mills said, “because it’s efficient and medically appropriate for them both to get vaccinated.”

But on paper and in practice, that spouse wasn’t eligible for COVID-19 vaccine then, and still isn’t. The state’s rules are focused on vaccinating people age 70 and older, patient-facing health care workers, long-term care residents, and public safety and critical response personnel. Public health officials reaffirmed last week that Maine won’t be adopting a so-called buddy system anytime soon like one started recently in Massachusetts, where people of any age can be vaccinated if they give an elder a ride to a clinic.

The governor’s answer highlighted the broader confusion around Maine’s eligibility guidelines, an evolving list of sometimes vague rules that may or may not be followed in the field. Yet last week, Maine Attorney General Aaron Frey announced he will consider legal and administrative sanctions against providers who administer the COVID-19 vaccine to people who aren’t eligible. And while vaccine clinics across the state continue to share leftover doses with willing recipients to keep them from going to waste, an ambulance company in the Rumford area was called out for trying to share leftover doses with a local school district.

More than two months into Maine’s COVID-19 vaccine rollout, lack of clear and consistent communication around the eligibility guidelines of the Maine Center for Disease Control and Prevention has created a rising tide of confusion and frustration:

• Eligibility guidelines have been updated and changed while vaccine clinics are underway, sometimes without being well publicized or fully explained to providers.

• Hospitals and other health care providers have no way to be sure and no authority to determine whether a person is truly eligible to be vaccinated.

• State agencies have contradicted each other when interpreting eligibility guidelines, including sending out different versions of the same guidelines.

• Individuals continue to struggle to register for vaccination appointments amid barriers that other states have dropped in favor of getting more vaccine into arms.

The dissonance is part of a nationwide struggle made worse by a vaccine supply that’s far behind demand, with each state setting its own rules, often based on shifting U.S. CDC recommendations. But reports of ineligible Mainers being vaccinated are mounting and eroding public trust, and some fear the problem will only get worse as more groups become eligible for vaccine, including people under age 70, essential workers, people with underlying medical conditions and underserved communities.

As state officials have tried to clarify and tighten eligibility criteria, they’ve also left them general enough to give providers some flexibility in distributing vaccine.

Maine hospitals and health systems have reported that some individuals have misrepresented their eligibility, but auditing systems are in place to prevent ineligible people from being vaccinated, said Jackie Farwell, spokeswoman for the Maine Department of Health and Human Services. Farwell did not respond to a request for details about the auditing systems Friday afternoon.

“We have also worked with providers to ensure that they understand and comply with the full use policy,” Farwell said. “As more groups become eligible for vaccination, Maine will continue to communicate eligibility information publicly, on the state vaccine website, directly with providers, and through various other channels.”

A variety of agencies have been caught up in confusion about the guidelines and rollout.

About 250 members of the Maine Ski Patrol were inoculated with permission from Maine Emergency Medical Services before the Maine Department of Health and Human Services said they didn’t qualify as public safety personnel currently eligible for vaccine. That left about 90 patrollers unvaccinated, most of them at Sugarloaf Mountain, one of the state’s largest ski areas.

“There’s been a lot of confusion and disappointment,” said Dirk Gouwens, executive director of the Ski Maine Association. “Why would you single out 90 ski patrollers? Maine is the only state doing this. It really doesn’t make sense because they truly are first responders.”

The ski patrol is among a long list of near-the-front-line groups vying for limited vaccine that cannot be accommodated until supply increases significantly, DHHS Commissioner Jeanne Lambrew said Thursday. They include teachers, funeral directors and direct-care providers who help homebound seniors bathe and go to the bathroom.

Med-Care Ambulance, an agency that serves 11 municipalities in the Rumford area, had to backtrack after offering 30 leftover doses to the superintendent of Regional School Unit 10. Like many vaccination clinic operators, the ambulance service had been advised to make sure no doses are wasted.

“We reached out to RSU 10 to inquire if they could provide any teachers meeting (the current) CDC criteria,” said Dan Milligan, ambulance service director. “The following day, Tri-County EMS, our regional EMS office, contacted us and advised that due to the fact that we would not necessarily be able to confirm that each individual receiving the vaccination would fully meet the criteria, it could put our vaccination clinic license in jeopardy.”

Instead, the 30 doses were delivered to the vaccination clinic at Rumford Hospital.

“I think it’s unfortunate the way the state is handling vaccine,” said Rumford Town Manager Stacy Carter. “We need to have a backup plan. You have to have contingencies for when things don’t go the way you plan.”

Maine’s Area Agencies on Aging also have been struggling to help seniors get vaccination appointments, including those without internet access and those who live in rural areas where public transportation is unavailable, which is about 72 percent of the state.

“There is currently no equitable distribution of vaccine to older Mainers,” said Jess Maurer, executive director of the Maine Council on Aging. “Everybody should get the same information and the same access, no matter who they are or where they live.”

Dr. Nirav Shah, head of the Maine CDC, said again last week that he is working to finalize a contract for a centralized vaccination registry and is communicating with providers to ensure their registration and appointment systems can successfully interact with the registry.

Hospitals leading the rollout temper their criticism of the state agency that’s providing the vaccines.

“Throughout the pandemic, keeping current with evolving information and shifting priorities has been challenging for both health care providers and public health leaders,” said Dr. Joan Boomsma, chief medical officer of MaineHealth.

“What is best practice or acceptable one week, can, with new information about the virus, personal protective equipment or vaccination, be subject to change a few days later,” Boomsma said. “Our intent has always been to balance the best available information and competing demands in a way that most benefits the people of Maine.”

Others say communication from the Maine CDC has improved and the effectiveness of the vaccine rollout will get better as supply increases and more groups become eligible.

“We strive to be nimble when facing changes in eligibility guidelines,” said Dr. John Alexander, chief medical officer at Central Maine Healthcare. “We understand that we are all working in uncharted territory. In conjunction with other health systems and community partners, we do our best to understand the thought processes behind these decisions and apply them accordingly.”

And some say the Maine CDC has always been clear, but they acknowledge their scope is more limited than other providers.

“For us, determining vaccine eligibility has not been a challenge given that we have demographic information for our patients and can easily determine those age 70 and above. As eligibility expands and moves away from solely age based, and we begin public vaccinations, we do anticipate it becoming more difficult,” said Steve Amendo, spokesman for Martin’s Point Health Care, a health care provider and insurer with practices in several southern Maine communities.

There has always been a lot of leeway in the state’s written eligibility guidelines, which currently say “vaccinations are planned to proceed consecutively through the groups identified in the phases below.” However, the next sentence says vaccinations “may not always occur precisely in this order due to the need to maximize all of the doses Maine receives.”

Questions about communication and enforcement arose after two of the state’s largest health care networks – hospital-based groups that are leading Maine’s vaccine rollout – came under fire for violating eligibility guidelines in ways that triggered widespread public criticism.

Augusta-based MaineGeneral Health offered vaccine to donors when piloting the network’s inoculation clinic, something that administrators there said was unintended. And Maine Medical Center in Portland, MaineHealth’s largest hospital, vaccinated out-of-state consultants who were hired to dissuade nurses from joining a union, just as the state changed the guidelines to exclude administrative personnel and restrict vaccine to Maine residents.

But the state didn’t publicly announce the changes until Press Herald columnist Bill Nemitz reported the MaineHealth controversy. While MaineHealth has said vaccinating out-of-state contractors was an error, it still doesn’t know exactly which health care workers are eligible to be vaccinated.

“The current state guidelines could be interpreted in multiple ways,” MaineHealth CEO Bill Caron said in a Feb. 12 written message to employees. The network has reached out to the Maine CDC in recent weeks to check the vaccination eligibility of several positions and is still waiting for a response.

Even when clarified, the eligibility guidelines can remain confusing. Hospital officials leading the vaccine rollout acknowledge the challenge of checking whether each person meets eligibility criteria.

Yet during a Feb. 11 meeting of the state’s Vaccine Planning Work Group, a PowerPoint presentation emphasized that providers must determine who is eligible, stating that “vaccinating people who are not currently eligible under the state plan is a violation of the provider agreement with the Maine Immunization Program.”

Despite the challenges, medical practices are forging ahead under the current guidelines, including InterMed, a group of health care providers and specialists with practices in Portland, South Portland and Yarmouth.

“We continually refine our processes to ensure that vaccines are being given to the appropriate populations,” said InterMed spokesman John Lamb. “This includes calling those with appointments to confirm their age or employment as a patient-facing healthcare worker, and also asking them to bring a driver’s license or proof of healthcare employment to their appointment.”

Another eligibility guideline that’s causing some confusion is the residency requirement. It has complicated matters for medical practices that regularly hire people from outside Maine. And it has made it difficult for snowbirds whose primary residence is outside Maine but who stayed here this year.

However, a close reading of Maine’s residency guidelines show they are far less restrictive than public health officials have suggested:

“A Maine resident is defined as an individual living in the state of Maine with the intent to remain in the state,” the state’s notice to vaccine providers states. “If the individual is living in Maine and has entered the state with a job commitment or seeking a job (even if only a temporary job such as migrant or seasonal workers), the individual is considered to be a Maine resident.”

The notice continues: “Let registrants know that they will need to bring some proof of identity and documentation that shows their Maine residence when they come in for vaccination. Documentation of Maine residence could include any of the following: Maine driver’s license or state identification card; a bill with their name and local Maine address; a letter or statement from their employer verifying their employment in Maine; or other mail that shows their name with a local Maine address.”

It also says, “in the interest of expediency, vaccination site staff may use discretion as to whether the proof of residence is sufficient.”

Portland Press Herald/Maine Sunday Telegram readers have reported conflicting experiences. One man said he was vaccinated last week after stating his intent to stay in Maine and showing mail with a Maine address. Another reader was initially told he would need a Maine driver’s license to be vaccinated, something he didn’t have. Afterward, he sent an email to the governor’s office and received a response with a slightly different outline of ways to prove residency:

“A Maine resident is defined as an individual living in the State of Maine with the intent to remain, or has entered the state with a job commitment or seeking a job. Proof of residency includes but is not limited to a Maine-issued driver’s license or state identification card; a bill or other piece of mail that includes the person’s name and Maine address; or, in the case of individuals entering the state for a job, a letter or statement from their employer verifying their employment in Maine.”

The gray areas aren’t always seen as a problem. State guidelines that seem ambiguous or contradictory to some may actually help vaccine providers be more effective, said Dr. James Jarvis, senior physician executive at Northern Light Health, a medical system that includes Mercy Hospital in Portland and Eastern Maine Medical Center in Bangor.

“We absolutely appreciate clarity and consistency, as well as transparency,” Jarvis said. “At the same time, (we) also appreciate that there is some leeway to our own judgment on the ground for whatever situations might come up.”

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