The Trump administration has fallen far behind on its initial pledge to vaccinate 20 million Americans by the end of 2020, with under 3 million people receiving COVID-19 vaccinations out of the 14 million doses that have shipped. Local health providers responsible for the last mile of the vaccine’s delivery are short-staffed and exhausted by the ongoing battle against the pandemic, and limited resources, prioritization plans and mistakes have also hampered the nationwide vaccination effort.

The first sign that the administration had overpromised came in late December, when officials modified their pledge — from vaccinating 20 million Americans by the end of the year to vowing to “make vaccine doses available” to 20 million. The top adviser for the federal vaccine effort known as Operation Warp Speed, Moncef Slaoui, admitted this month that the “wrap-up of immunizations — shots in arms — is happening is slower than we thought it would be.”

“That number is lower than what we hoped for,” Slaoui acknowledged again at a briefing Wednesday. He challenged anyone who can “help us further improve administration of the vaccine to come to the table, put your sleeves up, and come help us with specific ideas.”

The Health and Human Services Department said Tuesday it has allocated 19.88 million doses of COVID-19 vaccine through the end of December. But allocation isn’t the same as delivering the doses. Allocated vaccines must still be shipped out to destinations picked by states, and in some cases redistributed by state and local health authorities before health care providers giving the shots can begin to prepare their first doses.

“We’re getting the vaccines out as fast as they are available,” said Gustave Perna, the Army general charged with overseeing logistics of the vaccine distribution.

Though both the vaccine makers and federal officials insist there haven’t been major delays in producing or distributing the first 20 million doses, just 70% of the promised vaccines have been shipped. Some providers have reported they’ve only begun to receive their first shipments from state redistribution hubs this week — days after they had hoped to begin vaccinations.

States have been receiving fewer vaccine doses than they were initially allocated by the federal government. Earlier this month, Perna apologized for his “miscommunication” about vaccine allocations; he had revised the numbers of doses to be sent to some states after receiving more information from Pfizer about what was available.

“This is disruptive and frustrating. We need accurate, predictable numbers to plan and ensure on-the-ground success,” said Washington Governor Jay Inslee at the time.

Washington officials said they were among dozens of states whose vaccine shipments had been slashed — in their case by 40%— by federal authorities, though this particular issue appears to have been addressed. Inslee later praised Perna for his “candor” in explaining the issue, saying “there is no indication further reductions are likely to occur. That is good news.”

Administering the vaccine

Centers for Disease Control and Prevention data showed that as of Thursday, just 2,794,588 people had received their first dose of either Moderna or Pfizer-BioNTech’s COVID-19 vaccine, though the CDC cautioned immunization figures were “a day or two behind.”

Vaccine providers are given 72 hours to submit data on their vaccinations, which Dr. Nancy Messonier, the CDC’s top COVID-19 vaccine official, said Wednesday takes into account “that when they’re so rapidly looking to vaccinate people, it may take them a little time to be able to enter all the data.”

It hasn’t been easy for vaccine providers to navigate the prioritization tiers laid out in state and federal guidelines, balancing demands to prioritize vaccines for healthcare workers against pressure to administer shots quickly.

Vaccinators have also been frustrated with the rollout in long-term care facilities, after misunderstandings about consent requirements plagued the launch of the vaccination programs by pharmacy chains like CVS and Walgreens. Spokespeople for both companies said the consent snafu has been straightened out but declined to share specific figures on their vaccinations, which began nationwide last week.

But pharmacies have yet to begin vaccinations at long-term care facilities in some jurisdictions, Messonier said, because some clinics are holding onto doses until they have enough vaccine “for everybody in the facility that wanted the vaccine.”

The administration of the vaccine to people who aren’t on the top priority list is also delaying the reporting on who’s receiving the shots. Vaccine recipients appearing to “cut the line” have been met with outrage across the country, resulting in protests by frontline health care workers at Stanford Medical Center and an investigation into some New York vaccine providers. On Monday, New York Governor Andrew Cuomo signed an executive order cracking down on vaccinators who aren’t following the priority population process, fining violators up to $1 million and revoking all licenses, according to CBS New York.

In Southern California, a hospital defended its decision to vaccinate “non-front line healthcare workers” after reports that a Disney employee bragged that her connections had landed her a COVID-19 vaccine shot.

“Because the reconstituted Pfizer vaccine must be used within hours or be disposed of, several doses were administered to non-front line healthcare workers so that valuable vaccine would not be thrown away,” Redlands Community Hospital spokesperson Nikyah Thomas-Pfeiffer said in a statement.

While in Texas, officials have urged vaccinators to “pivot” to administering doses for any “readily available and willing” residents, even if not all frontline health care workers had been vaccinated.

“It has become clear that a significant portion of vaccine in Texas may not be administered yet. We know you have valid reasons as to why this has happened in some cases — but we also know that every day a vaccine sits on the shelf is another day that prolongs the pandemic,” Dr. John Hellerstedt, the top health official in Texas, said in a letter to clinics last week.

In Florida, local health departments are pleading for patience as phone lines crash and healthcare workers line up overnight outside vaccination sites, competing with other residents clamoring for the shots.

“Empty pockets”

The scramble to distribute millions of vaccine doses comes after a year that had already stretched public health budgets. “These health departments are coming into the vaccine distribution period with empty pockets already. They didn’t get enough money from the original COVID supplemental funds,” said Tremmel Freeman.

The Trump administration has touted the $480 million it’s given to local jurisdictions for flu and COVID vaccinations in September and December, with Operation Warp Speed providing syringes and other supplies to vaccinators across the country.

State and local health authorities will get some help from the recently-passed COVID-19 relief bill, which appropriated billions for vaccine development and distribution, though Tremmel Freeman said the money had yet to reach frontline health providers who are trying to ramp up their immunization programs quickly.

“I haven’t seen any language that holds anybody accountable for ensuring that the money goes beyond the state level into deeply the community to help with this effort either. We saw this happen with testing and tracing, and look at the disaster that occurred there,” added Tremmel Freeman.

The timing of the vaccine rollout has also collided with the Christmas and New Year’s holidays, which have strained manpower.

“There’s two holidays, there’s been three major snowstorms, there is everybody working through, you know, how to do the notification, how to make sure we’re administering it the right way,” Perna said Wednesday.

The public now has a clearer view on how the vaccine distribution is going: on Wednesday, the CDC unveiled a new virus distribution tracker that enables users to see how many doses have been distributed and administered each day.