Some of the most populous states are shelving federal recommendations and making coronavirus vaccines available to the elderly before providing access to grocery store employees, transit staffers and other front-line workers.

Officials are pursuing such strategies in Florida and Texas, where a combined 50 million people live. The divergence reflects differing needs in a highly diverse country where the coronavirus has killed unevenly, but it also highlights an emerging patchwork that could pose obstacles for the nationwide immunization campaign to corral the pandemic.

The differences also carry political undertones that recall varying approaches to mask mandates and stay-at-home orders. Republican-controlled states are breaking most openly with the expert recommendations at a time when advisers to President-elect Joe Biden are calling for greater federal coordination.

“We are not going to put young, healthy workers ahead of our elderly, vulnerable population,” Florida Gov. Ron DeSantis, R, vowed last week in an address at The Villages, the nation’s largest retirement community. A top infectious-diseases official in Texas, Imelda Garcia, said focusing on adults 65 and older and people with chronic conditions “will protect the most vulnerable populations.” In Ohio, Gov. Mike DeWine, R, is adopting a similar approach but also including school staffers in the early phase, emphasizing the need to return to in-person learning.

Medical workers and residents and staffers at long-term care facilities constitute the first tier in virtually every instance, in line with guidance released in early December by the panel advising the Centers for Disease Control and Prevention. The question now confronting state leaders: Who comes next?

The expert panel of federal advisers met again before Christmas, seeking to balance protecting workers whose jobs put them in harm’s way with shielding those most likely to suffer complications from the virus or die of COVID-19. The panel recommended putting people 75 and older and essential front-line workers in the next priority group.

Among those workers – who the Advisory Committee on Immunization Practices said were most critical to the functioning of society – are emergency workers, educators, manufacturing workers, corrections officers and transit staffers. Many could get access to the vaccine early in the new year, though timelines may differ considerably by state.

“It’s not ideal to have differences across the states, but in terms of getting the vaccine out and into arms as quickly as possible, it may not be such a bad thing,” said Claire Hannan, executive director of the Association of Immunization Managers. As long as states are putting vaccine doses into arms, they are on their way to meeting the ultimate goal, she said.

At the same time, the divergent approaches reflect the difficulty of policing access to the shots once immunization moves from health-care systems and nursing homes into the wider community. States and local jurisdictions will decide what sort of screening process to use, Hannan said, as vaccinators verify people’s ages, employment or health histories.

There are costs to adhering to the priority groups too strictly, she warned. “Everybody’s going to get it at some point, so turning people away is not where we want to be,” she said. Doing so, she said, may discourage people from returning at a later date.

Trump administration officials stress that governors are in charge of setting priorities for their states, consistent with the administration’s decentralized approach to managing other phases of the pandemic. Vice President Mike Pence, in a November phone call with governors anticipating federal clearance of the first two vaccines, told state officials they would be the “ultimate arbiters” of how the shots were rolled out, according to a call summary released by the office of Washington Gov. Jay Inslee, a Democrat.

Members of Biden’s coronavirus advisory board have suggested the federal government should play a more active role in aspects of the immunization campaign, the most ambitious in the nation’s history. Marcella Nunez-Smith, a co-chair of Biden’s advisory board and an associate professor at the Yale School of Medicine, said in an interview this month that more-detailed guidance about reaching particular populations within priority groups would help bring clarity to the allocation of finite resources while respecting the “wisdom and realities that will vary locally.”

In Florida, DeSantis made a point of setting his state on a different path. He traveled last week to The Villages, in Central Florida, to mark the state’s first two vaccinations of community members, as immunization quickly broadened beyond medical workers and nursing home residents.

“As we get into the general community, the vaccines are going to be targeted where the risk is the greatest, and that is in our elderly population,” DeSantis said, noting that 82 percent of deaths from COVID-19 were in that age cohort.

Nationally, 80.7% of deaths have been among people 65 and older, according to the CDC, while people in front-line jobs who cannot work from home or keep a safe distance from others are at highest risk of work-related exposure. People of color, who have been disproportionately affected by the virus, are overrepresented in such jobs.

Jared Moskowitz, director of the Florida Division of Emergency Management, said people older than 65 with chronic conditions are among the state’s most vulnerable residents, along with medical and emergency workers and residents of long-term care facilities. Vaccinating those most likely to wind up in the hospital alleviates burdens on the state’s health-care system, said Moskowitz, a Democrat.

That course of action conflicts with requests by unions and some industry groups that had lobbied for their workers to be next in line. The Florida Education Association, which sued state officials over the summer in response to what it termed a “blanket and arbitrary” reopening plan, had asked that teachers gain priority after medical workers and nursing home residents, said the union’s president, Andrew Spar.

The Texas American Federation of Teachers made a similar request, said its president, Zeph Capo. “Schools are one of the main spots where we have large congregations of people, much like residential health facilities,” he said.

Industry groups were similarly seeking early access by having their workers classified as essential. Emily Williams Knight, president and chief executive of the Texas Restaurant Association, said prioritization should go to those helping to “feed Texans.”

Florida and Texas have diverged perhaps most starkly from the recommendations of the CDC advisory group. But draft plans in other states, which are still being revised in response to the latest federal guidance, exhibit differences, too.

Arizona’s plan puts all essential workers – not just those in front-line industries identified by the expert panel – in the second phase. Colorado’s strategy keeps front-line workers in the next priority group, unlike plans in Florida and Texas, but also widens the group of older residents who are prioritized to people 65 and older. Some members of the CDC advisory panel had favored that approach, foreshadowing the differences now appearing in some states.

The move to include only people 75 and older in the next priority group prompted the lone dissent from the recommendations advanced by the panel. Henry H. Bernstein, a pediatrics professor at the Donald and Barbara Zucker School of Medicine at Hofstra/Northwell on Long Island, said he wanted to see people ages 65 to 74 included as well. He said he was not convinced that outcomes differed considerably for those in the slightly younger age cohort.

States will find that the process is messier as they move into larger segments of the population, said Josh Michaud, associate director for global health policy at the Kaiser Family Foundation, a nonprofit health policy organization. Some groups will be harder to reach than anticipated. Others will be more reticent about taking the vaccine. The result will be more-pronounced variations among states, Michaud predicted.

“The best-laid plans might not work out as they thought they would on paper,” he said.

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