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Minnesota has removed race as a preferential factor for determining which COVID-19 patients should receive scarce monoclonal antibodies, which are outpatient infusions that reduce the risk of severe illness and hospitalization.

Updated rationing guidance on Wednesday prioritizes infusions when they are in short supply for people who are immunocompromised or pregnant. It also gives preference to people who are older or have underlying conditions that increase their risk for severe COVID-19, but it switched to a scoring system that no longer considers race.

State leaders had been planning revisions because of the scarcity of monoclonal antibodies that was exacerbated last month when providers stopped using two of three versions because they weren't effective against the omicron variant. The policy switch occurred on the same day a conservative advocacy group, America First Legal, threatened to sue Minnesota and Utah, arguing that the states' racial preference policies were unfair.

The guidance is specific to providers who are part of the Minnesota Resource Allocation Platform (MNRAP), which includes the Twin Cities' largest health systems but not the Mayo, CentraCare or Essentia systems in greater Minnesota. The remaining effective antibody treatment is so scarce right now the scoring system identifies only the highest-need patients who are then chosen for infusions via lottery.

Minnesota's rationing guidance has changed several times. In July, the Food and Drug Administration considered it ethically appropriate to prioritize racial minorities for antibody infusions. The scoring system was added in December, based on a University of Minnesota study showing racial minorities are at elevated risk of poor COVID-19 outcomes even after factoring out age and underlying conditions.

"There is no question that BIPOC Minnesotans are dying of COVID at high rates and at younger ages compared to white Minnesotans," said JP Leider, a U health policy researcher who is overseeing MNRAP.

A weekly state pandemic report on Thursday showed that Black people make up 6% of Minnesota's population but 11% of its COVID-19 hospitalizations.

The America First Legal advocacy group countered that the system was unfair in a letter on Wednesday to state Health Commissioner Jan Malcolm, arguing that "the color of one's skin is not a medical condition akin to hypertension, heart disease, or obesity, which are known to aggravate the risk of death or severe illness among those infected with COVID-19."

The Minnesota Department of Health in a statement did not explain the timing or reason for the change, other than to say that it is constantly reviewing its policies to ensure "that communities that have been disproportionately impacted by COVID-19 have the support and resources they need."

Using population data to prioritize medical resources is a "thorny situation," Leider said.

The old scoring system ranked anyone with four or more points as the highest-need COVID-19 patients. Two points were assigned to minority members, which meant race wouldn't put COVID-19 patients in the priority group unless they also were elderly or had other conditions such as diabetes or kidney disease. Four points were assigned for people who were pregnant or immunocompromised.

Even without scoring for racial minorities, the new system provides some indirect weighting for people of color because it includes chronic diseases more common in some racial groups.

The omicron wave is increasing demand for infusions. Minnesota reported a record 20.7% positivity rate of COVID-19 diagnostic testing in the seven days ending Jan. 5 and a record per-capita infection rate. Viral loads found in sewage at the Metropolitan Wastewater Treatment Plant have tripled over the past month, according to data provided Thursday by the Met Council.

COVID-19 hospitalizations in Minnesota increased to 1,588 — though encouragingly the number of patients requiring intensive care has declined to 253. The state on Thursday also reported 52 COVID-19 deaths and 11,510 coronavirus infections, increasing its pandemic totals to 10,939 deaths and more than 1.1 million infections.

Weekly supplies of sotrovimab, the antibody that works against omicron infections, have declined from 1,374 in mid-December to an estimated 462 next week, according to state health data. However, next week's allocation includes 1,200 doses of Evusheld, the antibody therapy approved last month to protect immunocompromised people before viral exposure.

Minnesota received 4,960 courses of new COVID-19 antiviral pills last week and expects its allotment from the federal government to increase to 6,780 next week.

The state on Wednesday also issued ethical guidance for regional distribution of the new antiviral pills. The system increases supplies to communities that are more vulnerable to COVID-19 because of poverty and other factors, and prioritizes the elderly and those with underlying health conditions.

It also prioritizes the more effective Paxlovid for the highest-risk COVID-19 patients and makes the less effective molnupiravir available to a broader patient population.