Tension is mounting between state, local and federal officials over the strict priority groups states are enforcing for COVID-19 vaccinations.

The Trump administration is encouraging states to be flexible, and wants governors to allow vaccination of lower-priority groups. 

But with a limited number of doses on hand, governors want to make sure only those most at risk get their shots first, and quickly. 

Under guidelines from the Centers for Disease Control and Prevention (CDC), the first doses are recommended for health workers and residents of long-term care facilities. 

The next phase, known as "1b," includes people 75 and older and front-line essential workers like first responders, corrections officers and utility and transportation workers. Phase "1c" includes people 65 to 74, as well as people with high-risk medical conditions.

Most states drew up plans that initially followed CDC guidance for the first phase of vaccinations. But the rollout has been slow, marred by a lack of federal funding and unclear communication about the number of doses coming each week. 

As coronavirus cases spike across the country and in the absence of a national distribution plan, states have been reworking their plans as they go.

In New York, Gov. Andrew Cuomo (D) is proposing legislation that would impose criminal charges on facilities and health care providers that ignore guidelines on who is eligible for the vaccine. 

At the same time, hospitals will also face a $100,000 fine and risk not receiving further coronavirus vaccine shipments if they don’t administer doses within a week of getting them.

In New York City, close to 30 percent of health workers have declined a chance to be vaccinated, but hospitals aren't allowed to give the shots to others who may want it, like people over the age of 75, first responders, or transit workers.

New York City Mayor Bill de Blasio (D) wants eligibility widened. He says the city has thousands of slots available to vaccinate New Yorkers, but can't use them because of Cuomo's restrictions.

"Sometimes the federal government, the state government, need to stand back and let local government do what it knows how to do best," de Blasio said Thursday. “What we need is the freedom to vaccinate."

Health experts said they think it's important to prioritize certain groups, but it shouldn't come at the expense of leaving doses unused.

"You're going to end up with the opposite of the overall goal of the vaccination program, which is to get the vaccine into people's arms. And just because some people that are not in priority group 1a in a given state get vaccinated a little bit earlier than other people, that's not the end of the world," said Amesh Adalja, senior scholar at the Johns Hopkins Center for Health Security.

Josh Michaud, an associate director for global health policy at the Kaiser Family Foundation, said hospitals shouldn't be put into situations where they have to throw out vaccine doses because they're not allowed to move on to the next group in line.

"Placing some organization, and some sort of order in your vaccine efforts is important," Michaud said, because supply is so limited and demand is so high.

But, he added, "if you place too much emphasis on the prioritization, and turn a blind eye to the need for flexibility, then it's just adding rigidity and slowing the process. And what we don't want now is to add more barriers."

That view has been echoed in recent days by top Trump administration health officials. Despite repeatedly telling states that the federal government is not responsible for getting shots into arms, officials are now telling states to take steps to speed up the process.

"States not only can, but SHOULD aggressively expand vaccinations to other phases if current supply exceeds demand in phase 1a!" Surgeon General Jerome Adams tweeted on Thursday.

Health and Human Services Secretary Alex Azar on Wednesday urged governors not to micromanage the vaccination process. He said it's better to get shots into arms quickly, even if every single health worker hasn't been vaccinated yet. 

"Right now, there is no reason that states need to complete, say, vaccinating all health care providers, before opening up vaccinations to older Americans or other, especially vulnerable populations," Azar said.

"It would be much better to move quickly and end up vaccinating some lower-priority people than to let vaccines sit around while states try to micromanage this process. Faster administration could save lives right now, which means we cannot let the perfect be the enemy of the good," Azar said.

Azar specifically praised Florida Gov. Ron DeSantis (R), who last month said his state would prioritize people over the age of 65, ahead of essential workers who may be younger.

But Florida's vaccination system has been plagued by a flawed system that leaves local health centers in charge of planning. People have dealt with crashing websites, online scams and jammed phone lines, while others have waited in line for hours for a chance to be vaccinated. 

Kaiser's Michaud said governors need a balance — they can't be too rigid, he said, but they should have some limits, so as not to run out of available doses.

"We're not facing so much a supply problem as a distribution problem," he said. "You need to get vaccines into arms as quickly as possible, but you also don't want to have a free for all either. So there has to be a balance struck."