Vaccine mandates work, especially when they’re done right

On Monday, the US Food and Drug Administration gave formal, full approval to the COVID-19 vaccine made by the drug companies Pfizer and BioNTech. You might’ve already gotten a dose of it, of course; millions of Americans have, thanks to an “emergency use authorization” awarded in December 2020. But the new designation was more than just a formality. “If you’re one of the millions of Americans who said they will not get the shot until it has full and final approval from the FDA, it has now happened,” President Joe Biden said when he announced the approval. And, in the same speech: “If you’re a business leader, a non-profit leader, a state or local leader who has been waiting for full FDA approval to require vaccinations, I call on you now to do that—require it.”

Pretty much right away, a lot of places did. Vaccines are safe, effective, and free, but somewhere around 30 percent of Americans haven’t got their shots. Carrots didn’t work; here come the sticks. And they might be able to crush the fourth wave of the COVID pandemic in the US—if they’re done right.

Like the other vaccines still available under EUA, the Pfizer drug is extraordinarily good at keeping people from getting really sick or dying from COVID. But with more than 100,000 people in the hospital with COVID in the US—the most since January—and with the vast majority of them unvaccinated, it’s clear that alone isn’t enough. States, localities, and businesses have tried inducements like prizes, cash, or lotteries, little tricks designed to corral people into doing what’s good for them. In the language of behavioral economics, that’s called a nudge. But in states with low vaccine uptake, those nudges didn’t change the momentum. So now, it’s time for mandates. If you’re one of the 30 percent or so of Americans who haven’t gotten vaccinated yet, get ready for a good hard shove.

And nobody shoves harder than the Pentagon. The Department of Defense immediately announced it’d add COVID-19 vaccines to the more-than-a-dozen already required of service members. Big universities like California’s UC system already had mandates in place, but now more schools have joined: Ohio State, University of Michigan, University of Minnesota. City workforces in Los Angeles and Chicago came under mandate. The new governor of New York announced at her inauguration that she’d institute them, too, and New York City put them in place for public school teachers and the NYPD. In late July, pretty much every major medical and health care professional association signed onto an open letter calling for vaccine mandates across health care; the influential American Medical Association has now reiterated that position. Even the hardcore capitalists at Goldman Sachs won’t let anyone in their offices without proof-of-shot. In journalism, all it takes to make a trend is three examples. I think we’re there.

If that all sounds like jackbootery to you, the history of American public health law and policy says otherwise. Vaccine mandates and other rules that limit personal behavior in the service of societal well-being are super-legal. Just ask Supreme Court Justice Amy Coney Barrett, who reaffirmed that notion two weeks ago with a terse not-gonna-happen in response to a lawsuit brought by students at Indiana University against their school’s vaccine mandate. Barrett’s hard nope upheld an appeals court decision that was in turn based on Jacobson v. Massachusetts, the 1905 Supreme Court decision that gave the OK to requirements for smallpox vaccinations, among other public health regulations. (Most Americans support vaccine mandates, by the way. They are, of course, split along lines of political affiliation. One study this summer suggested that if elite Republicans came out forcefully in favor of vaccines—not just a “personal choice, ask your doctor” move, but full-bore encouragement, it’d increase the number who planned to get vaccinated by as much as 7 percent.) “Nobody has the freedom to go unmasked and unvaccinated in a crowded workspace or classroom. We don’t have the freedom in America to expose other people to an infectious disease,” says Lawrence Gostin, a public health policy expert at Georgetown University.

The point is, formal FDA approval wasn’t necessary for a mandate, but it’s turning out to be sufficient. Businesses, schools, and local governments that wanted to avoid a backlash over requiring “experimental” vaccines now feel like they have an even greener light. (This might’ve been a feint anyway; Texas Gov. Greg Abbott’s anti-mandate policy used to cite the EUA, and after approval it changed to specify any COVID-19 vaccine.) “They were worried about litigation, they were worried about employee perception, they were worried about public perception,” says Gostin. “We’re going to see, I think, an avalanche of companies and universities following suit in the coming weeks.”

The most important thing about vaccine mandates, though? “They work,” says Saad Omer, director of the Yale Institute for Global Health and an expert in vaccine acceptance. “A lot of the evidence comes from childhood vaccinations. For adults, it comes from influenza vaccinations for health care workers. It shows that having mandates is effective. It gets you from 70 or 80 percent to 90 or 95 percent.”

Public schools across the US require kids to show proof of vaccinations against various illnesses; different states have different levels of permitted opt-outs. One analysis of those requirements showed they increased overall vaccination rates by 18 percent. Flip side: back in 2006, Omer and his colleagues showed that states where it was easier to get exemptions for kids also had higher rates of pertussis, one of the childhood diseases with a widely available vaccine. (It could be worse; Australia fines parents for skipping kids’ vaccinations, and Uganda puts parents in jail.)

There’s a catch: you have to do mandates right. For one thing, mandate policies seen as extraordinarily harsh can spark an anti-vaccine backlash. But the real problem is one size can’t fit all. People are unvaccinated for lots of different reasons. Sure, some of them have political or philosophical disagreements. Some people don’t believe the (very good, very robust) science behind vaccines, or they subscribe to conspiracy theories about their creation. According to a Civiqs poll, 91 percent of people who identify as Democrats have been vaccinated, as have 64 percent of Independents; only 53 percent of Republicans have. And according to a different poll from the Kaiser Foundation, 5 percent of those Republicans say the only way they’d ever get vaccinated is if it was required. So… hi! It is now. Welcome!