A high rate of vaccination nationwide is crucial to controlling the pandemic’s threat to public health and ushering in a return to full economic activity. While the vaccination rate required to attain “herd immunity”—population-level resistance to the virus—is unknown and depends on a variety of factors, Dr. Anthony Fauci said he believes about 70 to 85 percent of people would need to acquire immunity through vaccination or previous infection with COVID-19.3 Reaching a vaccination rate of 50 or 60 percent—as the United Kingdom and Israel have—would dramatically lower the number of coronavirus cases and allow the United States to bring transmission under control.4 As of May 5, 32 percent of the total U.S. population, or more than 107 million people, had been fully vaccinated, and about 45 percent of the population had received at least one dose.5 President Joe Biden recently announced a goal to have 70 percent of adults—who represent 54 percent of the total U.S. population—receive at least their first shot by July 4.6
This issue brief discusses the measures that private entities can take to counter the slowing rate of vaccination in the United States, by improving vaccine access and incentivizing or, eventually, requiring COVID-19 vaccination. The final section of the brief describes principles for equitable adoption of digital vaccination certification.
10 ways that employers can support COVID-19 vaccination
Businesses and other organizations can take steps to increase the U.S. population’s immunity and help restore economic activity.
Improving access
1. Reimburse transportation to vaccination sites or connect homebound employees with in-home vaccination services.
2. Arrange on-site vaccination for employees.
3. Host vaccination clinics for the general public.
4. Offer workers paid leave to receive the vaccine and recover from its side effects.
Informing and educating
5. Provide educational materials to employees on COVID-19 and the benefit of vaccines.
6. Support community awareness campaigns, especially those that feature trusted messengers such as religious leaders, health care professionals, and local activists.
Providing incentives
7. Offer monetary incentives to employees for vaccination.
8. Give perks to vaccinated customers, such as discounts on services or merchandise and preferred seating at sporting and entertainment events.
Requiring and verifying
9. Consider requiring vaccination if employees’ jobs involve a high degree of COVID-19 risk to themselves, consumers, or the general public.
10. Use vaccine credentialing systems that prioritize consumer accessibility and respect privacy.
Vaccinations are slowing
At its peak, the United States’ vaccination campaign administered, on average, about 3.2 million doses per day.7 Yet the rate has dwindled over the past few weeks—which included the federal government’s pause of the Johnson & Johnson vaccine distribution to weigh the risk of blood clots, a rare but serious side effect—and there has been an even more rapid decline in the number of first doses administered per day.8 (see Figure 1) By mid-May, everyone who wanted a vaccination will have already obtained their first dose, according to projections by the Kaiser Family Foundation.9 Going forward, the United States will need to adopt new tactics to reach those who are not yet vaccinated.
Figure 1
Vaccinated individuals have a far lower risk of being infected with the coronavirus and suffering a severe case of the disease, and they are less likely to transmit the virus to others.10 When the population is only partially vaccinated, however, the threat of substantial community transmission persists. At the start of May, the incidence of COVID-19 in the United States was still high according to Centers for Disease Control and Prevention (CDC) definitions, and the new case rates were rising in some states as recently as April, fueled by more contagious variants of the virus and the loosening of public health restrictions such as social distancing and mask mandates.11
Besides threatening Americans’ health, the community spread of COVID-19 stands in the way of the U.S. economic recovery. Industries that have suffered during the pandemic, such as leisure and hospitality and spectator sports, are not expected to fully rebound until the public health crisis is completely under control.12
Businesses, educational institutions, and other private organizations should help the United States achieve greater immunity quickly by encouraging vaccination.13 Doing so makes business sense: Widespread vaccination is crucial for protecting workers’ health, safely reopening stores and operating plants at full capacity, and increasing customers’ comfort with in-person shopping and dining, in addition to slowing the spread in surrounding communities. The Wall Street Journal estimates that 75 percent of Americans would be vaccinated in September if the United States maintained its current rate of vaccination;14 yet many experts believe that hesitancy could prevent the country from reaching that level.15
The private sector can speed up the rate of vaccination
Once those who strongly desire the COVID-19 vaccine have received it, sustaining vaccine take-up will require greater education and outreach, stronger incentives, and, in some cases, mandates. People who have not yet been vaccinated cite a range of reasons, such as fear of side effects, inability to access vaccine registration portals or vaccination locations, concerns about missing work, distrust of vaccines, or insufficient information about the value of vaccines or the risk of COVID-19.16
According to an April survey by the Kaiser Family Foundation, among those who have not yet received any dose of COVID-19 vaccine, 21 percent say they intend to get vaccinated as soon as possible, 35 percent say they intend to wait and see, 14 percent say they would get the vaccine only if required, and 30 percent say they do not intend to get the vaccine.17 Notably, essential workers outside the health care industry are less likely to want to get vaccinated than the general population, according to a separate Kaiser Family Foundation survey.18 For example, an analysis by the Prison Policy Initiative found that the median rate of staff vaccination in federal prisons is 48 percent, despite the fact that jails and prisons have been the source of major outbreaks.19
Businesses and other organizations should leverage their roles as employers to help people overcome vaccine hesitancy. For example, reimbursing transportation to vaccination sites, arranging on-site vaccination clinics, or connecting homebound employees with in-home vaccination services is likely to improve vaccination rates.20 At little to no cost, employers can provide employees with educational materials on COVID-19 and vaccines to counter misinformation and fill information gaps that are at the root of some people’s hesitancy.21 Employers can also have a positive influence beyond their own workforces by hosting clinics open to the public and supporting community awareness campaigns, especially those that feature trusted messengers such as religious leaders, health care professionals, or local activists.22 Business associations, including the U.S. Chamber of Commerce and the American Farm Bureau Federation, are actively promoting vaccination among their members.23
All employers should offer workers paid leave to receive the vaccine and recover from its side effects, ensuring that no worker risks losing pay to get vaccinated.24 Most people who are not yet vaccinated report being concerned about the side effects, and many are concerned about missing work because of them.25 In April, President Biden unveiled a tax credit for small and medium-sized businesses and nonprofits to offset the cost of paid leave for vaccination.26
Employers should incentivize employees and customers to get vaccinated
Businesses and other employers are increasingly creating incentives for employee vaccination. The Kaiser Family Foundation found that of those who said in March that they wanted to “wait and see” before getting vaccinated, 38 percent would get the vaccine if offered a $200 payment.27 (see Figure 2) President Biden28 and Gov. Ned Lamont (D-CT)29 are among the leaders who have called for businesses to do more to promote vaccination through incentives. Some states are offering their own incentives. Gov. Jim Justice (R-WV) announced that West Virginia will give young people ages 16 to 35 who get vaccinated a $100 savings bond, and Gov. Larry Hogan (R-MD) offered $100 to state employees who become fully vaccinated.30 Gov. Andy Beshear (D-KY) is considering vaccination incentives for Kentucky residents.31
Figure 2
Some prominent big businesses are offering their employees incentives for vaccination.32 Darden Restaurants, which operates Olive Garden and other restaurant brands, provides workers up to four hours’ pay;33 pet product retailer Petco provides $75;34 and grocery chain Kroeger gives a $100 bonus.35 Target, meanwhile, is offering employees four hours of pay as well as Lyft rides to vaccine sites.36
The private sector can speed up reopening by spurring vaccination in the wider community. Retail pharmacies and grocery stores that are administering COVID-19 vaccines should consider enticing customers to get vaccinated with merchandise discounts; many already do so for the annual flu vaccine.37 Moreover, restaurants, bars, and stores could offer limited-time discounts to people who show a vaccination card or digital certification, similar to how some offer perks to seniors,38 to conference attendees,39 to students,40 or for birthdays.41
Professional sports has been among the industries to adopt vaccine requirements and incentives most quickly. In New York, the Yankees42 and the Mets43 now accept evidence of full vaccination in lieu of a negative COVID-19 test for entry to baseball games; and the Buffalo Bills and Buffalo Sabres announced that vaccination would be mandatory for game attendance in the fall.44 Likewise, the Miami Heat and Los Angeles Dodgers announced that they would reserve designated sections for vaccinated fans.45 Teams are also providing vaccines to fans: The Seattle Mariners, for instance, are offering vaccinations with no appointment at home games.46
Vaccination requirements would advance public health
While attitudes toward the COVID-19 vaccine are growing more favorable over time,47 a sizable portion of the U.S. population is likely to remain unvaccinated for the long run unless required to do so. Ultimately, some employers will likely need to consider mandating vaccination in order to operate safely and save lives.48
Vaccine mandates have been in place for more than a century. In the 1905 case Jacobson v. Massachusetts, the U.S. Supreme Court upheld a Massachusetts law that allowed cities to require smallpox vaccinations and impose fines on those not in compliance, noting that the law was for “the protection of the public health and the public safety.”49 Many private entities require certain vaccinations for the sake of public health. For example, hospitals and other health care providers commonly require personnel to be vaccinated against influenza;50 schools and child care providers require immunization for children; and colleges and universities can require students to obtain vaccines beyond the minimum requirements of state law.51
At present, the COVID-19 vaccines being administered in the United States are available under an emergency use authorization (EUA) from the U.S. Food and Drug Administration (FDA).52 To be granted an EUA, vaccines and other drugs must complete rigorous clinical trials to demonstrate efficacy and safety. Prominent legal experts argue that EUA status does not preclude private employers’ ability to mandate and that courts are likely to uphold employer mandates for COVID-19 vaccines.53 It is unclear if statutory law prevents public entities, including schools and universities, from implementing COVID-19 vaccine mandates prior to full FDA approval.54
The U.S. Equal Employment Opportunity Commission (EEOC) has issued guidance for employers on COVID-19 vaccines, explaining how requirements must comply with the Americans with Disabilities Act and provide reasonable accommodations for workers whose sincerely held religious beliefs or practices prevent vaccination.55 For example, some individuals may be unable to receive the vaccine because of an allergy or other medical contraindications.56 The EEOC is expected to offer guidance for incentives as well.57
In addition, state law may govern the exceptions and accommodations employers must allow, and legislators in many states have drafted bills to prevent employers from requiring vaccination.58 Many states have pre-pandemic laws related to school vaccinations: 45 states currently allow religious exemptions, and of those, 15 states also permit philosophical exemptions for other types of personal beliefs.59 Where possible, private sector organizations should limit nonmedical exemptions by making vaccination the default, with appropriate pathways for those facing religious barriers. For example, employers could require people requesting nonmedical exemption to consult with a health care provider or complete an educational exercise about the risks of remaining unvaccinated.60 Ample research has demonstrated that philosophical exemptions can have a cluster effect, creating communities at high risk for preventable disease outbreaks.61
If employers’ efforts to boost awareness of the vaccine’s benefits and improve access are insufficient to achieve a safe level of vaccination, employers may need to consider vaccine requirements. Those that do choose to require vaccination should provide information on how COVID-19 vaccines work and how to get vaccinated. They must also ensure that workers do not face any loss of pay due to vaccination. Employers should, however, allow workers ample time to become fully vaccinated before a mandate takes effect and recognize that vaccine availability has often not been equitable, particularly for people of color.62
It is also important that employers mandate vaccination to the full extent legally permissible if employees’ jobs involve COVID-19-related occupational risk; regular interaction with customers or members of the public who are unvaccinated or at high risk of severe COVID-19; or settings that are prone to high rates of transmission.
- Health care organizations should require that staff be vaccinated against COVID-19 for their own safety and that of their patients. Houston Methodist became the first hospital system in the United States to announce it would require COVID-19 vaccinations for all staff.63 More health care providers should follow suit; a recent nursing home outbreak illustrates how allowing some workers to remain unvaccinated can cost lives.64 The pandemic has been deadly for health care workers. Across all types of facilities, more than 3,600 health care personnel have died during the pandemic, with a median age nearly 20 years lower than the national median age for COVID-19 deaths.65 Notably, long-term care facilities, including nursing homes, are associated with one-third of COVID-19 deaths in the United States, with more than 179,000 deaths among residents and staff.66 Two of the nation’s largest operators of assisted living facilities, Enlivant and Sunrise Senior Living, have mandated employee vaccination.67
- Child care providers and schools should consider requiring employees to be vaccinated. While studies from last year showed that child care and K-12 schools with proper risk mitigation were not major contributors to community spread, educator and staff vaccination is still essential to protect unvaccinated children, minimize transmission among children, and allow students back into classrooms and other community spaces for in-person learning.68 The CDC reports that nationally, “Nearly 80 percent of Pre-K-12 teachers, school staff, and childcare workers received at least their first shot of COVID-19 vaccine by the end of March.”69 However, none of the three vaccines currently authorized for use in the United States is available for children under age 16, although Pfizer anticipates emergency authorization of its vaccine for use in children ages 12 to 15. There is no certainty that all teens can be vaccinated by the fall, and younger children are not likely to obtain vaccination until late this year.70
- Workplaces that are prone to COVID-19 outbreaks should mandate vaccination. One such category is high-density facilities not conducive to social distancing.71 This includes meatpacking and poultry processing plants, which have been the source of numerous outbreaks.72 Employee vaccination in shared housing facilities, including group homes, carceral settings, student housing, transitional housing, and domestic violence and abuse shelters, is also imperative for protecting both workers and residents.73 The CDC notes that residential congregate settings “may face high turnover of residents, a higher risk of transmission, and challenges in maintaining recommended physical distancing.”74
- The health of first responders and other essential workers should continue to be a priority. Employers of first responders and other essential workers should require vaccination of personnel who serve critical functions or are at high risk of close contact with unvaccinated individuals.
In addition, more than 100 colleges and universities have announced vaccine requirements for students,75 and some have mandated vaccination for faculty and staff.76 Rutgers University,77 the University of Notre Dame,78 Pomona College,79 and Yale University80 are among the many institutions where students will need to be vaccinated to return to campus in the fall. Likewise, the University of California and California State University systems81 as well as the Atlanta University Center Consortium,82 a group of historically Black colleges and universities that includes Morehouse College, are requiring that students, staff, and faculty obtain vaccinations before the fall term. According to an analysis by The New York Times, more than 600,000 COVID-19 cases have been “linked to American colleges and universities” throughout the pandemic; and there have been more than 100 COVID-19 deaths among college students and staff, the “vast majority [of which] occurred in 2020 and involved employees.”83 Given this track record, colleges and universities should offer vaccination on campus, especially for international students who may not otherwise have access. Some institutions are offering vaccines to students now to ensure that they receive them before the summer break.84
Vaccine certification must balance convenience with accessibility and privacy
As vaccine requirements and incentives linked to vaccination become commonplace, certification will become more important, as will efforts to ensure that certification tools are widely accessible.85 Although they are often referred to as “vaccine passports,” vaccine credentials exist primarily to document vaccination status, not authorize travel.86 At least 17 private companies are developing digital vaccine credential systems, and New York state has launched an “Excelsior Pass,” an application developed by IBM.87 Meanwhile, at least six states have banned or limited the use of “vaccine passports.”88 While the United States seems unlikely to have a national credentialing system,89 with so many independent efforts emerging, the government should consider providing guidance on privacy and other key issues for these nongovernmental efforts.
No national organization in the United States maintains immunization records, nor will the federal government be creating one for COVID-19 vaccinations; and existing immunization information systems maintained at the state level are of “variable quality.”90 So far, vaccine credential applications rely on individuals to upload photos of their paper vaccination card and self-report other details, posing validation concerns. The Washington Post reported that Albert Fox Cahn, a privacy advocate, “was able to load up a volunteer’s Excelsior Pass in about 11 minutes, using nothing more than that person’s Twitter posts and information from publicly available websites.”91 Similar vulnerabilities have been exposed for Israel’s Green Pass, touted as the first digital credential for COVID-19 vaccination.92
Organizations developing and using vaccine credentials will need to balance convenience with accessibility and privacy. Makers of credentialing systems should strive to make their tools accessible to everyone. When the digital credentials are designed as phone-based applications, alternatives modes of access will need to be available for people without smartphones or internet connection. Credential systems should also be made accessible to non-English speakers, those who are not technologically literate, and people with cognitive or visual disabilities, using Section 508 standards as a model. In addition, credential platforms that incorporate other forms of identity verification should consider workarounds for those without identification documents, such as undocumented immigrants.93 While some vaccine credential initiatives offer paper options, they are designed primarily for smartphone use.94
The U.S. vaccine rollout has been criticized for providing inequitable access to some communities, 95 particularly people without internet access,96 disabled people,97 and racial and ethnic minorities.98 Without broad accessibility, credentials themselves could become barriers to access for travel, commerce, and leisure events—deepening existing inequities.99 To ensure credentials are not used in unlawful and discriminatory ways, government actors and other authorities, including the European Union100 and the World Health Organization,101 have begun to set standards and bounds.102 Credential systems should prioritize the privacy and security of the data they collect, and Congress should prohibit the sale and abuse of vaccine credential data.103
Lastly, entities using vaccine credentials should bear in mind that vaccination, while highly effective, does not reduce the risk of COVID-19 to zero and that transmission in the United States remains high.104 Like New York’s Excelsior Pass, credentialing initiatives should encourage users to follow CDC protocols for social distancing and face coverings.105 Employers, sporting venues, airlines, and others must continue to engage in risk mitigation to protect the unvaccinated.
Conclusion
The COVID-19 vaccines have made it possible for Americans to begin to safely reunite with long-missed friends and family members, lessened the strain on hospitals once packed with coronavirus patients, and saved lives. To ensure that the United States vaccinates as many people as possible, the next stage of pandemic response will require stronger incentives, coupled with initiatives to improve awareness and access, to reach those not inclined to seek out the vaccine on their own.
Until a larger share of the population is vaccinated, precautions to prevent the spread of COVID-19 remain necessary. Vaccination is an issue of both national and local concern. Even if the United States achieves a high level of vaccination nationally, insufficient vaccination in some areas could allow pockets of high transmission to persist.106 Businesses and other employers must step up to promote population health and revive the economies of their local communities by doing their part to encourage vaccination.
Emily Gee is the senior economist of Health Policy at the Center for American Progress. Nicole Rapfogel is a research assistant for Health Policy at the Center.
The authors would like to thank Neera Tanden, Antoinette Flores, Khalilah Harris, Laura Dallas McSorley, Taryn Williams, Erin Simpson, Adam Conner, Maggie Jo Buchanan, Maggie Siddiqi, and Maura Calsyn for their thoughtful input.
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