Dan Gorenstein: After more than a year of pandemic darkness, that light at the end of the tunnel finally seems to be getting closer. 

News clip: The U.S. just recorded its lowest daily case number in seven months.
News clip: Vaccinations are so far up and cases so far down, some communities may reach herd immunity.
News clip: And with vaccinations climbing, restrictions are failing.

DG: Almost half of people in the U.S. have received at least one vaccine dose as of mid-May.

But a third of American adults remain unconvinced they need the vaccine, leaving the U.S. at risk of new variants and future surges.

Some people say they would get the vaccine if their job forced them to, leaving employers with a difficult decision to consider.

News clip: Should employees be required to take the vaccine before returning to work?

DG: Today, we return to the Research Corner with University of Minnesota health economist Sayeh Nikpay to learn what research can tell employers about the pros and cons of mandating their workers get vaccinated.

From the studio at the Leonard Davis Institute at the University of Pennsylvania, I’m Dan Gorenstein, and this is Tradeoffs.

DG: Sayeh, it is great to have you back on the show. I’ve missed you. How are you, my friend?

SN: I’m good. I’m good. I’m very heavily pregnant. I am 37 weeks, which means the baby is fully cooked and now we’re just waiting.

DG: Oh, my gosh. I cannot wait to meet the next member of your family. It’s going to be fantastic. Congratulations.

SN: Thank you. I will be very happy to deliver in a place with a lot of vaccinated health care workers. So I’m really excited to talk about vaccine mandates.

DG: Well, indeed. Fantastic. Thank you for that segue. We are going to be talking about employer based-vaccine mandates. 

And it’s starting to happen. We’re seeing some employers do this.

SN: Yeah, and it is mostly in health care, like nursing homes and hospitals. 

News clip: Houston Methodist wants to require all of their own employees to be vaccinated.

SN: But it is happening in some other places, too. 

News clip: Delta Air Lines chief executive tells me all future employees must be vaccinated before they start their first day on the job.

SN: So the Wall Street Journal reported in April that a Michelin starred restaurant in New York City did it, a telecom company in Alaska did it, which I’d like to visit less than the Michelin star restaurant. A plastics manufacturer in Louisville, which I would like to visit even less than the telecom company. They’re all requiring vaccines for new and existing employees, and they’re doing it because they work.

So take Houston Methodist Hospital. That was the first big hospital to announce a mandate at the end of March. And the hospital says 95% of its 26,000 employees have been vaccinated, and only two people have quit so far. And this lines up with at least a dozen other studies in health care settings that show that vaccine mandates do get more people vaccinated.

DG: And look, there are lots of reasons why employers want to get their workers vaccinated, right? I mean, it makes going to to the workplace safer. It should cut down on the number of people getting sick. 

For airlines, theaters, restaurants, places like this, it could convince nervous customers to come back, giving these folks a competitive advantage. 

And, Sayeh, every additional person vaccinated makes it less likely that we’re going to see new, more contagious strains take root here in the U.S., which is good for the country and good for business. 

Those are the pros. What, though, is the downside?

SN: The con here, the real con I would be thinking about if I were an employer is that companies could face some real pushback. 

So overall, polling from Kaiser Family Foundation and some other organizations show that Americans are really in a 50/50 split over this idea. And lawmakers in 40 states, or about 40 states, have introduced bills that would effectively ban employer COVID mandates. 

And at that hospital, Houston Methodist, yeah, most people got the shot, but more than 7,500 people have signed a petition saying that employees shouldn’t have to get vaccinated. 

And finally, there’s maybe the biggest motivator in all health care policy making, you might get sued. So there’s currently three lawsuits that are challenging these mandates around the country.

DG: But look, I’ve got to think these employer vaccine mandates are legal. Otherwise, why’re you going to have like about 40 states trying to pass these bans?

SN: Look, Dan, I’m an economist. I don’t know about the law, but thanks to some digging from the very fantastically talented Ryan Levi, our producer, here’s what I know.

The vaccines have only been approved for emergency use and part of the rules surrounding emergency use are that a person does have the right to refuse the vaccine. So some lawyers are saying that that makes the mandates a no-go. 

However, others point to the Equal Employment Opportunity Commission, which is a federal agency that enforces workplace anti-discrimination laws, and they released guidance in December, that said that employers could mandate the vaccine as long as they offered religious and medical exemptions. 

So that seems to be the dominant theory among legal experts right now.

DG: So employers seem to be on solid enough legal footing. But like a lot of things with this virus, the situation can get political super fast, and a mandate could, I can imagine this, really hurt morale.

Do we have a sense, Sayeh, of how companies are trying to thread the needle?

SN: Oh, my gosh, Dan. Very, very carefully.

Polls show that while many employers say they’re considering mandates, very few have actually gone ahead with them. 

And some of these employers are saying they’re going to wait until vaccines have full FDA approval and not just emergency use approval, which could happen in the next few months.

And many of them are just feverishly trying to avoid needing mandates altogether by persuading employees with educational campaigns, bonuses, extra time off, which research shows can work.

DG: So you’ve laid out the pros and cons of the employer vaccine mandate. 

But since this is Research Corner, Sayeh, what sort of evidence is out there for those employers who are actually wrestling with this question of whether or not they should introduce a mandate?

SN: I wanted to know this so badly when I started my literature review in this area. And the answer is not much, because this is just uncharted territory. 

You know, it would be great if there was that study that I was looking for that, say, looked at what happened at Target or Applebee’s and what would happen if those employers required all their employees to get the flu shot. 

But that study doesn’t exist because employer mandates are just really rare. This has never happened before at a Target or an Applebee’s or a Walmart or what have you. 

What we do have instead are papers about vaccine mandates in health care settings and sometimes in schools. 

And this is super common in economics. We have to look to papers sometimes about similar policies that we can use to triangulate our best guess of what the answer to our policy question might be.

DG: Great. Let’s do this. Let’s triangulate the information. What’s the first point of the triangle, Sayeh?

SN: OK, well, we’ve actually just already touched on it, which is that there’s a wealth of papers that show that mandates work. They get more people vaccinated, which, like you said, is good for business and good for the country. 

But what does that actually mean? How big of an impact will my 12 person mandate for my cafe or my 50 person mandate for my accounting office or thousand person mandate for my conglomerate actually have. 

What that employer really wants to know is, you know, what do I get out of risking blowback from my workers? Some of them might even quit. Some of them might even sue me.

So this brings me to the second point of this triangle.

Corey White: My name is Corey White. I’m currently an assistant professor of economics at Cal Poly in San Luis Obispo

SN: And he’ll soon have the exact same job at Monash University in Melbourne, Australia.

CW: Although I’m still waiting for a visa in order to be able to get to Australia because they’ve had their border closed for a year now. So we’ll see when that actually happens.

SN: Corey started out studying environmental economics, but he got a little worn down thinking about pollution and climate change all the time. So he went out there looking for something uplifting to study, and that’s what brought him to vaccines.

CW: When you get vaccinated, most people are just interested in what we call the private benefit. That’s the reduced risk of you catching the disease yourself. But there’s, of course, also reducing the risk of spreading the disease to everybody else.

SN: This is actually what economists call a positive externality. And it’s just like a perk or a benefit that we all get without having to directly pay for it. 

And vaccinations are just like a classic example of a positive externality. Everyone knows that when someone gets vaccinated, Dan, it’s good for all of us. And that’s the whole idea that we’re talking about when we keep talking about herd immunity. 

But what Corey wanted to do was actually measure the value of the societal perk and put a hard number on it rather than allowing it to just be squishy.

DG: So it sounds like Corey’s entering some of his own uncharted territory here, Sayeh.

I’m curious, how did he try to figure out how much of a societal impact these vaccine mandates could have?

SN: Ok, so what he did in a paper that’s coming out in the Journal of Human Resources is he looked at hospitals and counties in California that implemented these vaccine mandates for health care workers for the flu. And what he found is that the mandates increased uptake of flu shots by about 10 percentage points. And that lines up with other studies that we have in this area showing that mandates do work. 

But then what Corey did is he looked at the flu transmission rates after those extra health care workers got vaccinated, and he found two things. 

The first thing he found was that there was a 40% drop in the number of people who entered the hospital and ended up contracting the flu there.

And then the second thing he found is that there was a 20% drop in the number of people coming into the hospital with flu.

CW: So it appears as though these health care worker vaccination mandates are not only just reducing the spread of influenza within the hospital itself, but they’re actually reducing the spread of influenza in the community at large.

DG: OK, this seems really important, so let’s break it down.

From the perspective of a hospital as an employer — and hospitals often are one of the biggest employers in town all around the country — the paper seems to have some clear upsides, even though there is that risk that we’ve been talking about, Sayeh. 

One, more of your workforce gets protection from the flu, presumably meaning fewer sick days. 

The patients coming in, your customers, are less likely to get sick when they walk in the door.

And you’re helping out your community, keeping more people healthier, which is that whole business about being a good neighbor.

SN: Exactly, Dan, and that’s the reason why I was so excited about Corey’s paper because it actually puts some hard numbers to those upsides.

DG: And those numbers seem definitely useful for hospitals if they are considering a mandate like Houston Methodist.

But, Sayeh, what about other employers? How generalizable do you think this research actually is?

SN: OK, well, for places where you have a lot of sickness and vulnerable people in one place, like a nursing home or doctor’s office, I think Corey’s paper is really generalizable. 

But the big caveat here is that obviously COVID and flu just aren’t the same thing medically or socially at this point. COVID is much more political and a mandate is likely to evoke a much stronger response from employees than a simple flu mandate.

DG: Point taken. But still, it seems like there are lessons here for other non-health care employers.

SN: Yeah, Dan, I think that’s right. So Corey’s paper helps us see that if you run a business with a lot of employees who haven’t been vaccinated and you have all these people coming through your store, your office, or whatever it is, a mandate will have some impact.

And the same could be true with a small company, too, like if you run a really popular cafe in town, right. 

Basically, the more of a community hub that your business is with lots of people coming in and out and spending time, sharing air, the bigger the social benefits of you putting a vaccine mandate in place are likely to be.

DG: When we come back, Sayeh explains how letting people opt out of a mandate could actually be a good thing.

BREAK

DG: Welcome back.

We’re here with our Contributing Research Editor Sayeh Nikpay who is helping us triangulate the research we have to help guide employers who are debating whether to require their employees get vaccinated for COVID.

So, we’re two-thirds of the way through your employer vaccine mandate research triangle.

Bring us home, Sayeh, what’s your last … point? 

SN: Oh, Let me try and angle you to the last point, Dan. 

This last point is especially useful for employers who are worried about employee backlash. You see, Dan, no vaccine mandate is absolute. And in the U.S., they always contain some form of exemption or an opt-out.

DG: Like if someone has a medical condition that makes the vaccine unsafe for them or if they’ve got a religious objection or something.

SN: Right. Right. And sometimes you need a doctor’s note saying that it’s not safe for you to get the vaccine. But other times, all you have to do is just sign a paper saying, I don’t want this vaccine, and there will be no questions asked.

DG: Now, I mean, intuitively, I get the sense that a stricter opt-out is gonna be more effective.

SN: Yeah, Dan, you’re right. The tougher it is to get an exemption, the more people end up getting vaccinated. But there’s a brand new paper that actually suggests that the way that you design these opt-outs can actually end up leading to more people getting vaccinated.

It’s by Brandyn Churchill, who’s finishing up his PhD at Vanderbilt, which of course used to be my old stomping grounds. And next year he’ll be a professor of economics at Carleton University.

Brandyn Churchill: Carleton University, which is in Ottawa, Canada, as opposed to Carleton College, which is in Minnesota.

SN: In his paper, which is forthcoming in the Journal of Health Economics, he studies Washington, D.C.’s mandates for kids to get the vaccine for the human papillomavirus or HPV.

News clip: A new medical study gives an OK to the HPV vaccine. 

SN: HPV is a sexually transmitted infection and it’s actually the most common STI and can cause cancer in some cases. 

Like COVID vaccination, HPV is somewhat controversial as a vaccine.

News clip: Parents who declined the HPV vaccine for their daughters said their children weren’t sexually active, suggested it was inappropriate to give them the vaccine at their age or said they had safety concerns about the vaccine.

SN: Now that, you know, years have gone by, the vaccine has since been proven to be safe and incredibly effective. And it didn’t really result in any of that risky sexual behavior for teenage girls. 

But when D.C. started requiring it for girls when they went into sixth grade in 2009, families were anxious.

BC: Parents had the option to opt out. It’s really easy. It’s really generous. It’s just a form, just sign your name. And they had to do it once when their daughter was in sixth grade. Either get the vaccine or opt out once.

DG: So it was a mandate, but it was also super easy for kids and parents to get out of.

SN: Exactly, Dan. A stronger mandate would’ve been more effective, but Brandyn says the city council worried about a backlash. So that’s why they put in such an easy opt-out.

In 2014, when DC updated the mandate to also include boys, they kept the opt-out but changed it. So now parents had to do it every year instead of just in sixth grade.

BC: And my question was moving from a one time opt-out to an annual opt-out, could that actually improve vaccine take up as well? And what I find is yes, yes, it did. By about 11 percentage points, these girls who their parents had previously opted them out, when asked again at a later date, they changed their mind and said, “No, now I’m comfortable doing it.”

DG: Interesting. So even though they could still opt out for whatever reason, Brandyn found that once families had to do it every year, more folks started taking the vaccine. 

Do you think, Sayeh, that’s because this controversial vaccine had kind of just gotten normalized? Or was it something about the actual cadence, the act of asking people year after year that changed things?

SN: Unfortunately, Brandyn’s not sure — the data aren’t specific enough, but his hunch is that it’s a combination of the two.

BC: By the time that they moved from this one time opt-out form to the annual opt-out form, the vaccine had been around. You know, it was something that people did. It was a thing. People were used to it. People were comfortable with it.

SN: Just because someone is more comfortable with the vaccine doesn’t mean that they’re going to run out and get it on their own. 

Having that yearly prompt gave parents an opportunity to act on any potential increased comfort or knowledge about the vaccine. 

So I think this gives us a nice little roadmap for how we could possibly reach those folks who are really hesitant about getting a COVID vaccine: Give them some information, keep giving it to them, don’t give up. 

But there’s also actually this really cool additional finding in Brandyn’s paper that’s really relevant right now.

News clip: New CDC data shows 8 percent of people have missed their second shot of the Moderna or Pfizer vaccines.

SN: Like COVID, Dan, HPV is a multi-dose vaccine. 

So when D.C. first put in the mandate, 25 percent of girls got the first HPV shot, but then just stopped there. After D.C. made the switch to the annual opt-out form, more than a third of those girls that just stopped after that first dose, they actually went back and got their second shot.

DG: So even though this easy opt-outs might seem like Kryptonite to an effective mandate, Brandyn’s paper shows, in a few ways, that even companies worried about backlash can make a mandate that works for them.

SN: Yeah, Dan. This is how Brandyn thinks about it.

BC: COVID is sort of, it’s a different beast in and of itself. So I’m hesitant to oversell things in that regard. What I can sell, what I can comfortably say is, keep asking. I think that’s my big takeaway from the paper. Keep giving people this opportunity because presenting them with that opportunity, giving them the option, they might wind up getting vaccinated then. 

DG: And we’ve already seen this play out with COVID, Sayeh.

SN: Yeah, so as the months have gone by, people see the vaccine is safe and effective, they see people getting their lives back together, they’re getting vaccinated, they’re having fun, and they’re changing their mind about getting their shots.

DG: OK, Sayeh, you’ve gone through the research, you’ve talked to the experts. 

Now let’s imagine that you got a call from the CEO of Walmart or the head of a small business.

Based on the evidence that you’ve looked at and all these conversations that you’ve had, what advice would you give these businesses about whether or not to do a mandate?

SN: Everything has to begin with the caveat that COVID is new, employer vaccine mandates are new, so there’s no way to know exactly what’s going to happen. 

But I think there are key takeaways here, and they are that employers seem to be on solid legal ground. And while we have to triangulate research from hospitals and schools, that evidence does suggest that mandates work and they can help protect the community, even those mandates with opt-outs. 

DG: This all reminds me of a conversation that I had with Dorit Reiss, a law professor at UC Hastings who studies vaccine mandates. 

She said, “Sure, the information is imperfect, but it’s better to draw on imperfect data with caution and caveats than to go on no data because then you’re just guessing.”

Does that sound right to you?

SN: 100%. That’s like my personal mantra. She’s absolutely right. 

Like so much with this pandemic, there’s no one solution, and we don’t have any perfect research to guide us. So we just have to do the best with what we’ve got.

DG: Sayeh Nikpay, as always, thank you so much for joining us on Research Corner.

SN: It’s been really fun, Dan, thank you.

DG: If you head to tradeoffs.org, you can read more about Corey and Brandyn’s papers and sign up for our newsletter which includes research summaries from the country’s top health policy experts every week.

Again that’s tradeoffs.org or you can click the links in our show notes.

I’m Dan Gorenstein, and this is Tradeoffs.