Calling the Shots: Should Employers Mandate COVID Vaccines?

May 20, 2021

Photo by Phil Roeder licensed under CC BY 2.0

With about one-third of Americans still not convinced they need to be vaccinated for COVID-19, many employers are debating whether to require their workers to get vaccinated. We dig into the research to help employers weigh the pros and cons.

Listen to the full episode below, read the transcript, or scroll down for more information.

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The Question: To Mandate or Not to Mandate?

According to the April 2021 Kaiser Family Foundation COVID-19 Vaccine Monitor, 34% of Americans are still not convinced they need to get vaccinated for COVID-19. That level of resistance and hesitancy, experts say, may keep us from reaching herd immunity and leave us susceptible to new, more dangerous variants.

This has led some employers — including Houston Methodist health system, Delta and Yale University — to require their employees to get vaccinated. (Delta’s mandate only applies to new hires.) Surveys show other companies are considering mandates as well, but few have implemented them so far.

Adult vaccine mandates are incredibly rare in the United States. Some counties required restaurant employees to get vaccinated for Hepatitis A during recent outbreaks, but mandates have historically been limited to health care settings and children. Research from those examples suggests mandates would increase vaccination rates and contribute to broader herd immunity (more on that below), but there are many additional questions facing employers considering a COVID-19 vaccine mandate.

Scroll over or tap on the cards below for more details.

Is it legal?

Almost definitely.

Some lawyers argue that because the vaccines have only been approved for emergency use, mandates are not allowed. But consensus among most legal experts is that guidance from the federal Equal Employment Opportunity Commission makes it clear that employers can mandate vaccination as long as they allow medical and religious exemptions. However, no courts have ruled on this yet, and at least three lawsuits have been brought challenging mandates. Additionally, around 40 states have introduced legislation that would effectively ban employer mandates for a COVID-19 vaccine.

What do employees think?

It's complicated.

Polling from KFF and others show that Americans are split on whether mandates are a good idea, although young people are more supportive and less willing to return to work without guarantees that their coworkers are vaccinated. But COVID-19 vaccines have become very controversial, and requiring resistant employees to get vaccinated could provoke a backlash. At Houston Methodist, 95% of the company's 26,000 employees have been vaccinated, but two managers quit rather than get shots and more than 7,500 people have signed a petition saying employees shouldn't have to get vaccinated.

Would it be good for business?

Companies hope so.

Many sports and music venues have or are considering requiring proof of vaccination before people can enter. So-called vaccine passports are seen as a safety measure and business tool to increase capacity and convince people that it's safe to return to crowded spaces. Experts who study vaccine mandates say requiring employees to be vaccinated could similarly make the workplace safer and encourage wary customers to return, potentially giving companies a competitive advantage.

Are there other options?

Yes, and lots of companies are trying them.

Researchers have found a variety of tactics to be effective at increasing flu vaccine uptake among staff at nursing homes, including education campaigns, easing access to vaccines, and incentives. Many companies are turning to such tools — such as cash bonuses, extra days off and bringing the vaccines to the workplace — in the hopes of negating the need for mandates. While some academics worry incentives could backfire, recent COVID-specific research suggests cash could be particularly effective at convincing people to get a shot.

The Research: Triangulating the Evidence

Because COVID-19 is a new disease and non-health care employees have almost never been required to be vaccinated for their jobs, there is no direct evidence that can tell us what will happen if employers implement mandates.

This is common — academics and policymakers are often interested in understanding proposed policies that have never been implemented and therefore never studied directly. When that happens, they look to studies of similar policies to come up with a best guess of how the new policy will work.

In this case, University of Minnesota health economist and Tradeoffs Contributing Research Editor Sayeh Nikpay looked to three findings from the research on vaccine mandates in health care settings and schools to provide employers with more information to make their decisions.

Mandates Work

Finding: At least a dozen studies in nursing homes and other health care settings like hospitals show that requiring people to get vaccinated (usually for the flu) successfully increases vaccination rates.

Why It Matters for Employers: More workers vaccinated means a safer environment for workers and customers, fewer sick days, and less of a chance of new strains taking root.

Reduces Community Spread

Finding: A forthcoming study by Cal Poly, San Luis Obispo health economist Corey White found that after hospitals and counties in California implemented influenza vaccine mandates for workers, there was a 40% drop in the number of patients who caught flu at a hospital and a 20% drop in people coming into the hospital with flu.

Why It Matters for Employers: While not perfectly generalizable outside of health care settings, White's paper puts some hard numbers to the positive impact an employer vaccine mandate can have on the surrounding community.

Keep Asking

Finding: A forthcoming study by Vanderbilt PhD candidate Brandyn Churchill found that when the Washington D.C. City Council required parents to opt their daughters out of getting the HPV vaccine every year as opposed to just once before sixth grade, it led to an 11 percentage point increase in the number of girls getting vaccinated and a 9 percentage point decrease in the number of girls who only received the first shot of the multi-dose vaccine series.

Why It Matters for Employers: With many employers concerned about employee backlash to a mandate, Churchill's paper suggests that companies can include generous exemptions to their mandates and still increase vaccination rates if they repeatedly ask their employees about getting vaccinated.

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Episode Resources

Research Cited in the Episode:

Interventions to increase seasonal influenza vaccine coverage in healthcare workers: A systematic review and meta-regression analysis (Theodore Lytras, Frixos Kopsachilis, Elisavet Mouratidou, Dimitris Papamichail and Stefanos Bonovas; Human Vaccines & Immunotherapeutics; 5/5/2016)

Measuring Social and Externality Benefits of Influenza Vaccination (Corey White, Journal of Human Resources, forthcoming)

How Important is the Structure of School Vaccine Requirement Opt-Out Provisions? Evidence from Washington, DC’s HPV Vaccine Requirement (Brandyn Churchill, Journal of Health Economics, forthcoming)

Additional Reporting and Analysis of Vaccine Mandates:

How Employer Actions Could Facilitate Equity in COVID-19 Vaccinations (Samantha Artiga and Liz Hamel, KFF, 5/17/2021)

Health Advocate or Big Brother? Companies Weigh Requiring Vaccines. (Gillian Friedman and Lauren Hirsch, New York Times, 5/7/2021)

How health systems are deciding whether to mandate COVID-19 vaccinations (Kelly Gooch, Becker’s Hopsital Review, 5/2/2021)

Should the COVID-19 vaccine be mandated? Debate takes center stage, as hospitals, colleges and businesses start requiring the shot. (Andrew Dunn, Insider, 5/1/2021)

Want That Job Offer? A Covid-19 Vaccine Is Now Required. (Chip Cutter, Wall Street Journal, 4/26/2021)

Key Questions About COVID-19 Vaccine Mandates (MaryBeth Musumeci and Jennifer Kates, KFF, 4/7/2021)

‘Authorization’ status is a red herring when it comes to mandating Covid-19 vaccination (Dorit Reiss, I. Glenn Cohen and Carmel Shachar; STAT First Opinion; 4/5/2021)

Episode Credits


Sayeh Nikpay, PhD, MPH; Tradeoffs Contributing Research Editor; Associate Professor of Health Policy and Management, University of Minnesota

Corey White, PhD; Assistant Professor of Economics; Cal Poly, San Luis Obispo

Brandyn Churchill, PhD Candidate, Vanderbilt University

The Tradeoffs theme song was composed by Ty Citerman, with additional music this episode by Blue Dot Sessions.

This episode was produced and mixed by Ryan Levi.

Special thanks to Hannah Geressu.

Additional thanks to:

Dorit Reiss, Alison Buttenheim, Mark Rothstein, Arthur Caplan, Jasmine Travers, Emily Lawler, the Centers for Disease Control and Prevention, the National Conference of State Legislatures, the National Academy for State Health Policy, and our stellar staff!