Vaccine Refusal Will Come at a Cost—For All of Us

Image of a needle with a $100 bill in the background
Getty / The Atlantic

Imagine it’s 2026. A man shows up in an emergency room, wheezing. He’s got pneumonia, and it’s hitting him hard. He tells one of the doctors that he had COVID-19 a few years earlier, in late 2021. He had refused to get vaccinated, and ended up contracting the coronavirus months after most people got their shots. Why did he refuse? Something about politics, or pushing back on government control, or a post he saw on Facebook. He doesn’t really remember. His lungs do, though: By the end of the day, he’s on a ventilator.

You’ll pay for that man’s decisions. So will I. We all will—in insurance premiums, if he has a plan with your provider, or in tax dollars, if the emergency room he goes to is in a public hospital. The vaccine refusers could cost us billions. Maybe more, over the next few decades, with all the complications they could develop. And we can’t do anything about it except hope that more people get their shots than those who say they will right now.

If the 30 percent of Americans who are telling pollsters they won’t get vaccinated follow through, the costs of their decisions will pile up. The economy could take longer to get back to full speed, and once it does, it could get shut down again by outbreaks. Variants will continue to spread, and more people will die. Each COVID-19 case requires weeks of costly rehabilitation. Even after the pandemic fades, millions of vaccine refusers could turn into hundreds of thousands of patients who need extra care, should they come down with the disease. Their bet that they’ve outsmarted the coronavirus or their insistence that Anthony Fauci and Bill Gates were trying to trick them will not stop them from going to the doctor when they’re having trouble breathing, dealing with extreme fatigue, or struggling with other lasting effects of COVID-19. (A new study found that 34 percent of COVID-19 survivors are diagnosed with a neurological or psychological condition within six months of recovering from the initial illness.)

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The economic costs of vaccine refusal aren’t yet a major part of the political conversation. That’s likely to change as we move past the first year of the pandemic. “You have a liberty right, and that unfortunately is imposing on everyone else and their liberty right not to have to pay for your stubbornness. And that’s what’s maddening,” Jay Inslee, the governor of Washington, told me. Inslee is 70, and fully vaccinated. The three-term Democrat was in a good mood because he was on his way to see his baby granddaughter, whom he hadn’t hugged in a year. But after what he’s gone through since early 2020—the first American COVID-19 outbreak and the first explosion of COVID-denialist demonstrations were both in Washington—he’s angry and sad that so many people are refusing to get their shots.

He had the latest numbers: 15 Washingtonians had died of COVID-19 the day we spoke. More than 300,000 state residents who had been eligible for a vaccine for at least three months still hadn’t gotten one, including 27 percent of those over 65. Some of those people hadn’t been able to get appointments. Some may have been nervous, but would eventually get a vaccine. Some had just refused, and will continue to do so. Those people are “foisting [their] costs on the rest of the community,” Inslee said. “There’s a long, long economic tail of disease prevalence as a result of people who refuse to get vaccinated.” But, he stressed, “it pales in comparison to people losing their lives.”

Inslee read me some data he had gotten from the Republican messaging maven Frank Luntz, which the governor said was going to inform new public-awareness campaigns that the state is developing to break through to Republican men, the people most likely to say they won’t get vaccinated, according to polling. Two appeals seem to work best: First, the vaccines are safe, and they’re more effective than the flu vaccine. Second, you deserve this, and getting vaccinated will help preserve your liberty and encourage the government to lift restrictions. (That last idea is what Jerry Falwell Jr. focused on in the vaccination selfie he posted this week, captioned, “Please get vaccinated so our nutcase of a governor will have less reasons for mindless restrictions!”) Inslee hopes that emphasizing those points will persuade more Republican men to get their shots. But he’s not sure it will work.

The prospect of lower health-care costs has led conservatives to back health-related regulations in the past. In 1991, Pete Wilson, then the Republican governor of California, signed a law mandating helmets for motorcyclists, and made a conservative argument for the new regulation. “We don’t know exactly how much money and how many lives will be saved with this legislation,” Wilson said at the signing ceremony, which was held at a hospital in the state capital. “But we do know that the cost of not enacting it is too great for a civilized society to bear.” Then again, President Ronald Reagan was famously resistant to seatbelt and airbag laws, which also reduce health-care spending.

Though there are some notable vaccination holdouts among Republican officials, most in Congress and in state leadership positions have encouraged their constituents to get the shots. “I saw on some program last week that Republican men, curiously enough, might be reluctant to take the vaccine. I’m a Republican man, and I want to say to everyone: We need to take this vaccine,” Senate Minority Leader Mitch McConnell said at an event in Kentucky this week. Brad Wenstrup, who worked as a podiatrist before becoming a Republican congressman from Ohio, has been so eagerly promoting the vaccines that he got trained to administer them. But the Republican politics around COVID-19 remain treacherous, and when I reached out to several Republican members of Congress, telling their aides I’d be eager to have them make a Wilson-esque fiscally conservative argument for vaccination, I couldn’t find anyone willing to make that case to me.

Calculating the exact long-term costs is tricky; we have only a year’s worth of data on the lasting health consequences of COVID-19, and even less on the efficacy of the vaccines and Americans’ resistance to getting them. Krutika Amin, who conducts economic and policy research for the Kaiser Family Foundation, tried to sketch out what the taxpayer bill might be. Before the pandemic, about 1 million Americans were diagnosed with pneumonia each year in emergency rooms alone. About 1.5 million were hospitalized for pneumonia annually, at an average cost of $20,000 per stay. COVID-19 has been reliably shown to make pneumonia worse. In April 2020, a Kaiser Family Foundation study projected that the cost of treating just COVID-19 cases for the uninsured would range from $13.9 billion to $41.8 billion. If even close to 30 percent of Americans get COVID-19 because they refused to get vaccinated, Amin told me, you’ll see a massive spike in health-care costs.

Kathleen Sebelius, who spent five years as Barack Obama’s secretary for health and human services, told me that about a quarter of Americans are children, and so far, no vaccine has been approved for use in people under 16 years old. If all adults who say they’ll get a vaccine get one, barely more than half of the country will be immunized, which is far short of herd immunity. In kids, “we have a very vulnerable population where we know they may not get as sick and die as much as adults, but they can get sick and die,” Sebelius said. “We have to think about this a little bit like secondhand smoke. By making an adult choice, you’re putting a whole lot of other people at risk in a way that very few other choices do.”

As lockdowns are lifted, Sebelius hopes that vaccine passports will create social pressure, which might wear down hesitancy if unvaccinated people are barred from sports games, concerts, and other public events. But the political divisions on that are already clear, with leaders such as Republican Mississippi Governor Tate Reeves going on CNN to stress that he wants his constituents to get vaccinated, but that he’s opposed to vaccine passports. Texas Governor Greg Abbott on Tuesday signed a preemptive executive order banning them. Although this resistance may halt any federal vaccine-passport efforts, some states and many private companies are independently exploring the idea. So is the Republican National Committee.

Once getting a vaccine appointment is easy and health departments have filled the airwaves with PSAs, will 30 percent of Americans still say they won’t get a shot? Public-health officials and government leaders hope that vaccine hesitancy will drop. Some surveys suggest that could happen. In the meantime, winding down restrictions on gatherings will likely maximize the spread of concerning variants, Sebelius noted. Health complications for vaccine refusers who catch one of the new strains could be even worse than those caused by the original strain, she said. “We are still very vulnerable to things coming our way, and anybody who has not taken at least this preliminary precaution has no idea what’s going to hit them,” Sebelius said. For the unvaccinated, she said, the threat of COVID-19 “is not getting better.”

It’s not getting cheaper either.