With a surge of COVID-19 cases filling up hospital beds in Washington state and the rest of the country, the urgency of ending this pandemic is clear to everyone. And the solution is equally clear: universal vaccination. But with Americans hopelessly divided over the merits of mandates, vaccination rates have stalled.

We should not give up. There is a strategy based on an economic version of the Golden Rule: Do unto others but pay the costs. In other words, feel free to do as you please, but don’t expect others to pay for it. When it comes to your liberty and your pursuit of happiness, that’s on your tab.

It is true that the voluntarily unvaccinated already suffer many of the consequences of their decision, including higher risk of death, sickness and lost income. But what about the other costs associated with medical care, hospital capacity, variant production and infecting others. Who pays for those?

If you have no insurance and pay your own hospital bill, those costs stay with you. However, if you have insurance, your cost will be covered by other policy holders or in the case of Medicare, by taxpayers. Is that fair? If you reject the vaccine based on your personal choice, should others pay your medical bill?

The second major wave of COVID hospitalizations started in July and can be attributed almost exclusively to the voluntarily unvaccinated. Based on an average of 7,000 new COVID hospitalizations a day and an estimated average cost of $20,000 a patient, the nation’s COVID hospital bill was roughly $9 billion during the recent 84-day surge from July 1 to Sept. 22. This includes a 25% correction for patients who were admitted for other reasons but tested positive for COVID in the hospital. And it isn’t over yet.

There are other costs of remaining unvaccinated. We know that some people with serious illnesses have been denied hospital beds because they were filled with COVID patients. Is that fair? The person laying outside in an ambulance or waiting at home for a hospital bed is paying for the freedom of others to not get a COVID vaccine. Also, scientists point out that by prolonging the pandemic, the unvaccinated increase the potential to create even more contagious and deadly variants. Finally, we know that the unvaccinated are usually responsible for breakthrough cases affecting the vaccinated. Even though these costs are not as easy to value as hospital bills, the same principle applies: They should be paid by the unvaccinated.


Delta Air Lines recognized this problem and decided to charge its voluntarily unvaccinated employees $200 more a month for health care premiums. This ensures that the cost of treating them for COVID comes out of their own pockets. An added benefit of this policy is that people make better choices when they pay the costs. Within weeks of announcing the policy, Delta found 20% of the holdouts decided to get the shot.

Federal law limits the amount of discretion insurance companies have in charging premiums, and this is extremely useful. No one wants insurers to raise rates for people dying from cancer or heart disease, for example. But we also don’t want to subsidize behavior that prolongs an international pandemic that kills millions of people a year. It is possible to give a $200-monthly wellness credit to those who get the COVID vaccine, much like the benefit offered nonsmokers. A similar credit should also be provided by Medicare. The bottom line is that the vaccinated should not subsidize the unvaccinated.

Many insurance companies provided valuable help to distressed families by waiving deductibles and co-payments for COVID hospitalizations during the early stages of the pandemic. However, waiving these costs now for the voluntarily unvaccinated removes a financial incentive to get the shot. What was initially compassionate is now counterproductive.

Financial incentives cannot solve all COVID problems. When spillover costs are significant and cannot be fairly assigned, mandates may be the only option. For example, an unvaccinated employee may get COVID and infect fellow workers, customers, clients, patients or students. The unvaccinated employee generally pays none of the costs associated with additional sick time, reduced production, lower quality service or lost reputation. If they are not paying these costs then businesses, schools and government agencies should have the right to mandate employee vaccinations. How else are they going to protect their workforce, operations and services?

If a significant number of Americans want to reject vaccines out of an abundance of caution, to test unproven remedies or to prove political loyalties, the result is likely to prolong the misery. As Americans, we respect individual freedom, but we also believe in paying our own way. In the absence of universal vaccination, either mandated or voluntary, every health insurance company and Medicare should provide a premium credit for all those who reduce costs by receiving a COVID vaccine.