Monday’s Food and Drug Administration approval of the Pfizer-BioNTech Covid-19 vaccine is historic. It’s the first mRNA vaccine to ever receive full approval, the first approval to be completed end to end in under four months and it was approved with over 205 million doses having already been administered in the United States. The world may not be aware, but we’ve just witnessed a modern scientific achievement that will lead to even more medical miracles.
Right now, 52 percent of people in the U.S. are fully vaccinated; herd immunity won’t be reached until 85 percent to 90 percent are.
Some speculate that the FDA granting full approval could nudge millions of reluctant people to get vaccinated. But even if the estimated 3 out of 10 unvaccinated people who cited concerns about the vaccine’s emergency use authorization now get vaccinated, that won’t be enough for us to reach herd immunity. Right now, 52 percent of people in the U.S. are fully vaccinated; herd immunity won’t be reached until 85 percent to 90 percent are.
Prior to the vaccine’s full approval, employers and institutions such as universities and schools trying to implement vaccine mandates were challenged in court by people questioning the legality of mandating a vaccine the FDA had not fully approved. While the Supreme Court has refused to entertain overturning such mandates, across the country we’ve seen health care workers protest or quit over such requirements.
Only about 9 percent of hospitals, health systems or clinics have a mandate in place, and even with full approval it is not clear that mandates will become commonplace because hospital administrators fear losing staff. Hospitals and clinics have been willing to look the other way, arguably compromising the health of patients and their own workers, because the threat of losing trained nurses or technicians is too large when every bed is full and some patients are being turned away from emergency rooms.
Especially now that full approval has been granted, a mandate is essential for all health care settings, especially nursing homes. Low vaccination rates for nursing home staff prompted President Joe Biden to withhold federal funds from any long-term care facility that does not have a vaccine requirement.
There are still many public universities, particularly in states that voted for former President Donald Trump, that are reluctant to implement such requirements.
The next frontier for mandates must be active duty military. The requirements must then extend to the National Guard and other reservists who serve our nation and have a high risk of being placed in crowded settings. Others such as law enforcement, correctional officers and essential workers in fields including meatpacking, grocery and packing and processing must be vaccinated with haste or we might continue to repeat the headlines of the past year with outbreaks across the country.
Educational institutions are slightly ahead of the curve, with many universities announcing they will implement mandates upon full approval. K-12 schools are likewise instituting mandates with support from teachers unions and other labor movements as well as an acute awareness that around 20 percent of new Covid-19 cases are in children, many of whom (because they’re under 12) are not eligible for vaccinations.
But there are still many public universities, particularly in states that voted for former President Donald Trump, that are reluctant to implement such requirements for fear of retribution from Republican governors or state legislatures. Officials at Florida State University, home to approximately 40,000 students, have stated their “authority is limited by the State of Florida and the university cannot mandate vaccines” essentially making their students, staff and families sitting ducks in one of the largest hot spots in the world. Florida has topped 3 million infections, and the numbers are climbing. It’s uncharted waters, but we might need vaccination requirements for households with children under 12, many of whom are struggling to stay in person at school but are forced into rolling quarantines, particularly in low-vaccination areas. Household mandates would be novel and some would consider it overreaching, but it might be the only way to both preserve in-person learning and mitigate the detrimental effects of the delta variant and the variants that will inevitably follow if we don’t increase vaccination rates in the coming weeks. Finally, there is a growing consensus among policy experts to consider raising premiums or out-of-pocket costs for patients who refuse vaccination and end up in the hospital with Covid-19. There is precedent for this. The Affordable Care Act allows for insurers to charge higher premiums for smokers than nonsmokers. But such a slippery slope could be detrimental if other populations begin to be carved out, not just unvaccinated people, but patients who are obese or have conditions deemed to be unacceptable by insurers or segments of society. Nevertheless, changes to benefits might be necessary to create an economic disincentive to remain unvaccinated. Shifting our country’s mindset from individual exceptionalism to a communal one will be difficult; transparency and reporting efforts will be necessary to hold ourselves accountable. Any hospital that does not institute a mandate should be required to post the percentage of its staff that is vaccinated. Same for any school, grocery store, meatpacking plant or airline. People have a right to know so they can take steps to either avoid such environments or make arrangements to better protect themselves.
Dr. Kavita Patel
Dr. Kavita Patel is a teaching professor of medicine, Division of Hospital Medicine, at Stanford University and a board-certified internal medicine physician. She served in the Obama administration as director of policy for the Office of Intergovernmental Affairs and Public Engagement in the White House. Her area of expertise is around the intersection of health policy, clinical medicine and innovation. She also spends time advising venture capital and is a medical contributor for NBC News. 
