The counterplan exponentially increases vaccination by conditioning welfare on adherence – it’s feasible, constitutional, and cost-efficient.

The recent outbreaks of vaccine-preventable diseases have refocused attention on the threat posed by unvaccinated and undervaccinated individuals.1 Governments around the world have responded by strengthening laws and policies directed at increasing vaccination rates. The standard menu of options includes education and information initiatives, incentives, and mandates; these may be directed at the general public, health care organizations, or practitioners.

The term mandate is somewhat misleading, because there are exceptions —always on medical grounds, frequently on religious grounds, and sometimes on philosophical grounds. Moreover, the thrust of mandates is not to forcibly require vaccination but to predicate eligibility for a service or benefit on adherence to the recommended immunization schedule of vaccination. In the United States, every state requires proof of immunization for entry into public schools, and some states also have similar requirements for entry into daycare facilities and private schools. These requirements can seem coercive to families who do not have other feasible schooling or child care options. However, the logic and acceptability of these requirements are rooted in the fact that the risks posed by clusters of nonimmunized children are heightened in these very settings.

In Australia, half of its 6 states and 2 territories have vaccine requirements for school entry, and the 3 most populous states (New South Wales, Victoria, and Queensland) recently extended such requirements for entry to kindergartens and child care facilities. These rules overlay a more controversial policy: for nearly 20 years, the Australian government has linked families’ eligibility for government welfare and benefits to children’s vaccination status. In this Viewpoint, we describe a recent expansion of the Australian program and consider the relevance, legality, and ethics of such an approach in the United States.

No Jab, No Pay

In the mid-1990s, vaccination rates were dangerously low in Australia: only half of all children had the nationally recommended immunization coverage. To address the problem, the federal government implemented a multipronged strategy that is widely regarded as having been successful. The welfare incentive program was one component of the strategy.

In 2015, a controversial new law— titled, “No Jab, No Pay”—expanded the program and substantially increased the incentives.2Effective January 1, 2016, families’ eligibility for federal benefits worth up to US $15 000 per child per year (Table) depends on the immunization status of all family members through 19 years of age.2 The benefits are unavailable to families for each year in which an otherwise eligible family member in this age group does not have the recommended vaccines for 1-, 2-, and 5-year-olds or is not participating in an immunization catch-up program.2 The law also ended “conscientious objections” as a basis for exemptions,2 following the termination of religious exemptions earlier in the year. Only medical exemptions remain, which may be granted after a physician attests to the existence of a disqualifying condition, such as certain allergies and immunocompromising illnesses.

The government has projected savings over 5 years of US $380 million from the new law.3 About half the estimated savings is expected to come from benefits not paid, with an estimated 10 000 families expected to lose eligibility for payments in 2016-2017 alone.3 Although the effects of the law have yet to be formally evaluated, the government recently announced that 5738 previously unvaccinated children in families receiving benefits were immunized in the first 6 months of the new law’s effective date, and 187 695 children who were lagging on the recommended vaccination schedule had caught up.4,5With a total of approximately 5million children in Australia, these are substantial shifts.

Existing Incentives for Welfare Beneficiaries

In the United States, a number of state-based welfare programs already link welfare payments to vaccination status. For example, in California’s CalWORKs welfare program, families who fail to submit up-to-date immunization records or an exemption form for children younger than 6 years risk losing part of their cash assistance. Florida’s Temporary Cash Assistance program may withhold benefits from families with children younger than 5 years whose immunizations are not up to date. At the federal level, the Special Supplemental Nutrition Program for Women, Infants, and Children checks the immunization status of preschool children and encourages adherence with the recommended schedule.

However, stern approaches such as these are not widespread in the United States. Questions regarding whether they are warranted, lawful, and ethically acceptable warrant attention.

Prospects of No Jab, No Pay in the United States

A program designed to increase adherence with immunizations directed at welfare recipients would seem arbitrary, even discriminatory, unless vaccination rates in this population were especially low. Various state and federal initiatives over the last 20 years, most notably the national Vaccines for Children program,6 have substantially increased the proportion of preschool children in low-income families who receive recommended vaccinations. Nevertheless, low-income remains a significant risk factor for incomplete immunization.6,7 For example, the 2015 National Immunization Survey indicated that in households below the poverty level, the proportion of 19- to 35-month-old children with the recommended coverage across a range of vaccines was 3 to 10 percentage points lower than among children of the same age living in households above the poverty line.7 The association between low-income and undervaccination is sometimes obscured by the considerable attention focused on the large number of nonmedical exemptions claimed by white, high-income families. 8 It is debatable how much weight disproportionately low coverage among children in low-income households should carry. Some will argue that linking welfare eligibility to vaccination status remains indefensible unless the government can demonstrate that lack of immunization is not due to problems of access or cost.

Two lines of jurisprudence in US law converge to support the constitutionality of programs that condition welfare benefits on vaccination status. First, governments have long enjoyed broad legal authority to require vaccinations in the name of public health.9 This authority permits conditioning receipt of services (eg, public schooling) on adherence and penalizing nonadherence. Second, because welfare payments are not a constitutionally protected right, governments have considerable latitude in how they distribute those payments and are permitted to make distinctions among recipients. Distinctions made on the basis of constitutionally protected categories, such as race and sex, are unlikely to survive judicial review. However, a broad distinction based on adherence with a clinically recommended vaccination schedule likely would. To the best of our knowledge, the existing state programs that link welfare payments to vaccination status have not encountered serious legal challenge.