Almost 30 years ago I was working in the White House as part of a team working to win approval of President Bill Clinton’s proposal for universal health insurance. The effort was winding down. It was obvious it would fail. I was tired and depressed.
One of my last appearances in support of the plan took place in Colorado. The audience was strikingly hostile. Question after question attacked the plan as a government takeover of health care. They argued for individual rights, and especially the right of choice. In this case, it was the choice to not be insured. “I want government out of my health care,” said one middle aged man; “I can take care of my own family.” 
Finally, fatigue and depression took over. I lost my temper. “Ok,” I said, “I will make you a deal. I will go back to Washington and make sure that you and anyone else in this room gets written out of the health care plan. You won’t have to get insurance. But when you show up on the steps of the emergency room with your child in your arms and she needs major surgery, you better have a lot of cash with you. Anyone who chooses to stay uninsured will be expected to take care of their own.”
Fortunately, none of my superiors heard about the meltdown.
The Case for Vaccine Mandates: Moot or Compelling?
Front and center in the COVID-19 pandemic is a similar controversy: the matter of vaccine requirements. The U.S. Supreme Court rejected one of President Biden’s proposals for such a requirement by one government agency, but it accepted another. It also left the door open for mandates to be imposed by local or state governments, or other agencies of the federal government, including Congress.
Today the pandemic is driven by the roughly 20% of the U.S. population age five and older that is unvaccinated. While the Omicron variant has produced large numbers of breakthrough cases, hospitalizations and deaths continue to occur most commonly among the unvaccinated. A 2022 CDC study, for example, revealed that the unvaccinated are now 23 times more likely to be hospitalized than the boosted.
As COVID-19 cases decline in the U.S., a debate over mandates may seem moot. Why do we need to be so strident in the face of a declining case load? Yet, I would argue that the case for some form of vaccine requirement is equally compelling today. Public health experts have issued a clarion call for the nation to use this lull in cases to maximize our vaccination rates and prepare for a likely next spike.
Unfortunately, the opposition to any mandate–as with President Clinton’s insurance mandate 30 years ago–is intense.
Political Partisanship And The Myth of Choice
The most vociferous opposition to vaccine mandates today is not based on views of vaccine safety. It is driven more by resistance to government telling people what to do and an insistence on the right of individuals to choose. It is this opposition that connects the anti-vaccination cause with larger issues of values, politics and partisanship. As a result, partisanship appears to now be the strongest predictor of one’s vaccination status. Today, the unvaccinated are as much as three times more likely lean Republican than Democratic.
The issues of mandates and choice are particularly prominent in COVID-related policy debates. This is especially true in the case made by Republican leadership in opposition to President Biden’s vaccine requirement proposals. In my own analysis of the official websites of members of Congress, I found that Democrats’ websites by and large supported vaccination. Republicans’ websites, however, rarely expressed any view about vaccination. But if they did, it was usually to argue, sometimes aggressively, that Americans should have a choice about vaccination.
Advocating for individual rights is often a winning argument in American politics. But if the goal is to protect the public’s health, I would argue that the concept of choice here is somewhat mythical. Choice implies that there is more than one viable and reasonable option available. And in the case of COVID-19 vaccination, other than staying home in isolation or testing regularly, there really isn’t. I suggest that the emphasis on vaccination choice and individual rights has at least three glaring flaws.
Government Already Regulates Choice
First, the choice argument envisions a relationship between government and the public that disappeared decades ago. Government today plays an infinitely larger role in regulating choice, especially in matters of health and safety. For example, government limits individual choice about the speed at which you can drive. It requires you to wear a seat belt. It restricts where you can smoke and taxes you for doing so. And public schools already universally require childhood vaccinations.
Government also regulates organizations with regard to building safety. And it regulates an unlimited numbers of products, from airplanes to children’s pajamas. While many express concerns or even anger at government’s supposed insatiable thirst to control what should be left to individuals. But most of government’s expansion has, arguably, resulted from public demand. Given these realities and wide public acceptance, some form of vaccination requirement hardly qualifies as a unique imposition.
But most vaccine mandate proposals still offer some degree of choice. President Biden’s mandates allowed people to be tested regularly as an alternative to vaccination. While this still limits choices, and it is perhaps inconvenient, certainly there is no safety concern associated with testing.
The Health Risks of COVID-19 Vaccination Are Minuscule
A second flaw in the argument for vaccination choice is the near total lack of scientific evidence or rationale for resistance. There is extraordinary unanimity amongst the scientific, medical, and public health communities that the vaccines are safe and effective and the best means of protecting the population. And while we might wish that the vaccines provided even greater protection over time, the evidence that they are safe and effective also continues to grow stronger over time.
The risks of vaccination, real or imagined, pale before the risks of COVID-19. There are, indeed, some very rare side effects, most notably myocarditis (inflammation of the heart muscle) and blood clots. As of February 10, 2022, however, CDC reports 214 million fully vaccinated people in the U.S. with just 1,307 total verified cases of myocarditis in the U.S. That is 6 cases people per million people vaccinated. The risk of blood clots is even lower (3 people per million). And just 9 deaths in total have been causally linked to COVID-19 vaccination. By comparison, the U.S. National Weather Service reports an average of 27 deaths from lightning each year.
Furthermore, few consider that COVID-19 also causes these same problems, including death. The CDC estimates, for example, that infection raises the risk of myocarditis 16-fold. And the COVID-19 case fatality rate is 1.2% in the U.S (more than 1 per 100 cases).
Expressing a Right to Choose Limits the Choices of Others
The third flaw in the argument for vaccination choice is a flip side of choice itself. Expressing a right to choice impacts, almost always negatively, the rights and choices of others. The right to take a risk, in this case, does not occur in a vacuum. It is not that of a mountain climber taking personal risks to reach a summit. The COVID-19 risk-taker puts someone else (or many others) at risk. Millions have suffered from the ongoing pandemic physically, economically, psychologically, and multiple other ways that don’t require reiteration here. The right of choice should not include the right to put so many others in harm’s way.
The Strongest Link in the Weakest Case
As evidence continues to mount that the vaccinations are effective and nearly risk-free, the anti-vaccination case grows increasingly dependent on the argument for choice. Combined with the widespread devastation wrought by the pandemic, the case for vaccination is now so compelling that there is really no credible case for being unvaccinated.
The argument for personal choice thus becomes the best and only argument in the anti-vaccination case. It is the proverbial last person standing. The strongest link in a weak chain. But holding firm to this argument may serve a political purpose. Republican elected officials may wish to distinguish themselves from their Democratic rivals. But (as with climate change) they cannot credibly deny the value of vaccination or assert that individuals should avoid it. They can, however, support the right of choice which may provide a means of appealing to a core group of party adherents without having to adopt an indefensible position.
The unvaccinated, of course, are not responsible for all the negative impacts of the pandemic. But all of us have a responsibility to do our part to not make things worse. One has to wonder, at what point does a sizable majority, supported by virtually all the science and medically-based evidence available, have the right to demand something reasonable of a minority that doesn’t agree.
This isn’t about free speech or freedom of association or religion. It is just about getting vaccinated.
