There were strong reasons for many employers to implement vaccine mandates in the fall of 2021.
Today the world is a different place. COVID-19 remains more deadly than influenza, but those dying are largely elderly or have compromised immune systems. In Massachusetts, over the last two weeks for instance, 91% of deaths have been in those over age 70, who represent just 11.6% of the population.
The monoclonal antibody Evusheld provides some degree of protection for those with immune compromise. Also drugs like Paxlovid dramatically decrease risk of hospitalization or death.
Those who are unvaccinated remain more likely to get COVID-19 and be infectious. However, the difference in infection rate between vaccinated and unvaccinated people is now much smaller. Immunity rates from vaccination, infection or both, are high.
Prior employer vaccine mandates have substantially increased employee vaccination rates. Based on data from a study of vaccine mandates instituted at colleges, employer vaccine mandates likely saved at least tens of thousands of lives. Employees at workplaces with mandates expressed support for mandates and got earlier vaccinations. Of note, government mandates remain in effect for many government employees and healthcare workers.
But employers have used substantial administrative resources to implement and maintain these mandates and have generally not expanded the mandate to include boosters. Only about 30% of adults age 18 to 64 received a single booster.
It will be a challenge to get a majority of adults to get the new bivalent booster that provides protection against Omicron strains BA.4 and BA.5. I got my bivalent booster this month and had no adverse effects beyond a sore arm. I strongly recommend that those more than two months from their last COVID-19 shots or infection get this booster.
At this point, a mandate to have the initial vaccination without boosters doesn’t make clinical sense, since those who were vaccinated many months or even over a year ago have little remaining immunity from that vaccination. But employers are unlikely to voluntarily implement a mandate to obtain the new booster shot at this point, with the danger from COVID-19 substantially lower than it was a year ago.
Some employers should maintain COVID-19 vaccine mandates, including hospitals and nursing homes, which are required by the Centers for Medicare and Medicaid Services. The hospitals where I am on staff require that employees and staff are up to date with boosters as well as initial vaccination. Congregate living workplaces (including senior care and prisons) would be safer for all if they had mandates in place, although many have already removed these.
COVID-19 is still a serious health threat, and community transmission remains high in over 80% of counties. There are plenty of actions employers can take to keep the workplace safe.
Implications for employers:
Federal judge Reed O’Connor has ruled in favor of a small Texas employer that sued to avoid being required to provide first dollar coverage for drugs to prevent HIV infection and HPV vaccination on religious grounds. The judge found that the requirement for this coverage violated the Religious Freedom Restoration Act. His ruling also calls into question the Affordable Care Act’s (ACA’s) requirement that employers cover preventive care recommended by the U.S. Preventive Services Task Force (USPSTF) without member cost sharing.
As of this writing, the judge has not laid out the “remedy” for his ruling or determined how broadly it would apply. Therefore, the requirement to provide first dollar coverage for preventive care as recommended by the USPSTF remains in effect. His ruling about the constitutionality of the USPSTF does not apply to preventive care coverage recommended by the Health Resources Services Administration (HRSA) and the Advisory Committee on Immunization Practices. This ruling is likely to be appealed.
The requirement that employer-sponsored health insurance cover evidence-based preventive care is an excellent example of value-based insurance design, where the amount of out-of-pocket cost in a health plan is inversely proportional to the value of the care. We know that out-of-pocket costs decrease utilization, so making exceptionally valuable care cost less (or nothing) increases the amount of high-value care delivered.
Some employers have gone further than the ACA requires, for instance offering diabetes medicines and supplies without out-of-pocket cost.
Here are several things employers should keep in mind as they monitor implications of this ruling over the coming weeks.
Implications for employers:
Jeff is an internal medicine physician and has led WTW’s clinical response to COVID-19 and other health-related topics. He has served in leadership roles in provider organizations and a health plan and is an Assistant Professor at Harvard Chan School of Public Health.
