Vaccines and Wealth: Another Take on the Unvaccinated

vaccines and syringes

Sharoni Bandyopadhyay

Master’s Student in Health Management and Policy


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More than 1,200 cases of measles have been recorded in the US since the beginning of 2019.1

With outbreaks in thirty states, debate surrounding vaccine safety and vaccine refusal has stirred. As government officials, celebrities, and social media users all weigh in on the conversation, public health officials struggle to assure the general public that vaccines are not only safe but crucial for maintaining population health.

In all of this, public policy must keep up with the public health community in emphasizing the vital role vaccines play in keeping children healthy.

The World Health Organization ranks vaccine hesitancy as one of the top ten threats to global health.

Currently, the World Health Organization ranks vaccine hesitancy as one of the top ten threats to global health, signifying the dangers and costs of anti-vaccine sentiment.2 The US childhood immunization schedule has prevented an estimated 381 million illnesses and 855,000 deaths, as well as saved $1.65 trillion in societal costs from 1994 to 2016.While it is considered one of public health’s most successful endeavors, the growing critical mass of unvaccinated people ultimately jeopardizes herd immunity—resistance to the spread of contagious disease within a population when a significant proportion of that population is immune. Once vaccine compliance dips below 95% of the population, disease outbreaks of several infectious diseases are considered unavoidable. In February 2019, our MMR vaccine compliance was at only 92%.2

Historically, US laws and policies mandating childhood immunization permitted several exceptions, allowing vaccine refusal to flourish. Many vaccinations are required before a child may attend school, with some schools granting “conditional admission” and assuming parents will adhere to the immunization schedule.3 But it can be difficult to track and confirm that students actually receive scheduled vaccines. Furthermore, 45 states allow exemptions for religious reasons and 15 allow exemptions for philosophical or personal beliefs.3 This has allowed parents to opt their children out of receiving important vaccines.

It is important to distinguish groups who cannot afford or access vaccines from those who choose to abstain from vaccinations.

Relaxed exemption policies often lead to increased risk. A 2018 analysis of US vaccine policies found that measles-mumps-rubella (MMR) vaccination rates were 2.3% lower in states that allowed religious and philosophical exemptions, exacerbating the likelihood for an outbreak.3

It is important to distinguish groups who cannot afford or access vaccines from those who choose to abstain from vaccinations.

Unvaccinated children are more likely to be uninsured, live below the poverty level, and reside in rural areas.2 Social determinants—access to transportation, ability to be absent from work, access to health care services—impact a family’s ability to adhere to a child’s vaccination regimen. Children with private insurance are 15 to 30% more likely to be vaccinated than children without insurance.2 To address this disparity, the federal government created the Vaccines for Children program in 1993, providing equitable access to vaccines, including free vaccinations for those who qualify for the program. The program has been successful, preventing an estimated 419 million illnesses from 1994 to 2018.4

Yet, several studies indicate that vaccine refusal thrives in affluent communities that have access to vaccinations.3 Individuals who refrain from vaccinations cluster in geographic regions, such as specific counties and schools.5 In 2014 to 2015, vaccine exemptions for school children were most prevalent in areas of high socioeconomic status.6

 Response to the policy change was clustered by socioeconomic status.

Research consistently indicates that vaccine exemptions are concentrated in wealthy areas, clustered particularly around private schools.6 A policy intervention in California required providers counseling families applying for vaccine exemption to inform parents of subsequent risks to their children. While the intervention was successful in reducing the overall number of vaccine exemptions, response to the policy change was clustered by socioeconomic status. Private-school children responded to the policy change with only a minimal decline in vaccine exemptions while families living below the poverty level responded at higher rates.6

In response to recent outbreaks, several states have eliminated or curbed religious exemptions—including California, New York, Mississippi, Washington, West Virginia, and Maine—in an effort to increase vaccination rates. New York City has attempted to reduce vaccine hesitancy by financial penalty, instituting a $1,000 fine for unvaccinated individuals in certain Brooklyn ZIP codes due to a serious measles outbreak in the Orthodox Jewish community.

However, if we are to continue to keep the entire population safe from diseases we know how to prevent with vaccines, further resources and interventions need to address the outstanding wealth disparities in vaccine refusal.


  1. Centers for Disease Control and Prevention, Measles Cases and Outbreaks, Measles (Rubeola), 2019.
  2. Nancy Messonier, “US Public Health Response to the Measles Outbreak,” February 27, 2019, Testimony House Energy and Commerce Subcommittee on Oversight and Investigations.
  3. Belluz Julia, “Measles Is Back because States Give Parents Too Many Ways to Avoid Vaccines,” Vox (July 3, 2019).
  4. Centers for Disease Control and Prevention, Protecting America’s Children Every Day, Vaccines for Children Program, 2019.
  5. Centers for Disease Control and Prevention, State Vaccination Requirements, For Immunization Managers, 2016.
  6. Jones Malia et al., “Mandatory Health Care Provider Counseling for Parents Led to a Decline in Vaccine Exemptions in California,” Health Affairs 37/9 (September 2018).


Sharoni BandyopadhyaySharoni Bandyopadhyay is a master’s student in Health Management and Policy at the University of Michigan School of Public Health. She serves as the education chair in the Health Policy Student Association (HPSA), where she authors a biweekly health policy newsletter Out of Pocket. Her interests include health equity, population health management, and care continuity. She earned a BS in Public Health from the University of Houston in 2018.