Incentivization of COVID-19 Vaccines in WA Workplaces

The COVID-19 pandemic remains a priority issue in President Joe Biden’s administration as US residents approach over a year living in a pandemic. On March 11, 2021, President Biden stated that on May 1, 2021 vaccines will be available to all people over the age of 16 living in the US. This announcement was received by a polarized public that has grown increasingly anxious to return to in person activities. Additionally, local governments and state governments have begun lifting public health restrictions to reinvigorate the economy. Significant improvements in vaccine production, distribution and administration have come at a pivotal time, and now President Biden aims to have 90% of adults eligible for vaccination by April 19, 2021 (Mendez, 2021). Some states have taken the lead and have already opened vaccines to all individuals ages 16 and above. Washington state has announced that everyone 16 and older will be eligible for the vaccine starting April 15, 2021 (DoH, 2021). These eligibility updates alter the US’s vaccine timeline substantially.

The business sector constitutes a key stakeholder group with power to influence the COVID-19 vaccine effort in the state and country. As employers partner with the public sector, businesses play an outsized role in vaccinating the public and returning individuals to family gatherings, office buildings, restaurants, and other social settings. Not only do employers wield a significant amount of societal influence, but on an individual level, most US residents receive health insurance through their work. This benefit allows companies to take on the administrative cost of vaccines and remove barriers for workers. Additionally, employers are uniquely positioned to encourage, incentivize, or require their employees to get vaccinated. Vaccine requirements for other immunizations have been upheld by several Supreme Court cases and is currently authorized by the U.S. Equal Employment Opportunity Commission (EEOC), but several legal gray areas specific to the COVID-19 vaccine open businesses to legal liabilities. As Washington state moves closer to mass vaccination efforts, various policies and approaches to vaccination will emerge. This memo details early trends, policy options and tradeoffs, and risks and benefits primarily focusing on incentivization efforts by large and small employers. For the purposes of this memo, we will use the Healthcare.gov definition of small business (1–50 employees). Accordingly, large businesses will be considered those employing more than 50 people consistently for 12 months (HealthCare.Gov, N.D.).

Equitable Vaccine Rollout Considerations

Employer driven vaccinations (either through encouragement, incentivization, or mandates) will contribute to reduced prevalence and risk of COVID-19 but will not be the only tool to drive down cases. Careful and deliberate policies will be needed to reach minors and young children, marginalized communities, and vulnerable populations (e.g. prisons, community housing).

Employer/Employee Relationship

Structured workplaces, defined as office work with normal working hours (9:00am-5:00pm), and insurance offered as a benefit, are easiest to coordinate vaccination for employees. All company efforts to encourage, incentivize, or mandate vaccines will include these white collar workers. However, this leaves those who are considered temporary, custodial service, or any other worker not directly employed by the company outside of purview. (Consultants have been removed from those listed above due to their willingness to be independent from an organization and procure health insurance.) These workers will receive less benefit of any company policy regarding COVID-19 vaccination. Temporary workers are more likely to be women. For a variety of reasons (both economic and noneconomic), BIPOC identifying women aged 25–55 tend to work part-time when compared to their male counterparts (BLS, 2021). In 2020, over a third of the US workforce had a nontraditional employer-employee relationship through freelancing (Upwork, 2020). Employers ought to consider how to incorporate workers outside the structured workplace into any COVID-19 vaccination policy they implement.

Disproportionate Negative Outcomes among Racial Minorities in Essential Positions

Reports indicate that risk and death due to COVID-19 are higher among people working in essential services, who are disproportionately Black, Indigenous, or People of Color (BIPOC). The demographics of the structured workplace differ from maintenance, custodial services, and other essential work. In a 2020 study, researchers found Hispanics are overrepresented in building cleaning services by 40%. It is estimated that 38% of these workers are of immigrant status (Rho et al., 2020). While Latinx populations make up a disproportionate number of COVID-19 cases in Washington state, only 7% of the Latinx population has been fully vaccinated as of May, 2021 (Fowler, 2021; Washington State Department of Health, 2021). BIPOC and undocumented immigrant populations in general access health care at a lower rate due to structural barriers and the COVID-19 vaccine is no exception. The federal government is continuing to direct efforts to improve health by prioritizing equity. President Biden is also hoping to achieve greater health equity through the COVID-19 relief package. On a local level, Washington state public health officials are aware of structural inequities and are working alongside trusted messengers and community organizations. To aid vaccine expansion, Washington state plans to roll out mobile vaccine clinics to reach marginalized populations (Land, 2021). Despite these state efforts, it is critical that employers make targeted efforts to vaccinate people in essential positions and those who are employed through contracts and other indirect methods. While companies do not have control over all people in their workplace, they do have immense power to amend contracts to ensure everyone including direct and indirect employees are vaccinated. As mandated by the federal government, vaccines are equally available and distributed to all peoples living within the US, including undocumented immigrants. No personal identifying information is required to get a COVID-19 vaccine (Cava, et al, 2020). DHS has issued a statement that “US Immigration and Customs Enforcement and US Customs and Border Protection will not conduct enforcement operations at or near vaccine distribution sites or clinics” as it is considered a sensitive locations policy (DHS, 2021).

Organizational Resources

In contrast to larger corporations, smaller companies may lack cash reserves, access to additional banking support, and available funds to buy pandemic materials to weather rough times (Dua et al., 2020; Bartick et al., 2020). Governor Jay Inslee has received criticism from restaurants because indoor dining closures are most harmful to small businesses (Vinh and Clement, 2020). They argue that restaurants are taking proper precautions and this strict limitation is only placed on restaurants and not retail, galleries, etc. These closures are detrimental to small businesses as they often do not have enough liquidity to ensure paychecks are paid and rent is covered while closed. A recent study found that 66% of small businesses had fiscal challenges before the pandemic (ABA Journal, 2020). Restaurants make up a large share of small businesses in Washington State and as of December 2020 about 1,023 had closed permanently (Vinh, 2020). Government and public partners should consider organizational resources available to employers and how to leverage larger corporations’ strengths while uplifting smaller businesses.

Current Employer Approaches to the COVID-19 Vaccine

The following table demonstrates the variety of approaches companies are using with regards to the COVID-19 vaccine and illustrates their utilization by listing high profile and local companies in Washington state which have adopted each approach. This list, while not exhaustive, was curated through a review of digital news articles. This review was limited in that most employers are not publicly stating their plans with regards to COVID-19 vaccines.

How Employers Can Address COVID-19 Vaccination Among Employees

Table 1: Policy matrix of potential policy options employers are taking regarding COVID-19 vaccination among their employees. US companies are in black text, while Washington state-based companies are shown here in blue text. Sources include: (NBC News, 2021; Rutgers University, 2021; Groover, 2021; Morning Consult, 2021; Ives, 2021; Vigdor, 2021; City of Detroit, 2021; Fuller, 2021; Hartmans, 2021; Marriott International, 2021).

Policy Analysis

All employers have an obligation, as defined by Occupational Safety and Health Administration, to keep the workplace safe from environmental factors, discrimination, and general health (both physical and mental). Individual employee health is highly protected in most work settings but specific measures exist for employers to maintain a safe working environment. The first Employer Responsibility listed on the OSHA website is to “Provide a workplace free from serious recognized hazards and comply with standards, rules and regulations issued under the OSH Act” (OSHA, N.d.). COVID-19 vaccinations present a new challenge for employers. Protecting workers as well as customers from the spread of COVID-19 is essential to preserving labor rights and contributing to a prosperous business.

Individual health privacy is essential to workplace safety. One’s health information is often perceived to be highly sensitive so adequate measures must be in place by human resources to protect employee’s sensitive information. In accordance with legal standards related to workplace health records, individual’s health data is required to be kept separate from employment records with the exception of ADA required processes (Briscoe, 2021). This protection must be extended to potential reporting mechanisms. Many organizations are contemplating reopening the offices through self-reporting or documentation reporting of COVID-19 vaccinations. In requesting vaccination status, the employer opens itself to potential leaks of personal health information. Each of the following policy options will impact the health of employees and needs to be considered by employers. To compare policy options, our analysis uses criteria as defined in Appendix A.

The first option is that employers do not proactively make any mention of the COVID-19 vaccine — either to encourage or dissuade workers from receiving the vaccine. Several large corporations such as Safeway or Costco with locations in Washington state that offer the vaccine at their in-store pharmacies will provide convenience for their employees. However, this benefit applies to a small portion of employers.

Avoiding addressing vaccination in the workplace is the simplest policy option and avoids excessive costs and potential legal challenges. Avoiding discussion or action on the vaccine leaves employees to their own devices and does not help or hinder any employees’ access to vaccination. Through collective inaction by a company, this policy option proves to be high in equality. However in relationship to equity, leaving employees to their own self-direction does not promote an equitable vaccine rollout because it does not assist those with low personal resources (financial, internet, time, knowledge, etc.) receive the vaccine. This strategy also ranks highly because it does not require organizational resources, will not reveal anything about workers’ personal health conditions, is unlikely to violate workplace cultural norms, and reduces medical related legal repercussions. In addition, this policy option ranks poorly on ensuring workplace safety because employers will have no information regarding the vaccination status of their employees. For industries with many employees working in close proximity, this is a key metric when determining how and when the workplace will transition away from social distancing protocols. Legal conflict cannot be completely ruled out as an employee could bring litigation against an organization for not maintaining a safe workplace and negligence. Following the status quo by doing nothing to assist in employees getting vaccinated is not markedly different from actions being taken today, but could come at the expense of workplace health and safety and exacerbating social inequities.

The first alternative policy for employers is to encourage vaccine uptake through educational resources and/or communications that encourage employees to receive the vaccine. Several large corporations in Washington state– Google, Amazon, and Boeing — have committed to this strategy. Providing educational materials and messages may require minimal investment on behalf of the companies to assemble and disseminate. However, this strategy may result in a delayed office re-entry timeline, which may have implications for production, equity, and workplace feasibility.

Option 1 ranks highly in several criteria including cost effectiveness, health privacy, and legal risks. This option is highly cost effective due to little resources and infrastructure diverted. Many organizations are taking advantage of prepared materials by the CDC, local government, chamber of commerce, etc. A benefit of these informational resources for employers and their employees are that they are freely available online (CDC, 2021). These materials are likely shared via email and available on company websites. If an organization chooses to create tailored messaging or some other type of communication channel, it could become more expensive for the employer. Health privacy remains an important aspect of the workplace environment. This option allows for the organization to maintain ADA compliant and for employees to keep their health data confidential. Through securing health privacy, the organization significantly reduces legal risks due to noncompliance. There are several downsides to this option such as workplace safety and equity. In implementing the Encourage policy without associated tracking or reporting, employers will not be able to track who is vaccinated and confidently say their offices are safe to return to. In the event of an outbreak, Human Resources will be unable to track the virus in the office and may be forced to close the entire office causing further harm to the organization’s bottom line and reputation. This option scores low in equity as the organization is not taking proactive measures to ensure their employees who are most at risk are getting prioritized access to vaccines. Intersectionality is crucial to understanding inequity. Many employees, especially BIPOC employees, face multiple scarcities including material objects, time, resources, childcare support, and so on (Feinberg, 2015; anonymous interview, 2021).

Employers can require that employees get vaccinated. This could either be as a condition of returning to the workplace or simply as a general requirement. Benefits of this policy include ensuring that everyone (or nearly all workers) in the workplace have immunity to the coronavirus. This will protect the health and safety of all employees. In addition, this policy gives the employer valuable information through reporting mechanisms about which workers are vaccinated and which are not. Alienating employees is a concern within this policy alternative. Republican identifying individuals are among the most likely to have vaccine hesitancy; a mandate would be widely unpopular with the vaccine hesitant. Many are concerned that mandates would actually have a backlash effect, making people more resistant to the vaccines (Betsch et al, 2016). There are also legal risks to imposing a mandate that have not been clarified by federal agencies (EEOC, 2020); employers could receive legal challenges to their mandates.

Mandating vaccination in the workplace is the most difficult policy alternative to implement, but potentially has the highest reward for health, safety and equity. This option ensures equality among staff (except those who sought out medical waivers) to get the vaccine and removes bias due to position level, salary, and any other characteristics. In addition, this option likely yields the highest COVID-19 vaccine coverage among employees, protecting the most people from contracting the virus and speeding up the return to a safe workplace. This should allow workers to feel comfortable in the office environment without fear of spreading or contracting the virus.

This policy ranks poorly due to legal risks that could result in financial loss and potential for employee backlash. As detailed in the Appendix B, COVID-19 vaccine mandates contain a number of legal gray areas that could invite costly and public legal fights for employers. For example, one lawsuit has already been filed in New Mexico against an employer who instituted vaccine mandates (HR Daily Advisor, 2021). Potential lawsuits and opinion polls suggest workers may react negatively to employers requiring vaccination. That COVID-19 vaccines are politically polarized is evidenced by more than 23 Republican legislature states proposing legislation that limits employers’ ability to require vaccination of their employees (Quinton, 2021). Further, nearly half of white republican males state they do not plan to receive the vaccine, as compared to 83% of white democratic males (NPR, 2021, Funk and Tyson, 2021). 60% of Republicans say that a vaccine should not be mandatory among all workers, and 54% say that the vaccine should not be mandatory for essential workers, as opposed to 27% and 24% of Democrats, respectively (Morning Consult, 2021). Vaccine mandates may not effectively increase uptake or may even result in the opposite of its intended consequence. For example, there was no association between vaccine uptake and the implementation of Australia’s “No Jab, No Pay” and “No Jab, No Play” policies, which withheld multiple childcare-related state benefits for families whose children were not vaccinated and essentially mandated vaccines for those who were dependent on this source of income. Children of vaccine-hesitant parents were less likely to be fully vaccinated, as only 13% felt prompted to reconsider their stance on vaccinations and 25% of families planned to seek a medical exemption or not enroll their children. However, low-income families reported greater intention to vaccinate, which may indicate that these policies served as a reminder for families with lower health literacy or greater barriers to access (Armiento et al., 2020). This “boomerang effect” decreases the likelihood of vaccine uptake within wary populations. Emerging research suggests continued polarization and politicization of the COVID-19 vaccine. Some might conclude that vaccine mandates as a policy recommendation will ultimately fail due to risk of infringing on personal freedoms and workplace cultural norms.

A number of national brands are: encouraging vaccine uptake by offering paid leave to get the vaccine (Table 1). Many of the organizations researched were willing to provide a range of two to three hours per vaccine, this policy option allows employees flexibility to schedule a vaccine appointment during their 9:00–5:00 working hours and give them time to cope with any side effects. Alternatively, a cash payment or gift certificate can be used as a financial incentive for employees to receive both vaccine doses. Several employers have begun offering small and medium payments to encourage people to get vaccinated (Table 1).

Equity and workplace safety are positive aspects of policy option 4. Once an employee receives the vaccine, there are no position, title, or salary barriers to accessing this incentive. However, there are equity risks for employers who do not offer the incentive to people who cannot receive the vaccine due to health or religious reasons. Employers have an obligation to maintain a safe office environment, and this policy option allows for employers to track who has received the vaccine and to better protect the office from COVID-19 outbreaks. The Incentivize option does come at a significant cost to the employer and puts the organization in legal risk. Employers will have to pay for incentives and promised time off. Additional costs will be incurred to staff incentive logistical support and to find staff coverage for those taking advantage of the incentive. Finally, the legality of incentives is unclear because the US Equal Employment and Opportunity Commission’s guidelines on limiting value of incentives to “de minimis” have not been clarified between the outgoing and incoming administrations (Thelon & Kitson, 2021). Without clear guidance, incentives (especially large ones) may open the organization to potential coercion and discrimination lawsuits. Employees could be considered vulnerable to workplace power dynamics. Thus, employers must be sensitive to coercion and obstructing an employee’s own decision-making. Understanding workplace culture will be critical to understanding how incentives will be received, and the employer/employee relationship will greatly influence the risk of legal conflict.

The research is mixed on the effectiveness of incentives. Kuvaas et al. defines extrinsic motivations as the desire to perform an activity with the intention to attain positive consequences or to avoid negative consequences. Some studies have found that promotion of reward and punishment, which target extrinsic motivations, reduce the employee’s intrinsic motivation, that is, their self-determination and willingness to perform the task for its own sake (Kuvaas, et al., 2017; Underhill, 2016). Too much of an incentive or promotion can also result in increased wariness and hesitation (Kuvaas, et al., 2017; anonymous interview, 2021).

Those in a promotional position need to carefully examine the risk and benefit of under or over promoting a vaccine. Researchers at UCLA and UW have found that “low-personal-value, high-social-value” objects are motivators to complete a task. These objects can range from a sticker pronouncing “Protected!” or “I got my Fauci ouchie”, to free workplace swag and small gift cards to Starbucks, Subway, etc. (Ives and Jiménez, 2021). Some organizations are broadcasting larger rewards for receiving the vaccine.

The laws surrounding employer vaccine incentives are hazy. Making matters more confusing, the US Equality Employment Opportunity Commission has not issued guidance for employers providing incentives. As discussed in Appendix B, two major legal areas of inquiry are whether incentives are considered coercive or discriminatory.

For companies like Costco, Haggen, and Walgreens with onsite pharmacies, providing COVID-19 vaccines to employees is logistically simple. However, other employers without healthcare resources at their disposal are able to contract local health departments or insurer health professionals to host mobile clinics and “vaccination days” in the workplace. This would enable workers to get vaccinated during the workday and eliminates many barriers otherwise seen.

Option 5 is positively viewed as it eliminates many barriers to receiving the COVID-19 vaccine including accessing flexible time off, transportation, and time burden. The CDC asserts that employers and employees both benefit from improved morale due to providing vaccination in the workplace (CDC, 2021). Importantly, this policy promotes safety and the reduction of COVID-19 spread in the workplace. This policy option is likely to use workplace resources such as finances, office space, and time on the job. As described in Appendix B, if the employer themselves is administering the vaccine, there are possibilities for litigation based on health privacy regulations regarding the vaccine screening questions. In addition due to the office setting, there may be limited ability to provide privacy. Finally, this process may unintentionally exclude employees who do not work normal schedules or employees who work remotely.

The following policy matrix ranks each policy option as Satisfactory, Neutral, or Unsatisfactory. This three point scale was chosen to clearly indicate which policy options accomplish the goal of the criterion at hand (satisfactory), makes no change as opposed to the status quo (neutral) or work against the criterion at hand (unsatisfactory) as compared to Option 0: Status quo.

Policy Matrix and Potential Criteria for Employers

Table 3: This policy matrix lays out six criteria as defined in Appendix A used to measure the equity and effectiveness of each policy option.

Considering the Policy Alternatives

The policy alternatives presented here are not mutually exclusive, and several of them ought to be considered in tandem. For example, if a business chooses to mandate vaccination, it is important that reasonable accommodations are given to allow employees to get vaccinated. Offering paid time off (option 4), or hosting a vaccine clinic at the workplace (option 5) would help employees accomplish the goal of the policy. Without doing so, the burden of getting vaccinated will remain higher for workers with lower personal resources. Similarly, the Encourage option could be used to supplement any other policy option to make them more effective. In addition, there are several other logistical factors to be considered like reporting, procedures to ensure equitable outcomes for those who cannot take the vaccine, and support structures in place to protect personal information. Employees reporting vaccination can be conducted voluntarily or as a requirement of working or receiving an incentive. One risk of the incentivize option is that it could result in some employees being ineligible for the incentive due to medical or religious exemptions. To avoid discriminating against these employees, employers may need to provide an alternative action that will qualify workers to receive the incentive. One example could be a COVID-19 prevention training course. Finally, if employees are required to be vaccinated or the employer hosts a vaccine clinic, it is important that adequate personal privacy protection measures are put in place to safeguard individuals’ information.

One unanticipated consequence of policies meant to increase vaccine uptake may include workplace bullying against individuals who either cannot or choose not to receive the vaccine, which is facilitated through the de facto exposure of typically private healthcare records posed by mandatory vaccination and the subsequent protocol for employee interaction (HRD, 2021). Legally, individual’s health data is required to be kept separate from employment records with the exception of ADA required processes (Briscoe, 2021). However, if maintaining a safe work environment in the wake of COVID-19 means companies must prioritize vaccinated employees for high-contact roles, they run the risk of conflating health data with employment opportunities (Briscoe, 2021). The unintended and extensive reach of these vaccine policy impacts serve as important lessons for private corporations to consider as they continue to grapple with vaccine incentivization or mandation decisions for their employees.

In the above analysis, our research denotes that employers have a desire to vaccinate their employees. It should be noted that this is not the case for all and some employers may have moral, religious, or other objections. An example of such employer thinking is the alternative Miami-based Centner School. The school founders report that vaccines are dangerous for teachers and children. While many of these claims have been scientifically debunked, this private employer has vast freedom to hire and fire employees as they see fit.

Avenues for Government Support

Small businesses usually represent more minority populations and their subsequent livelihoods (Fairlie, 2020). They are also at a disadvantage for implementing policies raised above due to financial resources (see Appendix C). Intersectional research has found that women owned businesses saw about a 25% drop in revenue, and immigrant owned businesses saw approximately 36% loss over the past year as compared to 17% drop in white owned small businesses in the same time period (Fairlie, 2020; Santellano, 2021). Due to marginalization by the banking system, women and BIPOC business owners are more likely to take on personal financial risk and possess little liquidity, putting these small businesses in a precarious financial position (Bartik, et al., 2020). The Paycheck Protection Program sought to support many small businesses but was not purposeful in considering racial equity. As such this program was ineffective and led to increased distrust of government. This program has been renewed under the Biden Administration with the objective of reaching communities of color. One intervention that may prove salient for minority owned small businesses are small business loans (SBL) for the purposes of vaccine incentivization. For small businesses operating on extremely tight margins, offering incentives or other policy alternatives that require resources may not be feasible. However, government grants to fund these types of policies could be instrumental in achieving the state’s collective goal of 90% immunity. While available to the general public, SBL is considered a pro-equity option because grants will serve those businesses and workers most affected by the pandemic.

Appendix A

Appendix B

Legality of Vaccine Incentives and Mandates

Few companies have instituted a vaccine mandate either company-wide or as a requirement to return to the office. While statements from the federal government indicate that vaccine mandates are legal, several gray areas exist for employers (EEOC, 2020).

Without additional EEOC guidance, companies are hesitant to institute vaccine mandates in their workplaces. The Occupational Safety and Health Administration (OSHA) currently recommends making vaccines accessible and low cost, while providing educational resources on the benefits of the vaccines (OSHA, 2021).

Appendix C

Comparing the Impacts of Vaccination Options on Businesses by Size of Business

Table 2: Due to resource restraints and capacity, small and large businesses are impacted differently across policy options.

This table reflects the differences in policy options based on the size of the business. Business size determines how many employees the policy applies to as well as generally the amount of resources the business has access to. For the purposes of this analysis, small businesses refer to those that employ fewer than 50 people, and as discussed above, many are minority or women-owned and have been hit hardest by the COVID-19 pandemic. Assuming that these businesses have smaller profit margins and less liquidity, the options are determined to be satisfactory, neutral, or unsatisfactory. We compare this directly with large businesses to understand which policy options are more feasible for small businesses versus large businesses. As shown here, the Status Quo, Encourage, and Mandate options are comparably attainable regardless of access to resources. In contrast, the Incentivize option is far more attainable for large businesses as opposed to small. These cash payments or paid leave are difficult to offer as a small employer with limited resources. Finally, Onsite Vaccination is slightly more difficult for smaller businesses. While local health jurisdictions have been doing their best to support employers to provide vaccines at workplaces, larger businesses are more likely to have pharmacies embedded in their business model or simply have resources to absorb arranging an onsite clinic.

This article is one of four pieces within the Washington State COVID-19 Vaccination: Strategies for Expediting a Safe and Equitable Recovery. This portfolio was created as a final capstone for the Evans School of Public Policy and Governance. All components can be found below.

COVID-19 Vaccine Communication Strategies for Wary and Underserved Groups

Vaccine Passports: Risks and Benefits of Requiring Proof of Vaccination (forthcoming)

Washington State COVID-19 Vaccine Distribution — Stakeholder Analysis (forthcoming)

This work is supported by Restart Partners. Restart Partners is a 501(c)(3) non-profit organization committed to providing policy and technical assistance to Washington state and other communities to help reduce the spread of COVID-19 and mitigate its impact on citizens, communities, and economies.

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Behavioral science, emergency response best-practices and interviews with public health officials were used to explore policies and communication strategies to guide governments and employers as they implement COVID-19 policies.

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