COVID-19 vaccines could become mandatory. Here’s how it might work.

You walk toward the arena, ready for a big game, tickets in hand. But what you see is a long line wrapping around the corner of the building and a bottleneck at the entrance as people search their pockets and purses for a small piece of paper. To be cleared to enter, you’ll also need that document—proof that you’ve received a COVID-19 vaccination.

This is the future as some experts see it: a world in which you’ll need to show you’ve been inoculated against the novel coronavirus to attend a sports game, get a manicure, go to work, or hop on a train.

“We’re not going to get to the point where the vaccine police break down your door to vaccinate you,” says Arthur Caplan, a bioethicist at New York University’s School of Medicine. But he and several other health policy experts envision vaccine mandates could be instituted and enforced by local governments or employers—similar to the current vaccine requirements for school-age children, military personnel, and hospital workers.

In the United States, most vaccine mandates come from the government. The Advisory Committee on Immunization Practices (ACIP) makes recommendations for both pediatric and adult vaccines, and state legislatures or city councils determine whether to issue mandates. These mandates are most commonly tied to public school attendance, and all 50 states require students to receive some vaccines, with exemptions for medical, religious, and philosophical reasons.

Adult vaccine mandates—compelling employees and the public to inoculate themselves—aren’t nearly as widespread, but they’re not unheard of. U.S. states and cities can and have forced compulsory vaccinations on citizens. In 1901, for example, Cambridge, Massachusetts, adopted a law that required all citizens aged 21 and older to get vaccinated against smallpox. Failure to comply could lead to a five-dollar fine, or the equivalent of $150 today. Those who challenged the order in court lost. (The last outbreak of smallpox in the U.S. occurred in 1949.)

Shirt, shoes, and inoculation required

Today, the U.S. military requires troops to be immunized against multiples diseases, including tetanus, diphtheria, hepatitis A, and polio. Several states require workers at healthcare facilities to be vaccinated against diseases such as pertussis, chickenpox, measles, mumps, and rubella. Hospital systems often require additional vaccinations as a condition of employment. And legally, all employers, in any industry, can compel their employees to get vaccinated.

The mandates can be directed toward customers, as well. Just as business owners can bar shoeless and shirtless clients from entering their restaurants, salons, arenas, and stores, they can legally keep people out for any number of reasons, “as long as they’re not running afoul of any antidiscrimination laws,” says Dorit Rubinstein Reiss, a professor of health and vaccine law at the University of California, Hastings College of the Law.

When a COVID-19 vaccine becomes available, some experts think states will require targeted industries to enforce vaccine mandates for their employees, especially those we’ve come to know as “essential workers.”

“Grocery store workers get exposed to a lot of people, but also have the chance to infect a lot of people because of the nature of their work and the fact that virtually everybody needs to buy food,” says Carmel Shachar, executive director of the Petrie-Flom Center for Health Law Policy, Biotechnology, and Bioethics at Harvard Law School. Hospitality industry workers—those who work in restaurants, bars, and coffee shops, for example—could also see similar mandates.

“It’s in an employer's interest to make sure that their workplace is protected and that you can't infect your colleagues,” Shachar says. “Having a widely accessible vaccine gets a lot of employers out of having to control their clients’ behavior.” And with a vaccinated workforce, “you don't need to worry if the people you're serving at the restaurant have COVID-19.”

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Even the general public could be incentivized to get vaccinated. “Oddly enough, the best way to impose a mandate is to reward people with more freedom if they follow that mandate,” Caplan says. For example, with proof of inoculation, you would be able to attend a sporting event “as a reward for doing the right thing,” he says. “And I can imagine people saying, If you want to go to my restaurant, my bowling alley, or my tattoo parlor, then I want to see a vaccine certificate, too.”

Booster shots could also be required, depending on the efficacy of future vaccines. Flu vaccines are effective about 70 percent of the time, says Lauren Grossman, professor of emergency medicine at the University of Colorado Denver, and new shots are needed each year. Yvonne Maldonado, a health policy professor at Stanford University, warns that any COVID-19 vaccine may not elicit lasting immunity and could require frequent boosters. If that’s the case, mandates would likely also include proof of booster shots.

Certified vaccinated

While the enforcement of such mandates wouldn’t be without its challenges, it would hardly be impossible or without precedent. To board an Emirates flight to Dubai today, for example, all passengers must present a negative COVID-19 test certificate. Once a vaccine is available, airlines could put in place sweeping regulations requiring COVID-19 vaccination certificates.

Reiss says federal laws could require proof of a COVID-19 vaccine to get a passport—which would then display an emblem showing your vaccination status. Driver’s licenses could be updated in a similar fashion, Caplan says. At work, employee badges could carry vaccination stickers, and a paper certificate from your doctor could serve as vaccine proof for public events.

“Perhaps we'll get to a point where we need to sign proof of immunity to book an appointment,” Grossman says.

More than 150 COVID-19 vaccines are currently in development. Prices for various vaccines have begun to emerge, with some front-runners saying shots could cost as little as four dollars or as much as $37 per dose—which is about what a flu shot costs. Employers who mandate COVID-19 vaccines may help cover the costs, provide time off to obtain the vaccine, or offer on-site vaccinations, says Amber Clayton, director of the Society for Human Resource Management HR Knowledge Center. To help people without insurance or who are low-income or unemployed, some officials have suggested that the federal government could provide shots for free, but details of such a program have not been released.

If such mandates are put into place, not everyone will welcome them: a recent Gallup poll shows that as many as 35 percent of Americans wouldn’t get a COVID-19 vaccine even if it were free. And while anti-vaccine sentiment across the country remains low overall, vaccine hesitancy is growing, with some studies indicating childhood vaccine rates are dropping across the country.

Those with anti-vaccine sentiments are what Caplan describes as a loud minority: They often use compelling campaigns to spread fear about vaccines. For instance, some purport that the measles, mumps, and rubella (MMR) vaccine—required for all school-age children—causes autism. This assertion has been proven false, but it has also caused a decline in MMR vaccination.

Similar anti-vaccine campaigns directed at the vaccines under development for COVID-19 have started to spread, even before a vaccine has been approved for the public. Vaccine mandates, experts say, could be the target of aggressive campaigns from groups that say they are concerned with the safety and efficacy of a vaccine developed at record speed.

People who express hesitancy about a potential COVID-19 vaccine often say their top worry is safety, which raises concerns that some Americans could shy away from inoculation. But if a COVID-19 vaccine is proven safe, “I think the majority of people will want it,” Caplan says. “And if the majority of people want it, you won't have to mandate it—they'll be looking for it.”