Copyright 2017 American Medical Association. All rights reserved.
Linking Immunization Status and Eligibility
for Welfare and Benefits Payments
The Australian “No Jab, No Pay” Legislation
The recent outbreaks of vaccine-preventable dis-
eases have refocused attention on the threat posed by
unvaccinated and undervaccinated individuals. 1 Gov-
ernments around the world have responded by strength-
ening laws and policies directed at increasing vaccina-
tion rates. The standard menu of options includes
education and information initiatives, incentives, and
mandates; these may be directed at the general public,
health care organizations, or practitioners.
The term mandate is somewhat misleading, because
there are exceptions1
—always on medical grounds, fre-
quently on religious grounds, and sometimes on philo-
sophical grounds. Moreover, the thrust of mandates is not
to forcibly require vaccination but to predicate eligibility
for a service or benefit on adherence to the recommended
immunizationscheduleofvaccination.IntheUnitedStates,
every state requires proof of immunization for entry into
public schools, and some states also have similar require-
ments for entry into day care facilities and private schools.
These requirements can seem coercive to families who do
not have other feasible schooling or child care options.
However,thelogicandacceptabilityoftheserequirements
arerootedinthefactthattherisksposedbyclustersofnon-
immunized children are heightened in these very settings.
In Australia, half of its 6 states and 2 territories have
vaccine requirements for school entry, and the 3 most
populous states (New South Wales, Victoria, and
Queensland) recently extended such requirements for
entry to kindergartens and child care facilities. These
rules overlay a more controversial policy: for nearly 20
years, the Australian government has linked families’ eli-
gibility for government welfare and benefits to chil-
dren’s vaccination status. In this Viewpoint, we de-
scribe a recent expansion of the Australian program and
consider the relevance, legality, and ethics of such an ap-
proach in the United States.
No Jab, No Pay
In the mid-1990s, vaccination rates were dangerously
low in Australia: only half of all children had the nation-
ally recommended immunization coverage. To address
the problem, the federal government implemented a
multipronged strategy that is widely regarded as hav-
ing been successful. The welfare incentive program was
one component of the strategy.
In 2015, a controversial new law— titled, “No Jab,
No Pay”—expanded the program and substantially in-
creased the incentives.2 Effective January 1, 2016, fami-
lies’ eligibility for federal benefits worth up to US $15 000
per child per year (Table) depends on the immuniza-
tion status of all family members through 19 years of
age. 2 The benefits are unavailable to families for each
year in which an otherwise eligible family member in this
age group does not have the recommended vaccines for
1-, 2-, and 5-year-olds or is not participating in an immu-
nization catch-up program. 2 The law also ended “con-
scientious objections” as a basis for exemptions, 2 fol-
lowing the termination of religious exemptions earlier in
the year. Only medical exemptions remain, which may
be granted after a physician attests to the existence of
a disqualifying condition, such as certain allergies and im-
munocompromising illnesses.
The government has projected a savings over 5 years
of US $380 million from the new law.3 About half the es-
timated savings is expected to come from benefits not
paid, with an estimated 10 000 families expected to lose
eligibility for payments in 2016-2017 alone. 3 Although
the effects of the law have yet to be formally evalu-
ated, the government recently announced that 5738 pre-
viously unvaccinated children in families receiving ben-
efits were immunized in the first 6 months of the new
law’s effective date, and 187 695 children who were lag-
ging on the recommended vaccination schedule had
caught up.4,5 With a total of approximately 5 million chil-
dren in Australia, these are substantial shifts.
Existing Incentives for Welfare Beneficiaries
in the United States
In the United States, a number of state-based welfare
programs already link welfare payments to vaccination
status. For example, in California’s CalWORKs welfare
program, families who fail to submit up-to-date immu-
nization records or an exemption form for children
younger than 6 years risk losing part of their cash assis-
tance. Florida’s Temporary Cash Assistance program may
withhold benefits from families with children younger
than 5 years whose immunizations are not up to date.
At the federal level, the Special Supplemental Nutrition
Program for Women, Infants, and Children checks the im-
munization status of preschool children and encour-
ages adherence with the recommended schedule.
However, stern approaches such as these are not
widespread in the United States. Questions regarding
whether they are warranted, lawful, and ethically ac-
ceptable warrant attention.
Prospects of No Jab, No Pay in the United States
A program designed to increase adherence with immu-
nizations directed at welfare recipients would seem arbi-
trary, even discriminatory, unless vaccination rates in this
population were especially low. Various state and fed-
eral initiatives over the last 20 years, most notably the
VIEWPOINT
Y. Tony Yang, ScD,
LLM, MPH
Department of Health
Administration and
Policy, George Mason
University, Fairfax,
Virginia.
David M. Studdert,
LLB, ScD, MPH
Stanford University
School of Medicine and
Stanford Law School,
Stanford, California.
Corresponding
Author: Y. Tony Yang,
ScD, LLM, MPH,
Department of Health
Administration and
Policy, George Mason
University, MS: 1J3,
4400 University Dr,
Fairfax, VA 22030
(ytyang@gmu.edu).
Opinion
jama.com (Reprinted) JAMA February 28, 2017 Volume 317, Number 8 803
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