Jenny McCarthy (AP/Richard Shotwell)

How we beat the anti-vaxxers: The obvious solution all sides could agree on

The one proven policy to convince science-denying parents that protecting kids is in everyone's best interest


Nicholas J. Diamond
April 17, 2015 4:26PM (UTC)

Australian Prime Minister Tony Abbott recently announced an end to conscientious objector exemptions for childhood vaccinations for certain taxpayer funded state benefits as of 2016. Calling it a “no jab, no pay policy,” PM Abbott cited a decrease in vaccination rates among children age seven and under, particularly under the conscientious objector exemption. Australia isn’t new to strong public health policies. In 2006, it adopted contentious requirements for graphic health warnings on packaging for most tobacco products, which it expanded in 2012 to also require logo-free unappealing dark brown packaging.

Like the U.S., Australia doesn’t have a national policy requiring certain vaccinations, such as for measles, as a prerequisite to attending school. However, many, but not all, Australian states and territories require proof of vaccination for attending school. As in the U.S., various exemptions exist, such as for medical or religious reasons, as well as for conscientious objectors (we call these “personal belief” or “philosophical” exemptions).

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But Australia has a key policy that the U.S. doesn’t—it offers tax incentives for meeting national vaccination standards. Providing financial incentives to encourage compliance can be a powerful nudge. Like its tobacco packaging requirements, this is behavioral economics at work for public health. Of course, there are exemptions. Previously, exemptions were available for medical reasons, on religious grounds, or for conscientious objections. PM Abbott’s recent announcement lops the conscientious objector exemption off that list. Here in the U.S., personal belief exemptions have garnered criticism during the recent measles outbreak in California, so much so that California is trying to do what other states have struggled with—repeal that exemption.

It’s worth closely watching whether this change to Australia’s policy has a measurable effect on compliance. In many respects, this is sound policy. Australia has witnessed a significant increase in children under age seven not getting vaccinated over the past 10 years based on their parents’ personal beliefs about vaccines, which run counter to what medicine tells us to be true. For those keeping track, there are similar trends here in the U.S. Because Australia’s national-level policy aims to incentivize vaccination, its recent modification rightly tries to shore up this weakness.

On the other hand, the tax incentives applicable to Australia’s policy depend to some degree on your income. For instance, tax incentives under both the Family Tax Benefit Part A supplementand Child Care Rebate vary based on income, with higher incomes receiving no benefits at all. Thus, you could argue that Australia’s policy modification feels regressive because it stands to disproportionately affect lower income individuals who may rely on those tax benefits. This issue has been raised in the U.S. around, for instance, increasing the excise tax on cigarettes as a smoking deterrent. Statistics tell us that lower income individuals tend to smoke more than moderate and higher income individuals, so a tax increase would disproportionately impact their wallets, even though the tax applies equally across the board.

But it’s unclear at this early stage whether lower income individuals in Australia would be disproportionately affected by removing the conscientious objector exemption. While it mayseem regressive because of its close tie to certain income-tested tax benefits, the argument won’t hold up without evidence that lower-income individuals have tended to claim that exemption more often than individuals with higher incomes. What’s more, every tax benefit applicable to Australia’s policy doesn’t depend on income. For example, the Child Care Rebate, which caps out at a not-insignificant $7,500 per child, isn’t dependent on income. Also keep in mind how narrow the focus is here. This policy still provides for two of the three original exemptions. And the modification impacts a mix of tax benefits, not just income-tested benefits, to boot.

Putting aside political difficulties, it would be possible to enact a similar national policy here in the U.S. under the Constitution’s Article I, Section 8 power to tax and spend. As in Australia, such a policy shouldn’t provide for an exemption for personal beliefs, which we know to besusceptible to abuse. It’s uncertain whether such a policy would have the desired public health effects. Personal belief exemptions have been popular among the wealthy, for whom tax benefits would presumably matter less when it comes to incentivizing behavior. But as data from California suggests, personal belief exemptions have widespread popularity, not only among the elite.

What’s more, national level incentives could provide much needed support in an area traditionally left for the states to manage under their police powersVery high vaccination ratesamong school-age children in Australia demonstrates how national level policies can successfully supplement regional and local efforts. Australia should be applauded for thinking outside of the box. As the U.S. continues to feel the effects of the measles outbreak, isn’t it time for us to do the same? 

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Nicholas J. Diamond

Nicholas J. Diamond trained in both law and bioethics, and works as a health policy consultant in Washington, D.C. The views and opinions expressed herein are his own, and do not necessarily reflect the views or opinions of his employer.

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