It’s getting more expensive to be unvaccinated in the U.S.

Forgoing COVID vaccination can lead to layoffs, ineligibility to collect unemployment, higher insurance premiums, and growing out-of-pocket medical costs.

Nearly a year after COVID vaccines became freely available in the U.S., one fourth of American adults remain unvaccinated, and a picture of the economic cost of vaccine hesitancy is emerging. It points to financial risk for individuals, companies and publicly funded programs.

Vaccine hesitancy likely already accounts for tens of billions of dollars in preventable U.S. hospitalization costs and up to hundreds of thousands of preventable deaths, say public health experts.

For individuals forgoing vaccination, the risks can include layoffs and ineligibility to collect unemployment, higher insurance premiums, growing out-of-pocket medical costs or loss of academic scholarships.

For employers, vaccine hesitancy can contribute to short-staffed workplaces. For taxpayers, it could mean a financial drain on programs such as Medicare, which provides health care for seniors.

Some employers are looking to pass along a risk premium to unvaccinated workers, not unlike how smokers can be required to pay higher health premiums. One airline said it will charge unvaccinated workers $200 extra a month in insurance.

“When the vaccines emerged it seemed like everyone wanted one and the big question was how long it would take to meet the demand,” said Kosali Simon, a professor of health economics atIndiana University. “It didn’t occur to me that, a year later, we’d be studying the cost of people not wanting the vaccines.”

Alicia Royce, a 38-year-old special education teacher in Coachella, California, opted out of getting the COVID vaccine or having her two vaccine-eligible children get it. Royce’s parents got the shots, but she has been concerned by issues including reports of adverse reactions.

The decision puts Royce in a delicate spot. Her school, like others in California, began a vaccine mandate for staff last year. For now, Royce has a religious exemption and gets tested for COVID twice a week before entering the classroom. The situation has prompted her family to plan a move to Alabama, where schools have not imposed mandates, after the school year.