Understanding the “cost anxious”

The Issue

When COVID-19 vaccination efforts began in the United States, it became clear that vaccine hesitancy could not be explained reliably by traditional demographic categories (e.g., political affiliation, race, age, gender, economic status). Instead, some distinct personas emerged based on shared beliefs and barriers to getting the vaccine. These personas transcend and encompass the traditional demographic categories, and each persona includes at least some members of every demographic group.

According to the nonprofit organization Surgo Ventures, one of these personas is the “cost anxious.” Hesitancy among the cost anxious is related to possible financial costs and time costs of getting vaccinated.

What You Need to Know About the Cost Anxious

Based on polling and psychobehavioral analysis conducted by Surgo Ventures, approximately 9% of Americans are cost anxious.1 They likely have delayed seeking care for their health in the past due to the expense; some may have delayed seeking health care because of work and time.2

Many cost-anxious people fear that a COVID-19 vaccination will cost them money out of pocket. Concern about costs associated with the COVID-19 vaccine appears to be especially prevalent in Hispanic communities. Some cost-anxious people fear they cannot get time off work to get the vaccine or recover from side effects.

What Might Work

Perhaps the most important information to impart to the cost anxious is this: the federal government is providing vaccines free of charge to all people living in the United States, regardless of their health insurance status or immigration status. The Centers for Disease Control and Prevention (CDC) states that COVID-19 vaccination providers cannot3:

  • Charge for a COVID-19 vaccine.
  • Charge directly for any administration fees, copays, or coinsurance.
  • Deny vaccination to anyone who does not have health insurance coverage, is underinsured, or is out of network.
  • Charge an office visit or other fee to the recipient if the only service provided is a COVID-19 vaccination.
  • Require additional services for a person to receive a COVID-19 vaccine. (Additional health care services can be provided at the same time and billed as appropriate.)

Some vaccination providers may request insurance information. Providers can seek reimbursement from private health insurance, Medicare, or Medicaid for a vaccine administration fee and associated costs. Providers cannot charge the vaccine recipient the balance of the bill.

The latter point is critical because some unvaccinated adults cite concerns about a surprise bill as a reason for not getting the COVID-19 vaccine. Cost-anxious people may be accustomed to a health system where the bills are frequent, significant, and perhaps unexpected. This creates a feeling of mistrust that must be acknowledged.

When appropriate, share that the CDC does not require U.S. citizenship for individuals to receive a COVID-19 vaccine. Jurisdictions (state, tribal, local, and territorial) cannot add U.S. citizenship requirements or require U.S. citizenship verification as a requirement for vaccination.

Encourage the cost anxious to check with their employer to find out if they can have paid time off to get all doses of the vaccine and recover from the expected physical response. An added value of pharmacy-based vaccination is a broader range of hours for individuals to get vaccinated without having to take off from work. The pharmacy may also be closer in distance than other sites offering vaccination.

In areas with many cost-anxious people, a fruitful approach is to bring the vaccines to the people. Consider holding vaccination clinics in community locations people frequent, such as workplaces, religious venues, daycare centers, and supermarkets.


  1. Sgaier SK. Meet the four kinds of people holding us back from full vaccination. The New York Times. May 18, 2021. Accessed February 28, 2022. https://www.nytimes.com/interactive/2021/05/18/opinion/covid-19-vaccine-hesitancy.html
  2. Surgo Ventures. A large-scale Facebook survey of U.S. adults: leveraging precision health to increase COVID-19 vaccine uptake. May 2021. Accessed February 28, 2022. https://static1.squarespace.com/static/5f7671d12c27e40b67ce4400/t/60ad64608effeb7ebf03bd17/1621976164733/FINAL+for+posting_Facebook+Survey+Summary+Document+for+Website.docx+%281%29.pdf
  3. Centers for Disease Control and Prevention. CDC COVID-19 vaccination program provider requirements and support. Updated Sept. 22, 2023. Accessed Sept. 25, 2023. https://www.cdc.gov/vaccines/covid-19/vaccination-provider-support.html

Return to Playbook Topics View in Spanish