Understanding the “cost anxious”

The Issue

As COVID-19 vaccination efforts continue in the United States, it is becoming clear that hesitancy cannot be explained reliably by traditional demographic categories (e.g., political affiliation, race, age, gender, economic status). Instead, some distinct personas are emerging based on shared beliefs and barriers to getting the vaccine. These personas both transcend and encompass the traditional demographic categories—each persona includes at least some members of every demographic group.

One of these personas is the “cost anxious.” Their hesitancy 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 very likely have delayed seeking care for their health in the past due to the expense; some may have delayed seeking care because of work and time.2

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

  • 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 in order 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. This is because providers are permitted to 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 especially important 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 in which the bills are frequent, large, and often unexpected. This creates a feeling of mistrust that must be acknowledged.

When appropriate, share the fact 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. If a choice of vaccines is available, a vaccine that requires one dose instead of two (e.g., the Johnson & Johnson/Janssen vaccine) may be preferable.

In areas with many cost-anxious people, an ideal approach is to bring the vaccines to the people. Consider holding vaccination clinics in community locations that people frequent such as workplaces, religious venues, day care 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. https://www.nytimes.com/interactive/2021/05/18/opinion/covid-19-vaccine-hesitancy.html. Accessed July 28, 2021.
  2. Surgo Ventures. A large-scale Facebook survey of U.S. adults: leveraging precision health to increase COVID-19 vaccine uptake. May 2021. https://static1.squarespace.com/static/5f7671d12c27e40b67ce4400/t/60ad64608effeb7ebf03bd17/1621976164733/FINAL+for+posting_Facebook+Survey+Summary+Document+for+Website.docx+%281%29.pdf. Accessed July 28, 2021.

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