President Biden recently unveiled a series of regulations aimed to increase COVID vaccination rates. Impacting up to 100 million people, the president will require government employees, businesses with 100 or more employees, and federal contractors to be immunized.

He did not go far enough.

Like many pediatricians, I have spent hours addressing parents’ concerns about receiving a COVID vaccine for themselves or their children. Whether in a hospital, clinic, grocery store, or on a treadmill at the gym, physicians have patiently answered questions from the simple, “How long after the shot am I considered protected,” to the absurd, “Does the vaccine contain nanoparticle trackers that will magnetize my arm?”

For months, I hoped reassurances about the overwhelming safety and efficacy of COVID vaccination, as well as data regarding its impact on reducing community spread, would inch hesitant parents toward immunization.  I was incredibly wrong.

Many physicians feel those who remain willingly unvaccinated against COVID are so staunchly opposed to immunization that they are now essentially inconvincible.  After so many laborious attempts to encourage vaccination, I applauded President Biden’s attempts to provide some national policy on immunization requirements.  The patchwork of regulations that varied by state, county, and school district created different rules across America.

However, the president did not use the full extent of his authority.  He could have mandated the vaccine for interstate travel via airports and trains.  He could have followed the example of the Los Angeles Unified School District, which requires all eligible faculty, students, and staff to be vaccinated, and imposed immunization requirements for schools to be eligible for federal funding, helping to even out the wide variability in state vaccination rates.

These actions are warranted because the United States still lags behind in COVID immunization.  The U.S. rate of vaccines administered-per-100 people is last among major industrialized nations and trails Cambodia, Mongolia, and Turkey.

The results have been devastating, especially considering this new wave of COVID is essentially optional.  Roughly half of Americans remain unvaccinated.  Cases in children have increased to over 200,000 per week and many schools have just recently re-opened.  Deaths and hospitalizations have overwhelmed hospital capacity such that last month Governor Abbott of Texas has called for facilities to again delay elective procedures, a precaution not taken since the earliest days of the pandemic.  Governor Little of Idaho activated the National Guard recently to assist hospitals.

Like so many other frontline health care workers, I heralded the arrival of COVID vaccines, waiting patiently in line with my colleagues to get vaccinated last December – a time when my hospital was overcrowded with COVID patients.  The arrival of effective vaccines signaled to the medical profession the beginning of the end of sick co-workers, potential ventilator rationing, delayed surgeries, and chemotherapy treatments, and morgue trucks parked outside to accommodate the dead.

We spent the first months after the immunizations were released addressing conspiracy theories, including misconceptions about social control, fertility, changes to DNA, and COVID infection from vaccination.  Outreach occurred to communities traditionally distrusting of the medical community and the historically underserved.  The public health campaign for COVID vaccination has included everyone from public health officials, to primary care physicians, to social media influencers and is the largest public health education effort in modern history.

Vaccination remains highly effective.  While almost every case of “breakthrough infection” in a vaccinated individual makes news, COVID vaccines are highly successful at preventing hospitalization and death. Unvaccinated people are about 29 times more likely to be hospitalized with COVID-19.  The success of these immunizations has turned COVID into a vaccine-preventable disease.

Compassionate understanding for the unvaccinated is rapidly declining.  Last month, the Kaiser Family Foundation estimated preventable COVID hospitalizations among the unvaccinated cost the U.S. health care system $2.3 billion dollars in 2 months. Editorials and ethicists openly discussed whether the unvaccinated should pay for their COVID-related care or increase insurance premiums.  Delta Airlines instituted a $200 health insurance surcharge on unvaccinated employees.   Governor Kay Ivey of Alabama spoke for many last summer when she said, “It’s time to start blaming the unvaccinated folks.”

Meanwhile, as a public health tool, mandates are highly successful in increasing community immunization rates.  Requirements for health care workers to receive flu shots, implemented in New York State more than a decade ago, raised vaccination rates to greater than 98 percent.  A flu shot requirement for children in daycare resulted in over 80 percent of children being immunized in Connecticut.  Strong vaccine rules for public school attendance have contributed to over 98 percent of kids being vaccinated.

This is why so many large corporations are instituting them for employees.  Colleges, universities, health care systems, airlines, and technology companies have created vaccine requirements, and multiple states require COVID vaccines for all health care workers.  At least one local hospital requires frequent testing or vaccination of visitors.  New York City requires vaccination for places like restaurants and theaters.

The primary beneficiaries of these requirements would be the states most resistant to immunization but among those with the highest COVID rates per capita, like Mississippi, Idaho, Tennessee, and Alabama.  But the sad logic is the states most in need of strong vaccine requirements are the least likely to enact them, to the detriment of their residents and their valiant health care workers struggling to deal with dwindling intensive care unit space.  By creating stronger federal requirements for vaccination among eligible adults and children than those issued by President Biden, the White House could do a greater part in containing the spread of COVID, a measure gaining importance as new variants such as the “Mu” and “Lambda” strains gain traction.

These COVID measures may be unpopular, but they are necessary to ensure the public’s health, prevent the development of new variants, contain localized outbreaks, reduce the strain on hospital capacity and accelerate our return to “normal.”

Shetal Shah is a neonatologist.

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