The deserving and undeserving unvaccinated

The plan to make the unvaccinated pay is both wrong and stupid

There has been a disturbing trend of takes about unvaccinated people recently: that making them pay more for healthcare, either through insurance or burdening them with the cost of ensuing hospitalizations, is a desirable policy goal. Natalie Shure wrote about this for The New Republic last Monday:

It may be a seductive argument, but it’s nevertheless an utterly gruesome notion that deserves unequivocal repudiation before anyone spends another damn minute considering its implementation. It’s callous and not likely to work. Moreover, it threatens to undermine what little popular and political progress we’ve made toward universal health care.


In short, the American health care system still doesn’t distribute care remotely evenly. When Medicare for All advocates say that all care should be free at the point of use, we’re not just insisting on purity—we’re saying that individual health care use shouldn’t determine how much anyone pays into the system. After all, someone who is perfectly healthy can avoid paying any deductibles, copays, or coinsurance. Cost-sharing is a tax on sickness.

Natalie said it all best, so go read her piece. 

Since her piece came out, I’ve seen some more goofy arguments for using the American healthcare system’s unique way of forcing high costs onto patients as a lever, or just a punishment, against unvaccinated people. Michael Hiltzik (who often writes very good pieces about healthcare) wrote in the Los Angeles Times that "Americans have just about had it up to here with people who refuse COVID-19 vaccinations”—which doesn’t make a lot of sense, because the people who are refusing vaccinations are also American—and then goes on to identify which groups of vaccinated people he means:

There’s the cadre of Americans who can’t be vaccinated because of legitimate medical concerns, who shouldn’t be penalized for underlying health conditions.

There are pockets of vaccine skepticism in Black and Latino communities, where distrust of the government is widespread and vaccine access is wanting. Education and outreach programs must work to boost vaccination rates among these communities.

And there are adults who resist vaccines because of partisan reasons, or who have allowed themselves to fall under the sway of ideologically inspired misinformation or disinformation.

The idea here is to somehow identify only the Bad Unvaccinated, the white Fox News Brain holdouts, and punish them with higher insurance premiums or billing them for hospital stays. (At one point, he even suggests holding them criminally liable through the courts.) Still, he says, “penalties for vaccine refusal should be carefully implemented so they don’t unduly burden communities of color or low-income populations that may have difficulty accessing healthcare even in normal circumstances.”

But how are we going to figure out who is Bad enough to deserve to pay more, and how much more would it be? What if someone didn’t get the vaccine because they couldn’t get time off work—is that a good enough excuse, or should they have just figured it out? What if they’re just too tired from their job, like Zachary Livingston, a Subway manager in Denver who told the Washington Post that he simply hasn’t had time to get vaccinated because “by the time I’m out of work, it’s time to go to bed?” (He also is uninsured and hasn’t seen the doctor in years—one vaccine holdout who is beyond the persuasive reach of healthcare premiums.) What if they found the vaccine scheduling system overwhelming? What if they’ve never had a damn reason to believe anything could be free in this healthcare system before now? As of July, more than half of unvaccinated Americans lived in households that make under $50,000 a year; 22% made less than $25,000. Unvaccinated people are also much more likely to report being at risk of eviction or food insecure.

So who’s going to decide if they’re excused? Is the insurance company going to interview everyone who isn’t vaccinated and decide how much of a break to give them? “Well, you are pretty poor, so we’ll give you some leniency there, but then again you do have a car, so maybe you aren’t that poor. Sorry, that’ll be another $100 a month.” 

Others, like Larry Levitt of the Kaiser Family Foundation, wondered whether it would be “fair” for unvaccinated people to keep having their Covid-related costs waived if people with other conditions don’t:

And his Kaiser colleague, Cynthia Cox, compared Covid hospitalizations to cancer patients: 

As I said to Larry on Twitter: The thing that is unfair, and actually very disgusting, is that people pay for their own healthcare at all. The cost of someone’s healthcare should not be their individual burden; that is the only way to ensure that sick people aren’t punished for being sick. The total opposite is true in America, and it’s one of the many reasons the American healthcare system is so grotesque. If you have figured out that high deductibles are a terrible thing for cancer patients to face, why haven’t you figured out that they’re bad, period? Adding another way for insurance companies and hospitals to dump costs on individuals doesn’t make things more “fair.” It’s like if you had two children and one of them dropped their ice cream, so you throw the other one’s in the trash too: It might be an equally shitty afternoon for both of them now, but it’s not any more fair.

As a vaccinated person who pays health insurance premiums, I am simply not bothered by the idea of my premiums being spent on people’s care; I am certainly much more concerned about all the people dying (yes, even the unvaccinated ones) than the cost to the healthcare system. I don’t sit up at night fuming about people who got diabetes from drinking too many milkshakes, or gave themselves lung cancer from smoking, driving up my premiums. (I’d be much happier to contribute to the cost of their care if it were done fairly for all by the government, and not laundered through profit-making entities, of course.) I’m much more haunted by the fact that this country punishes people in the worst moments of their lives than I am by the thought that I’m subsidizing someone’s bad choices.

Supporters of the Make ‘Em Pay plan argue that Covid is different than those situations because being unvaccinated hurts everyone around you, and that’s true. But that doesn’t mean making unvaccinated people pay more is going to make them get the shot. If someone is refusing the vaccine on purely political grounds, they’re already accepting the risk of dying on a ventilator surrounded by strangers; if that isn’t frightening enough, the threat of a hospital bill sure wouldn’t be. (It also assumes they’re actually going to hear about this policy shift, which is probably unlikely if they get all their news from Tucker Carlson. My insurer’s cost-sharing waiver expires in 9 days and I haven’t heard from them about it, either.) If we want people to get vaccinated, what is the point of coming up with financial mechanisms to incentivize it when we could just impose vaccine mandates? This has to be paired with the sort of outreach that Bryce Covert talked about in her recent New York Times op-ed to ensure people aren’t being excluded unfairly. But there’s no world in which tacking on a bill for (possibly wildly inflated) hospital charges is a better way to increase vaccinations than just requiring it.

I can’t tell anyone not to be angry at unvaccinated people, though it’s not something I personally waste a lot of time on. Hospitals are clogged and healthcare staff are overworked; patients with other illnesses are being turned away; immunocompromised people still can’t feel safe going out. People who are genuinely refusing to be vaccinated because of Fox News are obviously a public health hazard. The problem of vaccine hesitancy and refusal is clearly complicated, and made far worse by having a healthcare system that is always gouging you and threatening you with unaffordable bills in the first place. As Natalie put it, the logic of imposing extra costs on people for any health issue is “vile,” and I won’t make an exception for Covid. Healthcare is a right for bad people, too.

A few more healthcare stories:

  • Two heat related stories: First, in DC, “heat islands” make some neighborhoods hotter, increasing the likelihood of heat-related deaths. (Many of the cooler, leafier neighborhoods are also wealthier.) This is a problem that is sure to worsen as climate change marches on.

  • And second, an investigation by NPR and Columbia Journalism Investigations found at least 384 workers have died from heat exposure in the last decade.

  • A JAMA study found that proportionally more healthcare dollars are spent on white people than Black and Hispanic people, even taking into account age and health conditions. This gap “could not be explained simply by rates of insurance coverage,” meaning factors like paid time off, access to hospitals, and medical racism can also play a part.

  • You may remember Gavin Newsom handing a sweet contract to Blue Cross Blue Shield for them to handle vaccine distribution (plus another to McKinsey). Well, it didn’t work: the contract “did not deliver” on the promise of ensuring equity in vaccine access, according to a new Washington Post piece, which looks at the role of private contractors in the vaccine rollout across the nation.

  • The New York Times has an absolutely fantastic report on hospital prices, using data that hospitals have only recently been required to publish (and many don’t anyway because the penalties for not doing so are so pathetic). Prices for procedures can vary wildly within the same hospital depending on your insurance plan, and in some cases insurance pays more than an uninsured patient does. The whole logic of American healthcare system financing is that insurance companies will negotiate the lowest prices they can—but they either can’t without losing access to networks of doctors, or don’t care to, because the higher prices are, the more they can charge in premiums and the more their total profit. It is pretty enraging, and also a good reminder of why price transparency is not really enough to change anything, as fun as it is to read pieces like this.

    That’s all this week. Next week I’ll be announcing some changes and forthcoming content here, so stay tuned.