Vol. 261 September 1, 2021 Should COVID non-vaxxers pay for their medical care if they get sick?

“Individuals who reject medical advice and remain unvaccinated whatever their reasons endanger themselves and impose costs on other individuals and society. . . . Understandably, people who made it their business to get vaccinated resent the idea of their insurance premiums or tax dollars being diverted to treat those who didn’t act responsibly.”
– Jeff Jacoby, Boston Globe, August 29, 2021



Mr. Jacoby seems to answer “yes” to today’s title question in the first half of his column, but then later he cuts us off at the knees with a curt, “NO”:

“Since when do we turn away patients—or saddle them with stiff additional costs —on the grounds that their own recklessness caused their sickness or injury? . . .  Refusing  or rationing care to the unvaccinated would be immoral and a dangerous step down a slippery slope.”

His “slippery slope” argument cites the motorcyclist who refuses to wear a helmut and crashes, the alcoholic who needs a liver transplant, the heart patient who refused to eat healthy and exercise, and the hurricane victim who refused to evacuate. He even throws in a dig at the Affordable Care Act which allowed health insurance companies to charge higher premiums for smokers, resulting in, according to him,  more uninsured rather than less smokers.

But in my view, that slope really ain’t that slippery. Many states have passed laws requiring (“mandating”, to use a very popular current word) motorcyclists to wear helmets. The majority of liver transplants are performed in patients suffering from Hepatitis B or C, both now preventable by immunizations or cured with injectable medications.  Many of our most costly medical conditions are chronic, related to life-long style choices, and their prevention is complicated, requiring much education, changes in thinking, and changes of daily practices over many years. Prevention of serious COVID illness is a brief event, twice, maybe three times. Those are two really different tops of slippery slopes.

I wholeheartedly agree that “the function of a humane health care system is to help people get better” and judgments, rationing decisions, or even cost-sharing adjustments  (like extra non-covered ICU fees) for individual patients should NOT be part of the job of medical care providers. (By the way, Costa Rica apparently does a much better job than we do of enhancing health, through primary care/public health investment, not high tech specialization to “get you better” once you are ill. (1) But that’s a subject for another blog.) Leave those cost adjustments of unpaid hospital debts and resource allocation decisions up to Medicaid and Medicare and other governmental levels.

Governmental mandates for COVID vaccination appear to be out of the question except for those people under their control, employees, and even that is being challenged by some unions. One writer suggested that the way to increase vaccinations is to “just make it suck more” not to get vaccinated. Let corporations “mandate” the vaccinated as favored people. Leave it up to private businesses, airlines, cruise ships, restaurants, venues, etc. to favor those who are vaccinated by requiring a show of proof of vaccination to use their services. One critic of that concept has invoked the hallowed civil right of “not having to show our papers”, trying to stir up, I guess, glimpses of past abhorrent foreign regimes. But, hello, I can get asked to “showing my papers” in a lot of situations; my drivers license, my car registration, proof of boat insurance, proof of malpractice insurance, my passport, my credit card, my health insurance card, and even my library card just to take out a book from my local library. I really don’t know why showing a COVID vaccination card from my wallet or a picture of it on my cell phone is such a big deal. What I think IS a big deal is some bureaucrat wanting to see a copy of my birth certificate! It is almost like they are denying the validity of all those data bases out there that already have that information!

One of the major sources of vaccine hesitancy is fear, apparently several different types of fear. Fear is an emotion and does not usually respond readily to knowledge. “Making not being vaccinated suck more” might just create enough annoyance, another prevalent emotion today, to supplant that vaccination fear.

In the meantime, protect yourself and advocate for universal health care insurance so that the “undue” burden of medical care costs of the unvaccinated will be spread over the largest number of payers. The funeral costs for any of the unvaccinated, or their family members, will still, of course, be their responsibility.

1)  Annals of Medicine: The Costa Rica Model, Atul Gawande, MD, The New Yorker, August 30, 2021

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