A very bad idea has picked up more steam than it deserves in recent days. Fed up with surging Delta cases and lagging vaccination rates, commentators have begun to opine that unvaccinated people ought to pay more for health insurance, or pay full freight for any care they require if infected. “Don’t want the COVID-19 vaccine? Then pay full cost if you land in the hospital,” declared one headline in MarketWatch. Elisabeth Rosenthal, the editor in chief of Kaiser Health News, argued for similar financial penalties in The New York Times, CNN, and MSNBC. Even prominent medical ethicist Arthur Caplan joined the chorus, telling an interviewer on WBUR that unvaccinated people ought to be held liable for the impact of avoidable ICU treatment on overall spending: “If you won’t vaccinate … you have to pay a financial penalty if you won’t drive down health care costs.”
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.
One of the most damaging ideological underpinnings of our market-based health care system is that patients are responsible for their own care, as consumers of commodities. We place the onus on individuals or families to navigate enrollment, to perform administrative tasks, and to select plans each year that fit their needs and budget. They are compelled to consider their health status and plan carefully for the insurance products best suited for them: An executive who can afford to buy peace of mind might pick their employer’s platinum family plan; a gig worker might deduce that a bronze plan that covers less is all they can afford. If someone is unlucky enough to get sick, they may find themselves tortured by hours of hold music on calls with insurers and providers, begrudgingly squaring up reimbursement paperwork on their own behalf.
Before the passage of the Affordable Care Act, or ACA, these problems were so much worse: Health insurers were able to individualize their products, charging patients based on what care they were likely to use. To the cash-strapped, they’d peddle cheapo junk plans that covered practically nothing. People with documented health conditions could be locked out of employer-sponsored insurance for up to a year; individual market plans could charge an enrollee eye-popping premiums or refuse to cover certain services; around 18 percent of would-be enrollees got rejected altogether. And to further hedge their bets against so-called medical loss, many insurance carriers capped an enrollee’s lifetime benefits at numbers that are easily maxed out by a health crisis.
But the ACA leveled the playing field in several respects. The landmark health legislation devised a package of 10 essential health benefits that compliant plans had to cover, so carriers were less able to cherry-pick the healthiest patients by excluding costlier care. Lifetime caps were axed, and insurers had to accept all enrollees. And premium prices could only vary by age or location. In other words, insurers were finally deprived of their go-to tactics to ward off less profitable patients.
These provisions transformed the lives of people with preexisting conditions: Insurance rates for Type 1 diabetics suddenly jumped 20 percent within two years of implementation; one study found that the vast majority of people who became insured thanks to the ACA had health issues that previously would have affected their premium pricing. The new rules helped women, too: Before it became illegal in 2014, insurers charged women 30 percent higher premiums than men on average, and only 12 percent of individual plans covered maternity care.
Taken together, these hard-won protections for people with preexisting conditions are among the ACA’s most laudable and popular achievements. Still, too many punitive aspects of the pre-Obamacare landscape remain, making life more difficult for people who require more care. Their premiums may be equal, but you’d be hard up to find a chronically ill person who doesn’t spend thousands more each year than a healthy enrollee on deductibles, copays, and coinsurance. People with extensive health needs also require more specialized services, relegating them to more expensive plans with more in-network providers. And the more care that someone gets, the more time they lose on the phone arguing with claims adjustors, begging for their bills to be paid.
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.
You’ve surely heard the arguments against this: “But why should I pay for other people’s care?! If people want to <insert risky behavior here>, they should pay for it themselves!” There’s also this popular line of thinking: “But without cost-sharing, people will have no incentive to live healthy lifestyles!” These highly consumerist arguments reflect health insurance’s early history as an outgrowth of property insurance, where pricing by individual risk makes sense—as in, “If people want to drive recklessly and total their cars four times a year, they ought to pay more than careful drivers with flawless records.”
But this logic is vile when it’s enshrined as the basis for a health care system, framing patients with complex health needs as money pits not only for insurers, but also to the healthy patients who resent “subsidizing” their sicker peers. The obvious problem here is that health, overwhelmingly, is socially produced: Life expectancy and relative morbidity differ starkly between rich and poor, Black and white, college-educated and those with no advanced degree—even by census tract and ZIP code.
The uncomfortable truth undercutting the bellyaching from the “Why should we all pay for someone else’s reckless choices?!” brigade is that even self-evidently harmful behaviors are mediated by class and social circumstance. But the architects of the ACA didn’t fully see it that way, and their folly has a lesson to teach: Insurers were allowed to charge smokers up to 50 percent higher premiums. But it turned out to be a god-awful idea. The penalty didn’t incentivize people to quit smoking, but it did lead more people to become uninsured. Smokers are already more likely to be poor and sick; effectively booting them out of the health care system isn’t just unspeakably cruel, it severs their relationship with care providers who could support their efforts to quit smoking or mitigate the habit’s harms.
And though you might not glean it from hissing media coverage framing tens of millions of unvaccinated adults as frothing, MAGA hat–donning anti-vaxxers, people who haven’t yet gotten the shot are disproportionately likely to be poor and uninsured. That doesn’t cause someone to forgo a jab any more than poverty causes someone to smoke, but structural forces have undeniably produced dramatically different “choices” by income level. Primary care providers are perhaps better situated than anyone to combat vaccine hesitancy, so blocking unvaccinated people from accessing them is lunacy. Financial penalties induce people to avoid necessary care, something people deserve regardless of vaccine status.
If health and choices are socially produced, they must also be socially addressed. We need Medicare for All with zero cost-sharing, and we must reject the idea of “individual responsibility” for health altogether. Charging unvaccinated people more reopens the door for insurers to sanction other health behaviors and preexisting conditions, undermining a bedrock ACA achievement. We must vaccinate as many people as possible to save lives. To do so, we should make it easier than ever before—and yes, we should couple an increased ease of access with mandates wherever it’s feasible. But threatening to revoke access to health care as punishment for not getting a shot is not merely counterproductive: It’s obscene. Health care is a right and it’s high time we treated it like one.
