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Should the unvaccinated pay the price for their folly?

Denying or rationing health care as a punishment would be terrible public policy.

Delta Air Lines says it will make unvaccinated employees pay a $200 monthly surcharge for their health insurance.Mario Tama/Getty

Show of hands, please: How many of you are fed up with people who refuse to get vaccinated against COVID-19 and think they should have to bear the full costs of their treatment if they get sick? How many think it’s only fair to hold anti-vaxxers financially liable for putting themselves and others at risk? How many believe that, with the Food and Drug Administration having given full approval to the COVID vaccine, anyone who still balks at getting a shot should be the lowest priority for care when there aren’t enough hospital beds for everyone? How many support Delta Air Lines, which announced Wednesday that unvaccinated employees will be charged an additional $200 monthly for company-provided health insurance?

If your hand is in the air, you’re not alone.


In recent weeks, several notable voices have made the case that unvaccinated Americans should have to pay their own medical bills if they come down with the disease, be charged higher premiums for their insurance policies, or go to the back of the line when it comes to treatment.

Don’t Want a Vaccine? Be Prepared to Pay More for Insurance,” announced the headline on a New York Times column by Elisabeth Rosenthal, the editor in chief of Kaiser Health News, and Glenn Kramon, the Times’s assistant managing editor. Writing in MarketWatch, economist Jonathan Meer pulled no punches: “Insurers, led by government programs, should declare that medically-able, eligible people who choose not to be vaccinated are responsible for the full financial cost of COVID-related hospitalizations.” In an essay for Barron’s, the noted bioethicist Arthur Caplan, together with law professor Dorit Reiss, argued that the unvaccinated “are imposing costs and harms on the rest of us” and therefore “they should pay.” Not only does Caplan want them to pay full freight for medical costs but perhaps, he told Los Angeles Times business columnist Michael Hiltzik, they should even be charged more for life, disability, and homeowners insurance.


The appeal of such arguments isn’t hard to grasp.

Individuals who reject medical advice and remain unvaccinated because of politics or stubbornness endanger themselves and impose costs on other individuals and society. Most of those now entering hospitals with COVID chose not to get the vaccine, and in many cases the care they are receiving is at the expense of other patients waiting for surgery. 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.

I agree that voluntary choices should have consequences. If you don’t pay your Internet bill and the service gets shut off, your neighbors aren’t going to cover for you. If you invest in a company that fails, the loss comes out of your pocket. If you run a red light and cause an accident, you’re on the hook for the damage you caused.

So if you insist on not getting vaccinated, shouldn’t you be prepared to bear the costs — all the costs — if you get sick? And if you can’t afford those costs, shouldn’t you be out of luck?


In my household, everyone has been fully vaccinated for months. I have little sympathy for anti-vaxxers whose defiance of common sense is prolonging the pandemic and delaying the day when we’ll be free of masks and other aggravations of COVID life. But denying needed health care to punish someone for making unwise choices is terrible public policy.


For most people, refusing the vaccine is indeed a bad decision. But 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? Are those prepared to slam the hospital door in the face of the unvaccinated prepared to do the same to the injured motorcyclist who wasn’t wearing a helmet? To the liver-transplant patient who drank to excess? To the hurricane victim who refused the call to evacuate? To the junk-food eater who never exercised and now needs bypass surgery? To the person who caught chlamydia or HIV during unprotected sex?

In law, the “clean hands doctrine” can prevent litigants from seeking relief when their own behavior has been unethical. But health care doesn’t work that way. Which is just as well, because there are few of us who don’t contribute in some way to our health problems. One way or another, nearly everyone engages in irresponsible or foolish behavior that others ultimately subsidize through taxes, insurance premiums, or higher medical costs.

“Doctors and hospitals are not in the blame and punishment business,” observes Daniel Wikler, a professor at Harvard’s school of public health, in a recent essay. He calls it a “feature and not a bug” that sinners and saints are treated alike in the examination room or the ICU. It is easy to lash out at people who refuse to get a COVID vaccine and then get sick or transmit the virus to others. But if we start withholding care from people who caused their own troubles, or rationing it through much higher medical bills, anti-vaxxers will have plenty of company.


Besides, it has been tried before. Under the Affordable Care Act, insurers were permitted to jack up the premiums charged to smokers. If that was supposed to wean users off tobacco, it didn’t work. The data shows that instead of giving up cigarettes, more smokers became uninsured.

There are, of course, better and worse reasons not to get vaccinated. Some people have genuine medical contraindications. Some have had COVID, recovered, and may now feel sufficiently protected by antibodies. There are those who should get vaccinated but are sincerely frightened of potential side effects or bad reactions. There are cultural barriers, too. While most Americans have gotten at least one dose of a vaccine, there are significant differences in the level of vaccination across racial and ethnic populations.

Distinguishing the “worthy” unvaccinated from the “unworthy” unvaccinated, in other words, would be no easy task. It might even lead to more inequities and ethical dilemmas than we have in our existing system.

The impulse to penalize unvaccinated individuals who come down with COVID, to tell them that they have made their bed and must now lie in it, is shabby. Not just because they are lying in it — in addition to being ill, possibly deathly ill, they are now confronted with the proof of their own folly. But more importantly, because the function of a humane health care system is to help people get better, not to drive them away with unsparing judgment and angry rebukes.


Refusing to get vaccinated is imprudent, irresponsible, and ill-advised. But refusing or rationing care to the unvaccinated would be immoral, and a dangerous first step down a slippery slope.

Jeff Jacoby can be reached at Follow him on Twitter @jeff_jacoby. To subscribe to Arguable, his weekly newsletter, visit