Should the Unvaccinated Pay More for Their Healthcare?

Arthur L. Caplan, PhD


January 18, 2022

This transcript has been edited for clarity.

Hi. I'm Art Caplan. I run the Division of Medical Ethics at the New York University Grossman School of Medicine in New York City.

Many people have been wondering whether we should take steps to increase the burden on those who get sick with COVID-19 if they are not vaccinated. They didn't take the proper precautions to protect themselves, got sick, wound up in a hospital in an ICU, and consumed medical care — and whether they got better or didn't, they certainly ran up a pretty good bill relative to the cost of hospitalization.

Some countries are moving in this direction. Greece has said that any person over age 60 who winds up in a hospital is not going to get their bill paid by government health insurance if they didn't get vaccinated. That's an example of trying to encourage vaccination, if you will, by threatening a pretty big bill.

Other people have proposed in other contexts to have those who aren't vaccinated pay a higher co-pay and pay more for their insurance if it's determined that they have not gotten the complete set of vaccinations — in the case of the mRNA vaccines, three shots.

What's fair? What's equitable? I'm not in favor and don't agree with those who say, "Well, if you're not vaccinated, you can't come into the hospital or you're going to get lower priority if you need to come into the hospital relative to those who did get vaccinated or who were there for other emergencies, like a heart attack or a stroke." I think that healthcare can't be discriminating on the basis of just vaccination status as to who can come into the ER or the ICU and who cannot.

I do believe that we want to encourage vaccination. In some contexts — say transplants, where it makes sense to plan the procedure and know that if you're not vaccinated, the odds of you successfully keeping your transplant are very low because you're going to be immunosuppressed and the virus, if you got it, would kill you and the organ — it makes sense to say that as a condition or eligibility to get transplanted, you've got to get all your vaccinations (including COVID-19) because you're going to become an immunosuppressed person at very high risk of losing the organ and maybe dying because of infectious disease. It doesn't make sense at the ER or the ICU.

On the other hand, it's very common in health insurance to say to people, "You're overweight or you engage in risky behavior, so you're going to pay more for your life insurance or your health insurance." Underwriting, as it's called, does that all the time.

There's nothing immoral or illegal about saying, "In order to decide how much you're going to pay for private insurance, we're going to take a look at your risk profile. If you're diabetic or have some other underlying condition, we're going to charge you more."

That's just the way it is in terms of trying to get people to pay for their risks. I think vaccination status could easily fall into that category of risk assessment.

At the end of the day, it's a tough call. I don't think you want to restrict access to emergency services, intensive care services, and things that are life and death just on the basis of vaccination status. I do think some procedures allow you to plan ahead, such as transplant. There, you may exclude somebody when it's not an emergency or a crisis, but rather a planned elective procedure, and say, "If you don't do this, you're not going to be eligible to get a transplant even if it means your life. You just have to do it in order for the transplant to work."

When it comes to money, particularly in the United States, private insurance does charge people more when they're at greater risk, for health, life, and disability insurance as well. Co-pays tend to be a little trickier because if you have a flat co-pay, the poor get hit harder than the rich. That doesn't seem right. If we could have, if you will, a scale or a gradient charging people more according to income or where a higher co-pay may be associated with a better insurance plan, then I think it might make some sense.

At the end of the day, the reason we're using these financial incentives isn't really to recoup costs imposed by those with COVID-19 using resources. What we're really trying to do is change behavior and say to people, "You're going to cost us more. That's a reminder. Get vaccinated."

If that strategy really works, we can look to Greece and other countries, like Germany and Britain, which are thinking about co-pays and financial penalties, and see how well it turns out. Then, I think we may have something we want to try. If it really doesn't move behavior, it's probably not worth doing.

I'm Art Caplan. I'm at the Division of Medical Ethics at the New York University Grossman School of Medicine. Thank you for watching.

Arthur L. Caplan, PhD, is director of the Division of Medical Ethics at New York University Langone Medical Center and School of Medicine. He is the author or editor of 35 books and 750 peer-reviewed articles as well as a frequent commentator in the media on bioethical issues.

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