All governments want to increase rates of vaccination against Covid-19. With the Omicron wave in full flow and health systems across the world under strain, anger at those who still refuse to be vaccinated is growing.
Desperate times, desperate measures, you might say. Measures like fining the unvaxxed. This week, it was announced that the Canadian province of Quebec would penalise the unvaccinated by imposing “significant” health tax (exact amount to be decided). Quebec joins Greece, which fines people over the age of 60 €100 for each month they don’t get their jab, and Singapore, where unvaccinated Covid patients are required to pay their own medical bills, despite the country’s otherwise universal healthcare system. There have – inevitably – been calls for Britain to follow.
Could it be that simple? There’s a pragmatic issue of whether coercive tactics such as fines and vaccine passports actually help push up vaccination rates. That is an incredibly complex question that depends on the level of vaccine take-up and the reason for vaccine hesitancy in the first place – so far the answer seems to be we’re not sure. Sometimes if you introduce a financial incentive for someone to do something, you reduce the power of non-financial incentives that might have been more effective.
But let’s say it does work. Does Quebec – or Singapore, or the UK – want a system where a person’s poor choices affect what they pay for healthcare? Because while charging unvaccinated patients extra may seem a relatively clear-cut example, once a universal healthcare system opens the door to imposing penalties for behaviour deemed medically reckless, it gets very muddy very quickly.
If someone who refuses to get inoculated against Covid deserves a health tax, what about other vaccinations – the flu jab, say? Because we’ve had devastating flu seasons before and never considered such a thing. Or should parents who decline the MMR vaccine be charged if their children then need care (and if they can’t afford it, are we comfortable denying treatment to children)? What about people who go on holiday to areas with high hepatitis or typhoid risk but don’t get the right travel inoculations? For that matter, what about people who travel to high-risk areas full-stop? Why should the UK taxpayer subsidise the treatment of someone who caught a rare tropical disease in a country they had no need to visit beyond their desire to see the world?
Then there are the other choices we make every day that could have adverse health outcomes. There are periodic demands that alcoholics, smokers and drug addicts should be made to contribute for the care they receive. It is interesting that those who enjoy extreme sports rarely incur the same ire – for some reason we seem much happier about taxpayers funding treatment for someone’s ski accident than we do about an addict’s overdose, even though the latter probably deserves our compassion more than the former. We might also consider the reasons someone is driven to drink and drugs – if their addiction is the result of past trauma or abuse, can they really be said to be at fault? It is all very well to bang the drum of personal responsibility, but not if those standards are applied haphazardly based on societal prejudices.
One solution, of course, is to do away with the idea of universal healthcare altogether. Let people make their own choices and pay for the consequences themselves, or look to the insurance market to assess the risks as is essentially the case in the US. Somehow, I don’t think that’s what the premier of Quebec had in mind when he announced the tax for the unvaccinated. He said, rather, that it was “a question of fairness”.
But fairness is hard to quantify when it comes to health spending. In Britain we talk often of the “cost” to the NHS of people who smoke or are obese – the health support service One Small Step, for example, points out that smoking costs the UK government £12.6bn a year, £2.5bn of which is spent on NHS smoking services. On the same page, however, it notes that “half of all life-long smokers die early, losing on average 10 years of their life”. Given how dramatically health, social care and pension expenditure increases as someone ages past retirement, those 10 lost years actually represent a saving for the taxpayer.
That is an immensely grisly – not to mention heartless – way to look at things. But if your argument is that those who cost more should pay more, it is vital to crunch the numbers. Despite the perception that certain lifestyle choices would save money as well as lives, a Dutch study from 2008 found that smokers and the obese were cheaper to care for over their lifetimes, while research from the Institute of Economic Affairs concludes that: “By dying early, overweight and obese people saved the government £3.228bn in pension, healthcare and benefit payments in England and Wales in 2014.”
The more you think about it, the darker it gets. It is a triumph of medical science that people are living longer and surviving conditions that would once have killed us: someone who three decades ago would have died of cancer at 70 can now have a life-saving operation and live another 15 years. That’s wonderful – but those 15 years of other age-related ailments and potential dementia have a price-tag attached, for the government purse as a whole and in terms of healthcare specifically. Figures from the Nuffield Trust in 2016 published in the Guardian show how health spending in the UK is skewed towards the over-65s: more than £7,000 a year was spent per person on those above the age of 85 compared to a national average of £2,069, with an 85-year-old man costing the NHS seven times more than a man in his thirties. Miraculous but expensive new drugs compound the challenge. The unpalatable truth is that, above a certain age, the most costly thing someone can do in terms of burden to the NHS is to keep living.
No one wants to live in a society where healthcare is rationed by age, with the elderly denied treatment because it is too expensive to keep them alive. But the logical conclusion of a model that allocates healthcare spending based on whose actions have cost the system the most money raises uncomfortable questions. The very premise of universal healthcare is that it is for the good of society as a whole that someone turning up to a hospital should receive medical attention free at the point of use, regardless of the decisions which may have led them there. However determined governments are to keep vaccination rates high, they should be wary of violating that principle.
This article appears in the 19 Jan 2022 issue of the New Statesman, The end of the party