Blurred Lines

You probably heard about the 6 year-old boy in Oregon who got tetanus after getting a cut; he hadn't had the recommended tetanus shot because his family did not believe in vaccinations.  He ended up having to be hospitalized for almost two months, racking up a bill of over $800,000.  His parents allowed the first round of the tetanus vaccine while he was in the hospital, but not the second round, nor any of other recommended vaccinations. 

Many people's response was "that poor kid," with many others thinking "those parents should be ashamed."  Me, I'm more cynical; my first thought was: hmm, I wonder who is paying that bill. 

That particular case actually happened in 2017, but was only recently reported by the CDC.  It comes at a time when the anti-vaxx movement has never been so widespread, nor as outspoken.  The United States is having measles outbreaks -- in 2019! -- such as the ones in Washington.  Those cases are tied to a tight knit community of Eastern European immigrants, who have very low rates of vaccination.  But, as the chart below from Vox illustrates, it's not now, it's not just them, and it's not just there.

As of March 14, there are 2019 outbreaks in 15 states: Arizona, California, Colorado, Connecticut, Georgia, Illinois, Kentucky, Michigan, Missouri, New Hampshire, New Jersey, New York, Oregon, Texas, and Washington.  This for a disease that was declared eliminated in the U.S. in 2000. 

It'd be easy to believe that the anti-vaxx movement is driven by religious objections or poor education, but it is way past that.  The beliefs that vaccines can cause autism have propagated widely, and now there are people who believe that getting measles can, at worst, be cured by antibiotics (measles is a virus) or, at best, that getting it can help prevent cancer. 

Seriously. 

People not letting their children get vaccinated not only put those children at risk, but others as well.  Schools can try to limit exposure by banning children without vaccinations from attending, but can also expect lawsuits.  There are, unfortunately, also reports of anti-vaxxers being vicious in their condemnation of those who follow the vaccine recommendations. 

What I am not clear on is who the anti-vaxx movement thinks should pay if someone in their family do end up with one of the diseases those vaccinations would have helped protect them against.  Unless they are in a community like the Amish that don't typically turn to insurance, I suspect they still expect their health insurance to assume most of the costs. 

That's something other people in that insurance pool might have some feelings about. 

It's easy to talk about holding anti-vaxxers accountable for not believing in vaccinations, but let's not stop there.  If we think we've got a measles outbreak, we have a far worse flu outbreak.  It's in more states, with more deaths, from more age groups.

There is a flu vaccine, but, as is usually true, it's effectiveness is not high.  The current one is estimated at about 47%, making getting it kind of a crap shoot.  Perhaps that is why rates of flu vaccination are fairly low -- for 2017- 2018 it was estimated at 37%. 

Should we similarly criticize people who don't get the flu vaccine? 

If we want to take this further, there are all sorts of personal responsibility we could hold people accountable for.  Are they getting their recommended preventive exams and screenings?  Are they following a recommended diet?  Do they get the recommended levels of sleep and exercise? 

If we're going to pick on anti-vaxxers for not following vaccine recommendations, we should be asking when we cross the same line for other recommendations. 

It doesn't help that it is often hard to know what the right recommendations are.  Eggs are bad for you...no, good...no, bad again.   Do 150 minutes a week of moderate exercise, or 75 minutes of vigorous exercise, or maybe just a few minutes of intense exercise.  Get an annual preventive exam...oh, maybe not.  Men should get PSA tests...umm, that's not so clear.  Women over 40 should get regular mammograms; really, who knows? 

The fact is that the basis for many of these recommendations is not as clear-cut as one might expect, nor do U.S. guidelines always agree with guidelines in other developed countries. 

If you are a smoker, it is permissible for your health plan to require higher premiums.  Employers are allowed to take that concept further, giving people who participate in the wellness program as much as a thirty percent discount in their premiums (which amounts, of course, to a 43% penalty for those who do not). 

Neither, though, impacts the level of coverage you get.  Fair?  To whom?

No wonder we usually just throw up our hands and agree to share in the costs even for people who (we don't think) are not doing all they could to maintain or improve their health.  Those anti-vaxxers are not as far out of the mainstream as we might like to think. 

There are lines here somewhere, but they're awfully blurred.  Not everyone who doesn't get a measles vaccination gets measles.  Not everyone who doesn't get a tetanus shot gets tetanus.  But, then, not everyone who smokes gets lung cancer, not everyone who is overweight gets diabetes, and not everyone who doesn't exercise has heart attacks. 

One line we could draw is whether your behavior is likely to impact others' health as well -- and whether it can be clearly shown that your doing/not doing something causes a clear risk to them.  E.g., measles and flu seem different -- the measles vaccine is close to 100% effective, the measles closer to 50/50, and measles is much more contagious than the flu.

But even that line is still arbitrary, and the step to financial responsibility is a big one. 

The thing is, we're going to be in a position to know.  Apple Watches, wearables, information from social media, etc. are going to track our behaviors, and Big Data is going to tell us what impact they have on our health.  It would be an natural next step to start expecting to hold people accountable for what they are doing, or not doing, to manage their health. 

It just won't be easy.

We shouldn't ignore the issue of financial consequences of personal responsibility, but knowing how and where to draw those lines is going to be difficult.