In the midst of the country’s worst measles outbreak in 25 years, President Trump made an abrupt about-face on vaccinations.
Before becoming president, he had spread vaccination fears by peddling anti-vaccine tropes on Twitter and meeting with anti-vaccine conspiracists. When faced with the growing measles outbreak, the president seems to have changed his tune and now urges Americans to “get their shots.” Behind the scenes, though, his administration’s efforts could undermine public health efforts to ensure that children and adults get the vaccinations they need to prevent illness.
The current measles outbreak is largely blamed on unvaccinated schoolchildren. Parents opposed to vaccines have taken advantage of state laws that allow kids to skip vaccinations based on personal or religious reasons. This is a significant threat to herd immunity, the idea that the more people who are immune to a disease, either naturally or through vaccination, the harder it is for that disease to spread.
The administration’s anti-vaccine actions come, surprisingly, in a federal lawsuit over health insurance. The plaintiffs in that lawsuit, a group of Republican state attorneys general, are challenging the constitutionality of the Affordable Care Act’s individual mandate — the requirement that all Americans buy health insurance or pay a tax penalty. As a practical matter, the mandate is dead. In 2017, the Republican-controlled Congress reduced the mandate’s tax penalty to $0.
The attorneys general are trying to use the dead mandate to kill off the Affordable Care Act. They claim that the lack of a tax penalty renders the mandate unconstitutional. If the mandate is unconstitutional, they argue, the entire Affordable Care Act must be scrapped. In a stunning decision, a federal judge in Texas agreed and the case is now on appeal.
This case, however, is not just about insurance coverage. The Affordable Care Act also promotes public health by, among other things, requiring health insurance plans to cover federally recommended vaccines with no out-of-pocket costs. In other words, the Affordable Care Act makes essential vaccines affordable by barring insurance companies from applying copays, coinsurance, or deductible requirements for vaccinations.
In a surprising twist, the Trump administration, acting through the Department of Justice, has thrown the full weight of the federal government behind the attorneys general. The entire Affordable Care Act, the administration argues, should be struck down.
If this bid is successful, it will strip 20 million Americans of their health insurance. Without coverage, they will have to pay full retail price for vaccines. Even for families that keep their coverage, insurance companies will no longer be required to pay for vaccinations with no out-of-pocket costs. Since many health insurance policies include a significant deductible, many insured families will bear the full costs of vaccines until they’ve met their deductible limit.
This would make vaccinations a serious financial burden for many families. Vaccine costs have risen over the last two decades. The cost to fully vaccinate a child up to the age of 18 is now more than $2,000. The retail price of adult vaccines for commonly preventable diseases is also quite high. For example, some adults — those born between 1957 and 1989 — may not be adequately protected against measles even if they received measles vaccines as children. Those who want an MMR (measles, mumps, rubella) vaccine will have to pay for it themselves. Some retail prices for the MMR vaccine exceed $100 per dose.
Trump’s actions will also make it harder for older Americans to get other recommended shots, including annual flu shots, tetanus-diphtheria boosters, and shingles vaccinations. A shingles vaccine, recommended for those 50 and older, costs $140. A tetanus and diphtheria booster, recommended every 10 years, can cost $55. The retail price of annual influenza shots ranges from $20 to $40. Yearly flu shots for a family of four could cost $80 to $160.
Many families can’t afford these expenditures.
A report on the economic well-being of U.S. households by the Federal Reserve found that a significant number of Americans are financially insecure. Forty percent of U.S. adults faced with a $400 emergency expense would need to borrow or sell something to pay the bill. Nearly one-quarter of adults forgo payment on some of their monthly bills, even without an unexpected expense. If forced to choose between vaccines and rent or food, the choice for many families is easy: no vaccines.
Immunizations are vital to the public’s health. That’s why the Affordable Care Act required insurance companies to cover vaccinations with no out-of-pocket costs. In light of the resurgence of measles, the Trump administration ought to be taking steps to expand access to vaccinations, rather than trying to make them unaffordable.
John Aloysius Cogan Jr. is an associate professor of law and the Roger S. Baldwin Scholar at the University of Connecticut School of Law.