HEALTH CARE/Joan Retsinas

A Policy No-Brainer: Vaccination Subsidies

The vaccination statistics are discouraging. In this, the land of technological wizardry, we have the expertise to guard against a hodgepodge of diseases: diphtheria, tetanus, whooping cough, polio, influenza, chicken pox, hepatitis, measles, rubella. Nineteenth century death certificates often list these diseases as "cause of death." Twenty-first century death certificates, at least in the developed world, rarely do. The reason is not arcane: we have vaccinations that protect us from those scourges.

Yet lots of Americans are not vaccinated. About one-quarter of toddlers don't receive the regular vaccinations on time. In pockets of the country, the statistic is higher. (Massachusetts scored the best: only 14% of toddlers are missing their shots.) Adults with diabetes would do well to get vaccinated against influenza, yet vaccination rates range from 29.9% in Puerto Rico to 79.9% in Maine.

Although some people eschew vaccinations on religious or philosophical grounds, most people don't get vaccinated, or don't get their children vaccinated, simply because it is low on their to-do list. If the shot will cost money, its priority drops further. If the family has lost a paycheck, in this, the land of rising unemployment, its priority plummets.

This prioritizing is not irrational. Other expenditures quickly trump an outlay for vaccination. If a tenant reneges on the rent for a few months, the landlord may evict him. If a diabetic skimps on insulin, he could die. These consequences are almost certainties. On the other hand, if a person doesn't get vaccinated for polio, in a country where virtually nobody gets polio, the chance for calamity is minuscule. Even for diseases like whooping cough, diphtheria and tetanus, the odds are good that the non-vaccinated person will be safe.

On a personal level, the family may be acting rationally. When large numbers of families act in this way, though, the possibility of contagion grows. It is the dilemma of the individual in a society: I am safe from disease x if everybody around me is vaccinated, so I can eschew vaccination. Yet when a certain number of "I"s act in their self-interest, we all are vulnerable.

If the effective demand for vaccinations is not robust, neither is the supply of vaccines. Vaccines are low on the priority list of pharmaceutical firms. A decade ago, 25 companies were producing vaccines. Today five companies are in the business. Not surprisingly, this past year there were shortages of some vaccines. And companies are not racing new vaccines through their development pipelines.

Again, companies' priorities are not irrational. In a for-profit world, companies concentrate on lucrative products, or products that may prove lucrative. Drugs for impotence, for cholesterol, for asthma &endash; all trump vaccines, no matter how essential those vaccines.

One company's rational decision to leave the vaccine market may do no collective harm if the market is robust. With one fewer company, the competitors will boost production to claim more market share &endash; and make more money. This, though, is a weak market. When most companies leave the vaccination business, we all suffer.

After an exhaustive study, the Institute of Medicine has proposed a two-prong solution: mandates and subsidies. To bolster demand, the government would mandate that all insurers pay for vaccinations and would subsidize vaccinations for the uninsured. To bolster supply, the government would subsidize the vaccine industry &endash; including the development of new vaccines. The upshot: more Americans will get vaccinated, and more companies will be making &endash; and developing &endash; vaccines.

Conservative ideologues, who see the words "mandate" and "subsidy" as anathema, see this proposal as one step on the road toward national health insurance.

Yet public health advocates see these mandates and subsidies as a no-brainer. Yes, mandates and subsidies push the government into the private sector &endash; moving Adam Smith's no-longer-invisible hand around. But we have pushed our way into the private sector before, in the name of the public good. We mandate air bags in cars. We subsidize education.

Conservatives also decry the cost. These mandates and subsidies will cost money, in premiums and in taxes. But the payback will be a healthier nation.

Indeed, the vaccination proposal is the policy no-brainer of the year. Yet Congress will surely dither. Can it? Should it? What if? No-brainers often consume vast amounts of brain-power.

Joan Retsinas is a sociologist who writes about health care in Providence, R.I.

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