The most American of values is individualism.
We deeply value independence and self-reliance, whether extolling the philosophies of individual natural rights or embodying the spirit of manifest destiny through rugged individualism. It is how most Americans define themselves.
And it is how we define our moral outlook – our thoughts on laws, individual conduct, and of late, healthcare policy. The ethos of individualism runs anathema to government interventions, namely vaccine mandates, which explains why they were incredibly unpopular and ineffective across the country.
We see healthcare policy through the lens of individualism, even for issues that affect our collective health. This is why we hear choruses of people chanting how they were vaccinated but respect the right of those who choose not to get vaccinated or to remain hesitant. Yet we fail to understand that vaccines are only as effective as the proportion within a population that gets them.
Vaccines are a ratio of fixed individual risk – arising from the inoculation and its side effects – to variable collective benefit – arising from the boost in individual immunity that collectively forms herd immunity if a sufficient percentage get inoculated.
So as far as vaccination goes, traditional concepts of individualism tell only a part of the story. To get a complete sense of the importance of vaccines and society-wide vaccinations, we need to re-imagine individualism in the modern era of expansive healthcare.
This begins by redefining individual values in healthcare. We value high quality care at low costs with optimal access. Unfortunately the three are not mutually exclusive, and prioritizing one comes at the cost of the other two, which means healthcare is an opportunity cost.
And in the United States, these costs depend upon insurance policies that utilize a cost sharing structure in which individual patients within an insurance plan – public or private – pay into an entity that then disseminates funds to cover the cost of care.
This means healthcare opportunity costs are interdependent, reliant upon the actions of others to influence the quality, cost, and access of care for the individual. Economists call this an externality. And in today’s healthcare, there are numerous externalities, both positive and negative.
If you live in an area with good sanitation, then you reap the benefits of fewer communicable diseases. If you live near a coal-fired factory, then you suffer the costs of greater cardiopulmonary diseases. Healthcare externalities are not cause and effect, but they are certainly associative. And the degree and nature of the associations determine their impact.
This gets lost in the debate over vaccine mandates, and really, the debate on all pandemic-based health policies. In our quest to espouse the virtues of individualism, we forgo any meaningful discussion on the role of healthcare externalities on individual health.
It has not always been this way. We agreed to outlaw cigarette smoking in most public facilities and private establishments because of the effects of second-hand smoke. This is a policy decision based on a healthcare externality. We require drivers to wear seat belts and fasten young children in car seats. This too is an externality, albeit it contrary to how many look at healthcare externalities.
Most see healthcare externalities as flowing in one direction – from the individual to collective society. So when we talk about public good or social welfare in healthcare, it is framed in terms of individual decisions or actions benefiting society. This is how we frame vaccine mandates.
But externalities are complex and multi-directional, growing in complexity as our understanding of healthcare evolves and expands. Until of late we never would have assumed that municipal zoning decisions over grocery and pharmacy locations would affect individual health. Yet we now know that these broad decisions affect access to care and individual healthcare outcomes.
Therefore, municipal zoning decisions, and the election of policy makers who make these decisions, become healthcare externalities – in which the impact is felt directly on the individual patient.
Traditional definitions of individualism fail to account for these externalities, because they frame healthcare policy from the perspective of the individual, which leaves us with an incomplete understanding of healthcare – with consequences that will linger on longer than the pandemic.
COVID-19 has changed American society, exposing fault lines in traditionally held assumptions about healthcare. The most glaring of which is the concept of individualism in healthcare.
Healthcare individualism is not the hermit waxing poetic in a Massachusetts forest, not the rugged frontiersman who pushes onward into the unknown, but the conscientious patient who makes decisions in her best interest while recognizing the primary and secondary consequences of her decisions.
Healthcare individualism is unique in its considerations, and unmistakably complex in its consequences. This is the nature of healthcare.
As healthcare grows to encompass a greater proportion of the overall economy, and expands in definition to embody concepts in society previously assumed to be unrelated to healthcare, our understanding of the individual in healthcare should change commensurately.
We must redefine American individualism for post-pandemic America, one that is uniquely sophisticated in all things healthcare as healthcare evolves to incorporate all things in society.
Per capita national health expenditures from 1960-2020
The data categorizes expenditures as national health expenditures, health consumption costs, personal health costs, administrative costs, and public health activities cost.
Source: Centers for Medicare & Medicaid Services, Office of the Actuary, National Health Statistics Group; U.S. Department of Commerce, Bureau of Economic Analysis; and U.S. Bureau of the Census.