Poor Health Care or Politics: Which Explains America's COVID Vaccine Hesitancy?

Some experts have argued that America's expensive, inefficient health care system is to blame for our intense vaccine hesitancy. While this is a plausible explanation, it misses the key problem—the politicization of medicine, along with almost everything else in our culture.

Why are so many Americans unwilling to get a COVID-19 vaccine? The standard answer goes something like this: disinformation superspreaders, folks like Joe Mercola and Mike Adams, have convinced some 80 million of us to avoid safe, effective shots. This analysis is correct so far as it goes, but the the problem is much broader than that.

Over at The Guardian, senior health care reporter Jessica Glenza made an admirable attempt this week to give America's vaccine hesitancy some more context. The US has plenty of shots to go around, she noted, “but health professionals found lacking another essential element essential to a successful vaccination campaign: trust.”

That's 100 percent correct; plenty of research has documented trust as an essential part of any science communication effort, so why do Americans distrust the medical establishment enough to skip COVID vaccines? The missing piece of the vaccine-hesitancy puzzle, according to Glenza, may be that Americans had a rocky relationship with the health care system long before the pandemic hit. We were much sicker than other developed countries and paying too much for health care:

In just a few examples, Americans have the highest infant mortality, children are less likely to live to age five, and the US has the worst rates of Aids among peer nations. The US also has the highest or among the highest rates of cardiovascular disease, obesity, chronic lung disease and disability ...

Americans know intuitively that their healthcare is expensive, frustrating and often unfair. Remarkably, even amid the pandemic, roughly 30 million Americans went without health insurance, exposing them to potentially ruinous medical debt.

While there's no denying the deficiencies in the US medical system, those problems haven't sufficiently weakened the public's trust in medicine to sustain widespread vaccine hesitancy. The real problem is that health care, like so many other topics, has become increasingly politicized, forcing Americans to think about their medical decisions as an extension of their ideological commitments.

A broken health care system?

The first challenge to Glenza's thesis comes from an August 2021 poll, which found that most Americans seem to trust their health care providers. As ABC News reported:

At least 7 in 10 Americans trust doctors, nurses and pharmacists to do what’s right for them and their families either most or all of the time, according to the poll from the University of Chicago Harris School of Public Policy and The Associated Press-NORC Center for Public Affairs Research. The poll shows high levels of trust among both Democrats and Republicans; men and women; and white, Black and Hispanic Americans.

There's a few reasons for this positive outlook, I think. As The Guardian acknowledged, “the US houses among the most advanced medical and research centers in the world,” meaning we have access to some of the best care available, and the number of Americans who can utilize these services has increased in recent years. As measured by decreasing poverty rates, living standards in the US consistently improved prior to the pandemic, which indicates that covering essential costs like health care is easier for an increasing number of Americans. Grinding the global economy to a halt with lockdowns slowed this growth, and there are certainly income disparities, but the long-term trend is still unmistakable.

It's true that life expectancy is slightly higher in several other developed countries, by two years on average. There are disparities in other outcomes as well. Maternal mortality, for instance, is lower in certain EU countries, but in the US it's still quite low in absolute terms. I'm not defending these outcomes, just pointing out that the disparities aren't big enough to drive distrust in the US health care system and thus vaccine hesitancy.

So what's the problem?

If Americans generally trust their health care providers to give them solid medical advice, why are so many hesitant to get a COVID vaccine? As Liz Hamel, director of public opinion and survey research for Kaiser, told ABC news, politics is the problem. “Hamel noted that attitudes toward the shots have become so politicized that people who trust a doctor to give them advice about other issues may not be open to hearing more about the vaccines.”

Hamel didn't elaborate on what she meant by “politicized,” but there are several data points that help explain how a person's opinion on vaccination became a partisan dividing line. For example, some public health experts have urged agencies like the CDC to tackle racism, gun violence and climate change—all incendiary issues, of course. The same experts have also reported that Americans of all backgrounds and political persuasions don't want the CDC to expand its role in this manner. As I wrote in May when that survey was published, “you can't blame partisanship for a poor pandemic response while arguing that public health experts need to wade into increasingly partisan territory.”

We've already seen what happens when the agency takes on new issues. As my colleague Dr. Josh Bloom has documented, the agency's opioid prescribing guidelines have done incalculable damage "to millions of pain patients."

Not to be outdone, political pundits have consistently defined vaccine hesitancy as a problem largely plaguing their partisan opponents. CNN contributor Max Boot made this blunder in July, arguing that “Republicans aren't getting vaccinated is because they're listening to this garbage, this misinformation and these lies that are being spread by sources like Fox News and many other influencers on the right." Boot acknowledged that young people and minorities are also highly skeptical of vaccines, though he had nothing to say about why. Glenza made the same error in her Guardian piece, claiming that “vaccine misinformation campaigns [are] overwhelmingly popular in conservative circles ...”

Depoliticize vaccines

This isn't to excuse sources like Fox News for seeding doubt about vaccine safety. When they amplify demonstrably false claims about immunization, they should be taken to task for misleading their audiences. But the fact remains, even when the media correctly identify the root cause of vaccine hesitancy, lack of trust in the public health establishment, they frame it in partisan terms.

The problem isn't that one side of the aisle has made COVID-19 vaccines a political issue, it's that almost every subject is a political issue, settled by a congressional vote or a presidential executive order. Even seemingly insignificant decisions, like the kind of soda we drink and which city gets to host the MLB all-star game, have become statements about our ideologies.

It's increasingly difficult for the average American to think about important subjects like immunization without having to first consider its political implications. As long as that continues, so will the widespread vaccine hesitancy we all agree is a serious problem.