The uneven toll of the Covid-19 pandemic has exposed preexisting fault lines within the United States—between who gets sick and who gets well, who receives care and who goes without, and those whose behaviors are rewarded—or punished—in the ongoing effort to maintain, or return to, some version of “normalcy.”

The latest fault line is between “the vaccinated” and “the unvaccinated.” But rather than revealing a new line, this distinction between Americans based on their Covid vaccination status traces an older division: between those of us who can freely choose to obtain health care and those who still—even in 2021, in the middle of a pandemic—cannot.

Common parlance, including the ire of at least a few public officials, might lead some to assume “the unvaccinated” are a self-selecting, selfish gaggle of anti-vaxxers. But the truth is that when compared to those have received a Covid vaccine, those who have not are more likely to be children, working-age adults who earn less than $40,000 per year, Black or Hispanic folks, and the uninsured.

These groups are not some random assortment of people best categorized by an aversion to modern medicine and science. They are our nation’s working poor—the people the US health care system has historically the most harmed by chronically neglecting their needs.

As that same system runs up against the limitations of its own design, many are befuddled that attempts to generously dole out Covid vaccines have met resistance among those who appear to be choosing to go without. Yet, when it comes to the US health care system, choice has always been constrained by broader forms of inequality and their profitability. Because it turns out that tiering care, such that some people are rendered more vulnerable to death and disease while others are rendered marginally less so, is quite lucrative.

Organized around the insurance market, the US health care system distributes resources in a hierarchical, racially segregated fashion, with care flowing toward the highest payers (people who work in industries that offer private insurance or have the personal wealth to pay out of pocket), not those with greatest need. That means that 97 percent of all US adults who are in the “coverage gap” (meaning their income is too high to be eligible for Medicaid but too low to qualify for Marketplace premium tax credits) live in the South. Which is also where the nation’s Black and Latinx population disproportionately lives.

Accordingly, regions with high rates of uninsurance and underinsurance, like the American South, experience higher rates of hospital closures. In these care deserts, which exist throughout the country, the ability to choose medical care is shaped by the availability of various services and an individual’s means to access those services. This turns poor and segregated communities into places where people are more likely to lack a regular source of care and a trusted space to seek and receive credible information about their health care options. As a result, poor, Black , and Latinx folks across the United States often delay or forgo care all together—increasing the likelihood these populations will suffer from chronic, untreated, and undertreated illness and have a greater dependence on emergency services in a crisis.

So when 41 percent of those still waiting to get a Covid vaccine say they are concerned about the cost, they aren’t just penny-pinching or ill-informed. Obtaining health care in this country is rarely cost-neutral, even when a shot is free. From forgone wages to child care obligations and gas money, parking fees or bus fare, people incur costs simply to arrive at and return from all manner of medical care, let alone a Covid vaccination. For those who lack sufficient income to cover such costs—or the necessary benefits to buffer unexpected health scares or the possible side effects of a vaccination—the choice to vaccinate has never been free.

To increase Covid vaccination rates, then, the US health care system will have to address these hidden costs of care.

What is more, when 78 percent of those waiting to be vaccinated report concerns that the “Covid-19 vaccines are not as safe as they are said to be,” such concerns are not markers of ignorance; they are markers of fragility. They reveal the inhumane choice before Americans: between the real and perceived risks of Covid infection and those of vaccination. That choice, while freely made by those who understand that the risks of Covid infection far outweigh the risks of vaccination, is not as easy to navigate for those who lack the information to predetermine which blows they can afford to weather—financially and physically—and which ones they cannot.

To increase vaccination rates then, America doesn’t just need free Covid vaccines; we need free primary care, hospitalized care, surgical care, and intensive care in every community in the country. Because even though 90 percent of Americans may live within five miles of a Covid vaccination site, too many still lack access to a regular provider who can recommend vaccination in the context of their specific medical history, familiarity with common processes to obtain care, trusted sites for medical procedures, and reliable transportation in a crisis.

In other words, to be successful, the Covid vaccination effort is going to require the kind of access to care our system has never created—access that is universally free.

And because access to care is often predicated on access to information about care options, every person in this country also needs access to credible health information that isn’t blocked by paywalls, lost in the digital divide, or usurped by disinformation campaigns. Credible science is best shared person to person, between a clinician and patient, where it can be contextualized alongside an individual’s specific concerns. While federally qualified health centers have attempted to fill that gap in the current vaccination effort, their recent growth remains dwarfed by the larger health care system that continues to lean away from people who cannot pay.

The fault lines that are gaping open during this pandemic have never been random nor uniformly distributed. These chasms between us are not about who wants care and who doesn’t. They are about who can freely choose it and who cannot. People who miss doctors’ appointments, leave medications at the pharmacy, or fail to follow up for specialty services are not choosing to be sick or defiant. They are choosing to go to work, care for their children, keep $5 in their pocket for an emergency, or to avoid the infirmities that accompany certain procedures.

Blaming people on the basis of vaccination status may be politically expedient. But it does little to help us understand why so many still lack the protection so much of the world is clamoring to receive. Vilifying “the unvaccinated” as a monstrous monolith misses this vital fact: that what “the unvaccinated” have most in common is how our health care system treats them—as a group to be punished or ridiculed for living shorter, sicker lives, instead of the group that deserves to have our entire health care infrastructure recalibrated to meet their needs. Instead of a vaccine lottery, they need—and deserve—universal care, information parity across educational and class backgrounds, universal paid sick leave, universal child care, and deep investments to repair a social safety net that when frayed allows generations of Black folks to fall through its gaps.

This is not to minimize any part of our current vaccination effort, which is nearly unparalleled in size and support. Rather, it is to note that it is remains incomplete. Redistribution of a hoarded resource like health care will take more than mass media pushes and singular pharmaceutical interventions. It will take massive investments, both fiscal and political, in universal interventions—like mandates for masking and distancing and universal care.

Many of the groups who have been disproportionately touched by Covid’s devastation paradoxically remain just outside the reach of the herculean efforts to vaccinate the country. The question is why, and what should we do about it? The answer is: We built it this way, on chasms and cracks. Erecting a new foundation will now require careful and deliberate investment in health care for everyone—not just those privileged enough to choose it.