SINGAPORE – As countries battle to convince stragglers to get vaccinated, Singapore has settled for one of its most aggressive strategies: the city-state is going to stop completely covering Covid-19 medical bills for the unvaccinated.
Singapore’s government has paid the full cost of treatment for nearly all Covid-19 patients since last year, as part of a pandemic policy to ensure that financial considerations do not increase public concern about the disease. On Wednesday, the government withdrew that support for those who choose not to get vaccinated.
“We need to send out this important signal to encourage everyone to get vaccinated if you qualify,” Health Minister Ong Ye Kung said last month.
Singapore is one of many countries that have taken steps to convince vaccine holders. Some European governments are tightening restrictions on unvaccinated people in restaurants and offices. From February, Austria will require all adults to be vaccinated. In Vienna, those who fail to show up for vaccine appointments can be fined up to $4,050. Greece has made Covid-19 vaccines mandatory for people over 60 and will start issuing fines in mid-January to those who have not received their first dose or made arrangements to receive their first injection. In Germany, politicians debate similar policies.
The US government is also pushing to boost vaccinations. In November, the Labor Department said all companies with 100 or more employees must ensure that their employees are vaccinated at least weekly or take a Covid-19 negative test and wear a mask in the workplace. But the rules have been challenged in court, and several early rulings violate federal workplace vaccine requirements.
However, Singapore has already achieved one of the world’s highest vaccination rates, with 96% of the eligible population – which excludes categories such as young children – fully vaccinated, the government said. It has achieved this in part by restricting activities in which unvaccinated people are allowed to participate: they cannot dine in Singapore’s food courts or enter shopping malls. However, that has not convinced everyone.
Of particular concern are approximately 44,000 unvaccinated elderly citizens. In early November, the Singapore government said about 95% of deaths in the past six months were aged 60 years or older, and 72% of deaths were among those who had not been fully vaccinated. The number of Covid-19 cases fell sharply in Singapore from the end of October, with a seven-day moving average peaking at nearly 4,000 cases per day. The country of 5.5 million people now has an average of just under 1,000 new cases per day, according to Our World in Data.
“Because of their choice, unvaccinated individuals are responsible for most of the hospital isolation and [intensive care unit] beds, and disproportionately add to the pressure on our health care system,” said a spokesperson for the Ministry of Health.
Epidemiologists say they believe Singapore will be the first country to implement a policy to withdraw medical coverage for Covid-19 specifically for those who choose to go unvaccinated. Many public health experts in Singapore and abroad say the government’s decision is justified.
“They have tried everything. They gave information, they provided facts, they let people tell their personal stories, they saw the ministers get their shots, what else can we do?” said Hsien-Hsien Lei, chief executive officer of the American Chamber of Commerce in Singapore and an adjunct associate professor at the National University of Singapore’s Saw Swee Hock School of Public Health. “We can’t afford not to use every tool in our toolbox, even if there is some level of sticking to it.”
But some are against the policies in the tightly controlled city-state. Some residents say it’s coercive or it could increase transmission by discouraging unvaccinated people from seeking medical care.
“The basic principle of public health is to provide free treatment for highly communicable diseases,” said Paul Tambyah, chairman of a small opposition party, the Singapore Democratic Party. “This encourages people to come forward to be diagnosed and treated rather than staying in the community, where they can eventually spread the disease to even more people.”
Sabrina Chiu, a 47-year-old unvaccinated Singaporean, said the new policy was unfair. She said she has not been vaccinated because she is allergic to many drugs, although doctors have not told her not to take the shot. “It’s like indirectly forcing people to get vaccinated,” she said of government policy.
Ms. Chiu said the new rules would not convince her to get vaccinated, although she could see it convincing older people in a less secure financial position.
A doctor in Singapore, who has been vaccinated and does not want to be identified, said the policy was sending the wrong message. “The health care system should be there for everyone, not just those whose choices we endorse,” he said.
A spokesman for the Ministry of Health said the new policy “reflects a civic and moral duty each of us has to ourselves and those around us, in exceptional times such as a pandemic crisis.”
The spokesperson said unvaccinated people who get sick will still receive government support for treatment, even though the government will not automatically cover their full treatment costs for Covid-19 as it did before.
Hospital bills for Covid-19 patients in intensive care units receiving Covid-19 therapy often add up to about $18,000, according to the spokesperson. But the Department of Health says means-tested government grants for health care and the country’s national health insurance program would cover costs significantly and lower the bill to about $1,500 to $3,000 dollars. The government says patients can withdraw money from their national medical savings accounts to fund the rest. “They will receive the best possible medical care,” said the Health Ministry spokesman.
Arthur Caplan, founding chief of the Division of Medical Ethics at New York University Grossman School of Medicine, said he thought it was ethical to threaten not to cover the costs of Covid-19 as a way to encourage vaccination. That’s partly because he doubts the unvaccinated in Singapore will face medical foreclosures, given that it is a prosperous society and medical prices tend to be subdued. “Having said all that, it’s not the policy I would choose,” he said, adding that it would still be difficult for those who become seriously ill and have to pay big bills.
But some medical experts elsewhere are looking enviously at Singapore and wish their governments would adopt a similar policy to boost vaccination campaigns. “That would help a lot of people and save a lot of lives,” said Jin Dong-Yan, a professor of molecular virology at the University of Hong Kong.
write to Jon Emont at [email protected]
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