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On Monday, Singapore announced that it would extend its free COVID-19 health care services only to vaccinated individuals, arguing that unvaccinated patients are straining the country’s hospital systems.

“Unvaccinated persons make up a sizable majority of those who require intensive inpatient care, and disproportionately contribute to the strain on our health care resources,” Ong Ye Kung, Singapore’s minister of health, said at a press conference on Monday.

Singapore has a universal but privatized health care system, with the government providing a sliding scale of subsidies for health care costs based on income levels. For COVID-19, Singapore made an exception, footing the bill for all medical costs related to COVID-19.

In effect, the new policy will force unvaccinated Singaporeans to bear the costs of health care as they would with any other non–COVID-19-related health condition.

But Singapore also said its new policy will apply only to those who are “unvaccinated by choice,” meaning children younger than 12 and those who are exempt from vaccination for medical reasons will still be able to access free COVID-19 treatment.

The new policy has divided health experts, with some arguing that it is wrong to deny patients free health care on any basis. Others say that Singapore is simply cutting out a COVID-19–related perk to those who are not willing to get vaccinated.

Singapore uses a financing system (medical savings accounts) that under normal circumstances requires people to pay out of pocket for their own care so in some ways this is mainly defaulting back to old system. But agree, still raises issues of equity. https://t.co/6Bhno9vv0k
— Dr. Karen Grépin (@KarenGrepin) November 9, 2021

Singapore’s unvaccinated population is small. The city-state reports that 85% of its population is fully vaccinated; 18% have received a booster dose.

The health care announcement comes as Singapore’s recent surge of infections appears to be tapering off. Singapore has recorded roughly 2,851 new COVID-19 cases per day in the past week, compared with averaging over 3,700 cases per day two weeks ago. According to government data, the vast majority of infections, 98.7%, are mild or asymptomatic cases, thanks in large part to the city’s high vaccination rate.

But Singapore’s recent COVID-19 surge has strained the city’s health resources. Singapore has recorded 358 deaths in the past month, representing 70% of the 511 COVID-19–related deaths it has logged since the beginning of the pandemic. Singapore reported on Monday that 68.5% of the city’s intensive care units (ICUs) are occupied by COVID-19 patients and unvaccinated individuals make up a disproportionate number of those beds.

Singapore reports that 5.2 out of every 100,000 unvaccinated people are critically ill or intubated in ICUs owing to COVID, compared with 0.5 out of every 100,000 fully vaccinated people.

The city-state is one of the former “COVID zero” countries that had no tolerance for any cases early in the pandemic. But now it’s employing a two-pronged strategy to live with COVID: reopening quarantine-free travel from countries like the U.S. while maintaining social distancing restrictions, like five-person limits at indoor restaurants, to keep cases down.

Singaporean officials say that getting vaccinated remains the best way for the country to fully get back to normal, and they consider free health care an incentive that might convince holdouts.

“Our hospitals really much prefer not to have to bill these patients at all, but we have to send this important signal, to urge everyone to get vaccinated if you are eligible,” Ong said Monday.