People who choose not to get vaccinated shouldn't have to pay for COVID care in hospital

When I went out in Melbourne for a coffee with a friend earlier this week, the waiter verified my vaccination status before allowing me to sit down. But for the unvaccinated in Victoria, New South Wales, and the ACT, it’s a case of no clubbing, no coffee catch-ups, no movies.

Many employers have even gone beyond the government-mandated minimum and required all staff to be vaccinated as part of ensuring a safe workplace.

These mandates are designed to reduce the number of COVID-19 outbreaks and their consequences as Australia’s “lockdown states” open up. Introducing different rules for the vaccinated and the unvaccinated also gives people an incentive to get vaccinated as soon as possible.

Singapore went a step further this week, announcing people who are unvaccinated by choice will have to pay for their own health care.

This isn’t the right way to encourage vaccination, and shouldn’t be replicated in Australia.

What if an unvaccinated Singaporean gets COVID?

Singapore has a complicated system of health insurance which includes “medical savings accounts” from which people can pay for their health care and keep the balance for distribution to their estate when they die.

Read more: Creating a better health system: lessons from Singapore

Under the new policy, unvaccinated Singaporeans will still get care, but could be substantially out-of-pocket when or if they recover. COVID-related hospital care can be expensive and so could easily wipe out a medical savings account balance.

Singapore’s new policy is implemented with the best intentions – to reduce demand on a stretched health system by reducing the number of avoidable hospital admissions among the unvaccinated.

Why some are calling for us to follow Singapore’s lead

Despite high rates of vaccination in Australia (more than 80% of over-16s are double-dose vaccinated) and COVID cases trending down, hospitals in NSW, Victoria, and the ACT are still under pressure.

And even though the unvaccinated are only a small proportion of the population in those jurisdictions, almost everyone with COVID in an intensive care unit bed is unvaccinated.

Former NSW premier Bob Carr endorsed the Singaporean approach and called for Australia to follow suit.

Others have hopped on the bandwagon. I strongly disagree.

The importance of universal coverage – for everyone

Australia’s Medicare system provides universal coverage for medical and public hospital care. It’s not a system just for the poor, or just for the well-behaved. It promotes social solidarity.

Widespread vaccination was always going to be the best way out of lockdowns and the path to reopening Australian and state borders. Grattan Institute’s Race to 80 report supported vaccine passports and other strategies to encourage vaccination. But how far should these nudges to increase vaccination rates go?

Undermining Medicare’s universality – by excluding the unvaccinated from its financial protection – is a bridge too far.

Sure, I think anti-vaxxers should know better; their vaccination status poses a risk to themselves and all of us.

But the Singaporean policy statement has hidden in it the root of the problem – it is targeted at those who are unvaccinated by choice.

The evidence shows vaccination in Australia – like other aspects of health care – suffers from a distinct social gradient. Poorer people and those less well educated have lower rates of vaccination.

This may be because their lives are less well organised, and they can’t take time off from precarious employment to get vaccinated. It may be they are more susceptible to misinformation campaigns.

Whatever the case, their “choice” may not be a fully informed and freely made one.

Read more: Just the facts, or more detail? To battle vaccine hesitancy, the messaging has to be just right

Failures in the government’s vaccination program

Penalising unvaccinated Australians by excluding them from Medicare would be a convenient way of shifting responsibility on to individuals for government failures.

Early on, the federal government did not make vaccination easy to get. And the government has failed to ensure the whole population has all the information it needs to make good vaccination decisions.

If the unvaccinated were barred from Medicare, these government failures would magically become a problem for a small number of individuals, and no longer a political failure.

If we exclude unvaccinated people, where to next?

If we exclude the unvaccinated from Medicare’s protection today, tomorrow we might exclude the smoker, the day after the drinker, or the person who did not go out jogging, or has not taken up private health insurance.

Hospital emergency department staff regularly have to care for a drink driver and their victim on the same day. They have an ethical obligation to treat everybody equally. Similarly, as frustrating as it might seem, the health system must still be there for the unvaccinated.

The health system needs to be there for everyone, not just people who look like us, nor just for people we like, nor just for people whose choices we endorse.

Nudges to encourage people to get vaccinated are good public policy. But if they undermine the universality of health care, these well-intentioned policies would cause more harm than good.