The case against universal health care
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In a recent post Ms. Meena N Swamy made an extensive case for Universal Health Care. It defines in great detail the meaning, scope and the motives for Universal Health Care (UHC). Her argument in favour of UHC rests on three points which I shall paraphrase as follows:

  • Moral – “Can we as a society, be morally justified in rating our financial constraints higher than the livelihood of those who fall on hard times in spite of their best efforts?”
  • Economic – “Overall health of the society is a prerequisite for social stability. Health is highly correlated with economic status, and the unprecedented levels of economic inequality translate to lopsided and unstable growth of the society leading to chaos and unrest.”
  • iii. Financial Hardship -”Burgeoning treatment costs have meant that a single treatment can deal such a debilitating loss to an otherwise financially stable individual/family as to push them into poverty.”

I will begin my counter to the argument above with the following poser:

If you have Rs 1000, and there are ten individuals needing your care, nine of whom are starving but otherwise healthy, whereas the tenth has suffered a broken hand. Securing food for the ten and getting them to an employable state requires Rs 100 each, but the treatment of the tenth alone will cost Rs 900.

Are we morally justified in spending 9/10ths of our resources on treatment of an individual at the cost of getting 9 others to an employable (and subsequently self-sustained) state? Although I believe that we aren’t morally justified in making such a choice, I’d be willing to listen to an argument persuading me that we might in fact justified in doing so. If there was such an argument made by the author, it was not evident to me. However, I reject that notion, that our moral duty to provide treatment to this individual is self-evident.

Now, consider the third argument put forth by the author, that of financial hardship: I believe that high cost treatments are needed mostly for dangerous but rare diseases or common but not necessarily devastating disabilities. This assumption seems prima facie valid, as a disease that is both common and dangerous would wipe out large swathes of people akin to the black plague and it can be dealt as a special case outside the purview of UHC.

Thus, if a treatment is expensive enough to cause financial hardship, by nature it is rare. Utilizing a portion of our limited resources to supply expensive healthcare to an individual, at the cost of multiple others seems unjustified to me.


Figure 1: Causes of deaths in India: Total deaths are about 680 per 100k [1]

According to a World Health Organization (WHO) report [1] cardiovascular and infectious diseases, perinatal disorders and injuries as leading causes of unnatural deaths accounting to about 60% of the total deaths in a year. However, the total deaths are a miniscule 0.7% of the total population. To include the effect of diseases on quality of living, WHO uses Disability adjusted Life Years (DALY) – which surprisingly uses Japan’s Life expectancy as the baseline and not individual countries’ average life expectancies- which is estimated at about 300 million years.

The proportion of “preventable” afflictions (based on hygiene, knowledge, diet etc) is not well documented [2], but reports indicate the burden contributed directly by lifestyle choices (diet, and exercise) is close to 20% [1]. In addition, they may also contribute to other risk factors which are separately evaluated like High blood pressure, cholesterol levels etc.

Now compare that burden with the burden of poverty – a whopping 32.7% of our population remains below international poverty line [3] ($1.25/day adjusted to PPP) and as much as 68% of our population remains below $2 per day (adjusted to PPP). This amounts to about 680 millions who suffer from poverty every day. Should we account for their suffering throughout their lives, this number undoubtedly dwarfs even the sympathetic DALY estimate that is used to tout UHC.

Thus, we can make a fair utilitarian argument that the same funds to be used in providing UHC are better served at improving standard of living for the 68% of our population. In addition, far better improvements in societal health can be achieved by focusing on basics such as education (of diseases and ways to prevent them) and sanitation, rather than on health care devoted to treatment.

Please note that I did not set out to make an argument against UHC in all cases, but have limited my argument to the state India is in. Perhaps rich, developed nation states may be able to provide free health care to all its residents. But, that is not a position I am trying to debate. UHC is a luxury for the rich, the poor cannot afford4.

  4. With apologies to the author of the original quote (I couldn’t locate the source unfortunately) “Socialism is a luxury for the rich, the poor cannot afford”.