Openomics 2018

National Therapy

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The promise and pitfalls of keeping India hale and hearty

AT ITS MOST primitive, the idea of pooling the risk of bodily harm borne by individuals goes a long way back, perhaps all the way back to early man’s first grunt issued in warning of a wild beast that drew a ring of weapons out in group defence. Trial-and- error is probably all it took to make safety in numbers apparent. The very origin of language, the great leap that’s reckoned to have expanded the human brain about 300 millennia ago, is traced by some anthropologists to the exigencies of pack survival. Synaptic sizzles set off by twists of the tongue marked an inflexion point in evolution. For the next significant shield against danger, though, mankind had to await the invention of the zero—and the mathematical conquest of risk.

Going by what’s verifiably on record— rather than, say, delusional posts on social media—modernity got its big break only in the Common Era’s migratory phase, once a variety of ideas began to span the globe and challenge one another. As Peter Bernstein notes in his 1996 classic, Against the Gods: The Remarkable Story of Risk, the great enabler was the Hindu-Arabic numeral system based on the concept of zero. Put into practical use by minds keen to crack puzzles of random events, it gave people an entirely new outlook on life. ‘The revolutionary idea that defines the boundary between modern times and the past is the mastery of risk: the notion that the future is more than a whim of the gods and that men and women are not passive before nature,’ he writes, ‘Until human beings discovered a way across that boundary, the future was a mirror of the past or the murky domain of oracles and soothsayers who held a monopoly over knowledge of anticipated events.’ From advances in numeracy across the Mediterranean to outcomes of dice rolls recorded by an Italian doctor called Cardano who liked to gamble, and from French theories of probability yielded by an interrupted gamble that got Pascal and Fermat scratching their heads to insurance deals struck at Lloyd’s cafe in London that tracked the odds of trade ships lost at sea, Bernstein’s book offers a fascinating account of how the modern economy drew upon diverse insights to emerge over the past couple of centuries or so.

While the word ‘risk’ itself comes from ‘risicare’, an Italian verb for ‘to dare’, the dreadfully derivative ‘Modicare’—as distinct from a multi-level marketing company modelled on Amway—that has gained media traction of late is derived directly from ‘Obamacare’, the former US president’s policy to get all American citizens covered by health insurance so that vulnerable folk like the poor and already-ailing would not find themselves locked out of a market where everything’s costly and getting costlier for the reason that the majority don’t have to pay their own bills (and thus feel no pinch), a market with prices more or less at the mercy of a grand bargain of profits shared by insurers and the healthcare industry. Of course, state intervention in any market attracts frowns in capitalist countries, and Obamacare faces a revolt in the US from those who don’t want the burden of other people’s health bills, but social precepts on the wisdom of everyone chipping in a little for the sake of the few struck with ill fortune have been around from time immemorial. Even the Code of Hammurabi that was etched out some 3,800 years ago spoke of compensation for strokes of bad luck. Other artefacts of antiquity found in various river basin zones suggest similar assurances made by the state. So integral has the concept of sharing threats been to civilisation that it’s a wonder that access to healthcare should remain so uneven in the 21st century. Yet, this is not only so, it is appallingly so in India.

Might Prime Minister Narendra Modi’s National Health Protection Scheme be the answer?

Under an ideal system, identity and income would be irrelevant to the ease of getting health services. It should offer access to everyone

Modi’s insurance scheme, proposed as part of the Union Budget for 2018-19 that goes into effect on April 1st, has attracted popular attention chiefly for being touted as ‘the world’s largest health protection plan’. If it works out, the scale of its coverage alone is expected to qualify it for that distinction. Funded by a Government subsidy, it aims to cover 100 million households—and thus 500 million individuals—that can’t afford to pay their own hospital bills. If that figure isn’t enough to stagger the most sober, what has dropped jaws is the annual limit of the grant: a generous Rs 5 lakh. This matches the coverage of yuppie policyholders, even those who admit themselves to posh hospitals without batting an eyelid. Granting multitudes of have-nots access to private healthcare is clearly part of the whole idea.

True to the Modi Government’s style, the big round figures could also be interpreted as an advertising device for the new scheme. In essence, after all, it’s a repackaged version of the Rashtriya Swasthya Bima Yojana that ended up in a whimper at least partly because of low enrolment, a failure traceable to high levels of apathy all around. The old Yojana was way too modest to make an impact, say analysts, but now that a far more dramatic proposal has been trumpeted, it’s that much easier for the Niti Aayog and Health Ministry to work something out that could achieve its aim. In its pre-rollout talks with insurers, the Niti Aayog has reportedly asked for the annual family premium to be kept under Rs 1,200. This is an impressively low sum, given that private coverage of Rs 5 lakh usually costs at least twice as much. It would have the advantage of keeping the government subsidy outlay down to just Rs 12,000 crore.

Such a strikingly low fiscal cost would assume the fulfilment of several conditions. First and foremost, it would call for almost full enrolment. As every insurer knows, it takes a vast spread of coverage for health afflictions to attain a low stable rate that allows the actuarial math to be done with accuracy, which in turn is necessary for the general pool of funds to pick up hospital tabs without logging losses. On this, India has always had an edge in theory that has gone wasted in practice all these decades. In recognition of the need for large numbers, the Health Ministry has proposed using eligibility criteria that goes by the database of India’s Socio- Economic Caste Census (SECC) to sign up most rural families, some urban ones dependent on low-wage jobs, and also all those who qualify on at least one of seven specific deprivation parameters. Apart from the insurance cards issued, Aadhaar would likely be the identity proof needed to claim benefits. Whether this approach will open the scheme up to half a billion of the country’s worst off is unclear at this juncture, given the complexity of the exercise and alleged infirmities of the SECC database. Eligibility has not been laid out yet.

Do private hospitals have what it would take to treat millions more armed with insurance cards? Not right now, but given a few years, demand could attract supply, with fresh facilities sprouting up

While public participation needs to be maximised, what needs to be minimised is a phenomenon called ‘adverse selection’, a classic problem insurers face in markets where the concept is a novelty. For the healthy multitude to look after the unhealthy few, the former need to sign up en masse, just in case they find themselves among the latter some day. In practice, however, medical insurance tends to attract mainly those with failing health. The rest need persuasion, a task compounded by a peculiarly Indian strain of fatalism that salesfolk say they encounter among have-nots.

Another headache of the business is what insurers call ‘moral hazard’, which refers to the needless use of a facility only because it exists. To take but one example, nearly half of urban India’s hospital births are now Caesarian sections, as surveys report, disproportionately high for the simple reason that health policyholders couldn’t be bothered by the extra cost these surgeries entail. In general, the scope for bill inflation is high in any market where the final cost bearer is not present on the scene and only specialists know what’s going on, but healthcare in India has all but acquired notoriety for it. Hospital regulations do exist, but regulatory scrutiny hardly goes beyond the most glaring cases of malpractice. Aware of how all this could send costs haywire, sources say the Health Ministry is toying with robust infotech systems to monitor and verify claims. As another safeguard, the list of medical interventions approved by the scheme is likely to be rather slim. The fineprint on exclusions may sound like a put-off to some, but analysts don’t see how else it could work without risking budgetary chaos.

THOSE WERE THE ‘ifs’. The big ‘but’ that the scheme is posed with is this: where are the doctors? In terms of overall capacity, the inadequacy of Indian healthcare is so stark that it risks turning into a national neurosis. The stress is apparent in the statistics. According to the Medical Council of India, the country has just over a million allopathic physicians, a ratio of about 0.75 for every 1,000 people, half of China’s and well below the WHO baseline of 1. Unless the dubious services of sundry ayurvedic practitioners are to be relied upon, that count cannot be raised at anything other than an organic pace. The hospital bed ratio isn’t much better. As for the public health network, what exists on the ground is too scanty to serve even as an apology for what exists on paper. Rural India is supposed to be served by a chain of nearly 200,000 primary clinics, but an estimated seven of every ten villagers who fall ill are carted off to the nearest urban centre for private consultation. While the Centre envisages 150,000 Wellness Centres being set up to address that gap, these will only offer basic services. Moreover, with its cover of Rs 5 lakh, the National Health Protection Scheme appears to endorse the country’s mass shift towards private sector care.

Do private hospitals have what it would take to treat millions more armed with insurance cards? Not right now, but given a few years, demand could attract supply, with fresh facilities sprouting up to make the most of a business opportunity. This is not only what the Government expects, it’s what ought to happen.

In the interim, there is reason to suspect that cynicism would need to be fought. For the poor, cashless care is of the essence. If insurer payouts prove too sticky or stingy, private hospitals might resist admitting the scheme’s cardholders. Most operate at full capacity anyway and are known to deny patients admission. Reports say far too many of the old Yojana’s beneficiaries found themselves turned away. In a country riddled with so many exclusion variables that go unstated, attitudinal shifts on identity would have to accompany any effort to open healthcare up to its most needy.

Tales of woe abound. The son of an ironing man who’d tried getting his ailing father into a private clinic in Gurugram last summer tells me he was daunted by the way the reception staff looked his rags up and down. ‘Shame shame, puppy shame,’ he reports, is what their expressions seemed to convey. He slunk away and took his father to a local vaid instead. Aware of Modi’s initiative, he is hopeful of a warmer welcome one day.

Under an ideal system, identity and income would both be irrelevant to the ease of getting health services, which in turn would call for an equal assurance to every individual. It would rid people not just of the need for any access card, but also the approval rigmarole that can get somewhat Kafkaesque even for the better off. For this to be financially feasible, though, both the economic pie and slice allotted by the state to health might need to double. If free treatment is restricted to general ward patients, as the Prime Minister’s Economic Advisory Council Chairman Bibek Debroy suggests, the state may be able to afford a universal system even now.

Either way, open healthcare ought to be the country’s goal. It’s a social instinct that evolved long before money, after all; perhaps even before language.