Two years ago, Kabita Kanhar delivered a baby girl but couldn’t pay her medical bill.
The hospital in Choudwar, India, quickly discharged her.
Without her baby.
They told her she’d get her child after she paid.
When she returned the next day with the money, hospital officials at first said they couldn’t find her child, according to news reports.
Local authorities proceeded to launch an investigation.
The story is an example of a well-known problem in India.
This isn’t the only story of money and healthcare in India.
This summer, more than 60 children died within five days at a large public hospital serving the poor in Gorakhpur, in the state of Uttar Pradesh.
Most of the babies died because Uttar Pradesh officials failed to pay a company supplying the hospital with oxygen for its intensive care ward.
Uttar Pradesh, which has about the same population as Brazil, suffers from one of India’s highest infant mortality rates.
India’s economy is booming, but the benefits are going heavily to the rich.
According to French research published in September, the share of national income held by people in the top 1 percent of earnings is now 22 percent, slightly higher than it was when the British first established an income tax in 1922.
“Third world problems,” Americans might think.
Yet the figure is the same in the United States, using similar calculations.
The United States and India have something else in common: a complex mix of public and private healthcare and insurance.
And both score low on standard measures of health, compared to similar countries.
A pivotal moment
Healthcare is at a crossroads both here and in India.
India is moving toward making healthcare more available.
In March, it approved a new national policy that aims to cut out-of-pocket spending and bring everyone free essential drugs, tests, and emergency services in public hospitals.
The government already caps costs for certain drugs.
India also proposed to increase public spending on health.
In the United States, Congress spent the year stalemated over a series of health insurance proposals.
The 20-year-old Children’s Health Insurance Program (CHIP) awaits reauthorization.
Various Republican healthcare plans include sharp cuts to Medicaid and proposals to give states more options on how to spend federal money.
“The biggest challenge for both India and the United States is their shared view [from government to practitioners to patients] that health care is an ‘industry’ rather than an ‘entitlement,’” Vikram Patel, a psychiatrist and professor of public health at Harvard Medical School, told Healthline. “This is what sets them apart from their peers: The United Kingdom or Canada for the United States, and China and Brazil for India.”
Healthcare as big business
In these two large democracies, well-paid doctors, hospitals, insurance companies, and drug companies lobby politicians for policies that serve them.
In both countries, you can get world-class treatment.
But in India as well as the United States, patients too often get unnecessary surgeries, tests, and other treatments that benefit private providers, said Sakthivel Selvaraj, an expert on health financing at the Public Health Foundation of India.
Take cesarean deliveries (C-sections), the most common major surgery in the United States.
Almost half are unnecessary and undesirable, observers said. They complicate future pregnancies and can lead to infection.
What factor has the most impact on whether you get a cesarean delivery for a low-risk delivery? According to Consumer Reports, it’s the hospital you choose.
Hospitals make all the difference in India, too.
Some 15 to 19 percent of deliveries do require cesarean delivery, experts have said. But in India’s private hospitals, cesarean delivery rates are higher than 20 percent in nearly 85 percent of the nation’s districts.
The rates are lower and vary more in public hospitals. In some poorer areas, they’re less than 5 percent.
Who pays for healthcare?
Around the world, people in the poorest nations pay out of pocket or go without care.
In India, 65 percent of the country’s healthcare spending in the years from 1995 through 2014 came out of personal budgets, according to a study published in April.
Most of that money went to drugs.
In China, by contrast, out-of-pocket expenses ran less than 35 percent.
In richer countries, more costs are covered by the government or insurance.
Out-of-pocket costs over that period were around 11 percent in the United States and 6.5 percent in France.
Without outside help, any significant illness can ruin a family.
Medical costs pushed 50 million Indians back into poverty in the 10 years from 2004 to 2014, reported IndiaSpend,a nonprofit data-driven publication.
In the state of Haryana, for example, about 30 percent of households run into catastrophic health expenditures. In the poorest fifth, it’s 38 percent.
Haryana is one of India’s richest states, although it contains pockets of poverty.
Insurance hasn’t filled that gap.
Rashtriya Swasthya Bima Yojana (RSBY), India’s version of Medicaid, was launched as an “experiment” in 2008. It covers only hospital care.
But non-hospital costs account for most of the medical expenses borne by the poor.
“Outpatient care and pharmaceutical costs are the primary reason for healthcare-related impoverishment,” Patel told Healthline.
Even when it comes to hospital care, RSBY has been inadequate.
It pays only up to a cap, which remained the same while hospital costs rose.
One study found that in 2010 to 2011 in the Patan district of Gujarat, 44 percent of patients presenting their insurance card still had to pay out-of-pocket costs to the hospital.
The program has also had implementation problems, including misbehavior by providers. Participating hospitals may be turning these patients away or asking them to pay for drugs and tests while in the hospital — even though those services should have been covered.
Many poor people, as much as a third, don’t even know about the program.
What Americans can learn from India
Republicans in Congress have been looking for ways to give states more choices about how they use federal funds for health.
As it is, state-run Medicaid programs aren’t equally generous and 19 states, including nearly all of the relatively poor South, opted against expanding Medicaid under the Affordable Care Act.
Indians also debate how much power the central government should have over healthcare, noted K. Sujatha Rao, a former secretary of health and human welfare.
The public health system is now run largely by India’s 28 states and seven territories. The differences among them can be stark.
Goa, a state with less than 1 percent of the population of Uttar Pradesh, spends five times more per person on health.
Three states opted out of RSBY entirely or in part because they have their own more generous insurance.
Uttar Pradesh, on the other hand, didn’t do much to sign people up.
Enrollment varies from single-digits in parts of Uttar Pradesh to nearly 90 percent in many districts of Chhattisgarh and Kerala, as of September 2016.
The state’s politics are considered a bellwether for the nation as a whole.
A factor is the diversity in the population: Higher castes make up around 20 percent, balanced by the “backward caste” Yadavs (8 percent) and the “untouchable” Jatavs (11 percent).
The lesson for the United States may lie in the fact that Medicaid expansion disproportionally benefits non-whites.
India’s example can also teach Americans about partial insurance policies.
Republicans in Congress are drawn to giving individuals more choice in private “catastrophic” plans.
Proposals for a single national plan to cover “catastrophic” expenses have also been floated here.
India’s example shows in big red letters that if key costs aren’t covered — particularly prescriptions — partial insurance doesn’t prevent financial distress.
In Vietnam, by contrast, a government-run health insurance policy began covering non-hospital costs alongside inpatient costs in 2002.
The change led to lower out-of-pocket expenditure and fewer days of missed school and work.
The fate of mothers and children
Congress is looking at cuts to Medicaid in order to cut taxes.
In many states, Medicaid pays for most births. Hospitals already say that the program isn’t paying enough — warning that they’ll need to favor patients with better insurance.
Will birth become a catastrophic expense here — as in India?
Will we read ugly stories of children dying in hospitals in large states with many uninsured people?
The bottom line: American healthcare for the poor may become more like India’s.