The trouble with Modicare
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On 23 September, India’s populist BJP government introduced the world’s biggest-ever health insurance scheme to much fanfare.
Dubbed ‘Modicare’ after Prime Minister Narendra Modi, it promises free cover – ‘Ayushman Bharat’ in Hindi – to between 100 and 500 million people. The state is implementing this alongside ‘Swasth Nagrik Abhiyan – a ‘social movement for health’ that means people stay healthy and rely less on hospital care.
Sounds great – on the face of it. Social media-savvy Modi has even made a cartoon YouTube video 'Yoga with Modi' to explain his vision of ‘a social movement for health’. But Modicare has been widely criticized. One complaint is that the scheme simply repackages existing initiatives, which now have a higher insurance ceiling that will benefit the private sector.
Another is that under Modicare, the government has invited private companies to develop primary-care services, as neglected public health services deteriorate due to a lack of resources. The national insurance scheme appears to me be more geared at creating openings for the private sector than any genuine attempt to establish universal healthcare coverage.
Modicare is just one example of a private healthcare initiative that uses a particular rhetoric espousing supposedly ethical and social values. This new narrative of justice and fairness marks a step change. For many years, privatization has been promoted to the public by emphasizing ‘enterprise and efficiency’.
But in the emotive field of healthcare, these values proved to be a more difficult sell than other sectors. Now, corporations – in collaboration with complicit governments – are reframing their messaging to make private health services more acceptable to the public. This includes – but is not limited to – co-opting the language of social movements.
Take the core aim of Modi’s Swasth Nagrik Abhiyan ‘social movement for health’. It does have some admirable objectives such as the promotion of quitting smoking, a healthy diet, and eliminating open defecation. And of course it’s desirable for people to ‘stay healthy and rely less on hospital care’ – sounds like a no-brainer.
But when you look more closely, it appears to be a strategy to promote more atomized, profit-friendly solutions that make use of de-skilled clinical staff, volunteers and low-cost tech solutions. And a distraction from government failings to invest in the public health system. The truth is, India needs more hospital beds – not less.
The same can be said for Britain – the rhetoric of NHS England bears striking similarities to that of Modicare. NHS England has commissioned a Five Year Forward View (FYFV) plan, which draws from reports co-authored by the World Economic Forum and management consultants McKinsey (who are, incidentally, openly enthused by the business opportunities presented by Modicare).
The plan crafts a story about ‘communities’, ‘care closer to home’ and positions the NHS ‘as a social movement’. Woven into these friendly sounding aims are recommendations that primary-care services work towards fixed per-capita budget insurance models, which restrict patient care and work along the lines of the Accountable Care Organisations used by the national health insurance programme Medicare in the US. Make no mistake: these models – which we are currently challenging in the UK courts – pave the way for further corporate takeover of health services in England.
NHS England has done a good job of window dressing this plan by commissioning the progressive New Economics Foundation (NEF) and the Royal Society of the Arts (RSA) to develop the idea of health as a social movement. Their evaluation report puts an emphasis on ‘community and personal resilience’, and peoples’ abilities to ‘better help themselves and others to stay well, get ill less often and for shorter periods of time’.
Neither the RSA nor NEF advocate for privatization of the NHS. An RSA spokesman said it is concerned with ‘how the NHS can genuinely improve patients’ outcomes through better engagement with patients’ groups and the local community’ while, in a similar vein, NEF say their involvement was motivated by the need for communities ‘to build their power and take action on what matters to them’ to improve health outcomes.
But I believe both groups have fundamentally misunderstood the impact that the Five Year plan will have. A focus on behaviours and individual choices unwittingly supports a shift in responsibility for health and social-care away from the state towards individuals and the voluntary sector that is being advocated by those who would remodel the NHS along neoliberal lines.
In India, a grassroots-led movement for health, such as India’s Jan Swasthya Abhiyan (JSA) a coalition of civil-society networks that forms part of the global People’s Health Movement, has different goals from Modi’s government. The JSA questions why Modicare equates health care with insurance and not public health services. It says it would prefer the prioritization of a publicly-run health system, with reach in rural areas, and genuine efforts to address the wider social determinants of health.
In terms of the latter, the JSA’s principal concerns are the health impacts of ‘enduring poverty with all its facets’ and ‘the resurgence of communicable diseases including the HIV/AIDS epidemic’. In a similar vein, in the UK, The Marmot Review, an extensive report analysing health inequalities in the UK, recommended improving prenatal and early years provision, better drug addiction treatment and raising social security payments.
In other words, as the wealth of evidence suggests, the health of society’s poor and vulnerable can only be effectively addressed at a structural level by the state, a solution that is antithetical to the ideology of neoliberalism that permeates the privatization agenda.
The rhetoric and realities of Modicare and NHS England are instructive. In the fight for universal healthcare systems, flashy headline offers and buzzwords must be subject to careful examination, and the implications – how these policies are likely to pan out in practice – explored and disseminated. Policies that sound positive to the public may be a misleading representation of profit-focused models that are not in the best interests of patients.