NEW DELHI — In October 2008, Henry Konczak went to get a blood test.
“I was getting short of breath,” says Konczak, a 65-year-old musician and video producer from Ohio. “All of a sudden they said, ‘Get to the hospital immediately.’”
Konczak had a blood infection and spent the next month receiving intravenous antibiotics, but his misfortune didn’t stop there. A doctor discovered that he had a heart murmur and would need surgery to replace his mitral valve. He called the nearby Cleveland Clinic to inquire about costs. The quote? A whopping $130,000, not including the surgeon’s fees.
Konczak says his insurance had been abruptly terminated when he turned 50 and he could not afford a replacement. When he heard the procedure price, he was shocked.
“I said, ‘I’ll send you my financials. I don’t make that kind of money,’” he recalls. “She said, ‘Well, good luck with that.’”
Facing a choice between bankruptcy and death, Konczak chose a third option: India. On Dec. 23, 2008, Konczak successfully underwent surgery at Indraprastha Apollo Hospital, a prominent private facility in New Delhi. The entire three-week trip — from flights to lodging to medical fees — cost $10,000.
“I saved my life, and I saved my business,” he says.
Konczak’s story may seem unorthodox, but he’s hardly alone. For Americans struggling to meet health care costs, medical tourism has become a surprisingly common choice. Estimating the number of medical tourists is tricky, but according to a government survey, more than 300,000 U.S. residents may go abroad each year for health care. There are many reasons why Americans travel for treatment, but the main one is money.
India is a particularly attractive choice for American patients, since it has a number of hospitals offering quality care from English-speaking professionals at affordable rates. Vinayak Shourie, the international marketing director at Fortis Healthcare, estimated that 20 percent of his company’s business comes from foreigners — and that figure is growing. India introduced medical visas in June 2005 to promote the industry, and it recently began allowing citizens of nearly 150 countries to apply entirely online. The tourism ministry issued more than 170,000 medical visas in 2016, a 45 percent increase over the previous year. It’s become a big business for the country, and business is booming.
But India also has one of the world’s most unequal health care systems. The gap between the services available to the wealthy and the poor is yawning, and roughly 86 percent of the rural population lacks health insurance.
“If you have a lot of money, you can access a lot of medical care,” says George Thomas, an orthopedic surgeon from Chennai, India. “On the other hand, very large numbers of people in India cannot access even basic health care.”
Medical tourism thus presents both opportunities and risks. At its best, the industry can help India grow its health care system, using the revenues generated from international patients to improve local care. At its worst, it risks shifting resources to private hospitals catering to elites at the expense of public institutions serving the poor.
“What’s the effect on health care for Indians? Here, the answer is the story is kind of messy,” says Glenn Cohen, a professor at Harvard Law School and an expert on medical tourism. “But there’s some reason to be concerned.”
I am a poster child for the quality of India’s top medical facilities. One month after moving to New Delhi, I started to feel lightheaded and dizzy while walking back from my Hindi class. Shortly after reaching my home, I collapsed, had a seizure, and was rushed by my roommate to the nearest emergency room.
After being discharged, I went to see a neurologist my friend recommended at Max Super Specialty Hospital, a well-regarded private institution. I was admitted for three days and underwent a battery of tests, none of which revealed anything serious. My stay — in a hotel-like private room with free meals and Wi-Fi — was comfortable. My total costs, before insurance, were $2,892.
This was a small fraction of the approximately $25,000 bill I could have been saddled with in the United States. Yet the average annual income in India is only about $1,600, meaning that for many, my medical expenses would have been more than a year’s worth of pay. That stays true if you subtract the roughly $250 extra the hospital charged me as an international patient. Eventually, my health care plan reimbursed me for the majority of my expenses. But most Indians don’t have any medical insurance.
The average Indian hospital, of course, is not nearly as pricey as the top-tier private institutions frequented by wealthy locals and medical tourists. The country’s central and state governments operate hospital networks, and they have enacted various programs to try to ensure that India’s poorer residents don’t have to pay at government facilities.
Public hospitals are overburdened and deficient, frequently producing stories about patients who suffer from medical malpractice. Recently, a government hospital in Uttar Pradesh — India’s most populous state — made international headlines after 63 people died in two days when the facility ran out of oxygen.
It’s therefore no surprise that Indians prefer private health care. A 2016 government report found that the country’s public facilities treated less than 30 percent of people’s illnesses. The preference is particularly stark in cities, where most of India’s high-quality private hospitals are located. Between 2004 and 2014, the public-to-private distribution of urban hospitalization cases shifted toward the latter by roughly 6 percent. But private health care is more expensive, and during the same period of time, the average amount spent on each urban hospital visit increased by approximately 176 percent.
For the industry’s proponents, medical tourism’s promise is this: My experience (and payments) can be channeled, redirected, and perhaps ultimately replicated for India’s less affluent, nonexpat communities. Some, for example, argue that medical tourism inspires Indian doctors to return home — reversing brain drain. Others say it improves services nationwide. Apollo Hospitals executive Preetha Reddy recently wrote that medical tourism helps “contribute to the objective of health for all.”
Josef Woodman, the CEO of Patients Beyond Borders, says the industry is pushing hospitals to seek international accreditation.
“When you get a JCI [Joint Commission International] that comes in and makes certain demands of the hospital, that’s a benchmark for the rest of the health care system,” he says.
But many academics are skeptical that the industry will improve things overall. Valorie Crooks, a health geographer at Simon Fraser University, says medical tourism’s potential spillover benefits were “mostly pie-in-the-sky things” for which there’s little evidence.
Crooks is determinedly nonpartisan in debates about whether medical tourism is, on the whole, good or bad. But she does maintain that any benefits for the local population require well-enforced redistribution.
“Where the benefit can be is in relation to the revenue and ensuring that the revenues that are brought in have some benefit, not just to that private institution but back into the public sector,” she says.
Deepanshu Mohan, a professor at the Jindal School of International Affairs who researches Indian health care, agrees.
“The distribution of the revenue that has accumulated in the private sector has to be worked out,” he says.
Mohan argues that after India’s economy opened up in the early 1990s, the amount of private health care spending shot up while public expenditures languished. The result, he says, is a staggering gap between the nation’s private hospitals and its government facilities.
To see what he meant, I visited the All India Institute of Medical Sciences (AIIMS), New Delhi’s most prominent public hospital. Constructed in 1956, the AIIMS campus is a collection of mostly brown, white, and green buildings packed with doctors, nurses, and medical students. Hundreds of patients and their families camp out on the surrounding lawns and walkways, waiting for treatment. Many have traveled hundreds of miles in hopes of receiving quality, affordable care.
Some are lucky to have reached AIIMS at all. Emergency medical services in India are far more fractured than in the United States or Europe, especially outside cities. Residents of rural regions may not know that ambulance systems exist, and those in need often have to wait long periods and travel substantial distances to find suitable doctors. It’s therefore no surprise that trauma victims in India are more than twice as likely to die as their counterparts in wealthy states.
Among those gathered outside AIIMS is Vishnu Dayal, a 32-year-old farmer who arrived at the hospital two days ago with his mother. She was suffering from bile duct stones — a painful condition that often requires surgery. Dayal had come from Pilibhit, a district roughly 150 miles away.
“Our district hospital is very bad,” he says, explaining why they chose an eight-hour bus ride over receiving local treatment. His criticism is indicative of Indian health care’s structural flaws. According to the Organisation of Pharmaceutical Producers of India, nearly 80 percent of Indian doctors work in urban areas, serving only 28 percent of the country’s population. Those who do practice outside cities are often dismally unqualified. A World Health Organization report released in 2016 found that only 18.8 percent of people working as doctors in rural India had medical credentials.
Like many of the other patients and attendants sprawled about the site, Dayal was living outside. He spent most of his waking hours sitting on a makeshift mat near the hospital’s central buildings. At 8 p.m., when the AIIMS grounds closed to nonpatients, Dayal packed up, left, and went to sleep on a nearby road.
Despite this, Dayal says he felt santusht (“satisfied”) with his experience. He had good reason. Dayal’s mother had to wait only one day before being admitted, a comparatively short period of time. There are reports of some AIIMS patients waiting months before starting treatment, even when suffering from potentially fatal ailments. Additionally, AIIMS doctors are highly regarded. There was a big gap between AIIMS and the smooth, five-star experience at top private facilities — but an even bigger one between the nation’s flagship public hospital and its desolate rural counterparts.
“It tells you a lot about the quality of medical resources in the area that he is coming from,” Mohan says. “You have a proliferating demand for medical services in cities because there’s a huge amount of migration coming from rural areas.”
Most of these deficiencies are related to low government spending. In 2014, roughly 1.4 percent of India’s public GDP expenditures went to health care, the 15th lowest in the world, and less than half the 3.3 percent of private GDP that was spent. The lack of financing shows. Many government hospitals — especially outside the biggest metropolises — lack critical technology such as ventilators, leading to needless deaths. Rural regions depend more heavily on government facilities and are therefore especially impacted by the lack of public resources.
This scarcity extends to doctors. The country has only one government physician for every 10,189 residents, and these practitioners work more but are paid less than their counterparts in the private sector. As a result, most doctors try to move into the lucrative private hospitals located in large cities. Some states are trying to make rural service compulsory for recent graduates of government medical schools. But the idea has received strong pushback from students, and these requirements can be poorly enforced. Physicians serving in public hospitals, for example, are known to open better-paying, time-consuming private practices on the side.
“Without an effective redistribution mechanism … doctors trained within India are more and more likely to migrate from the public health care system to the private health care system,” Mohan says. “The medical tourism industry may lead to an exacerbation.”
The government’s support for the private hospitals that take international patients is also worrying. India’s central government provides financial support to these institutions as part of its Marketing Development Assistance Scheme. Forty-three of New Delhi’s private hospitals received city land at concessional rates. The government made these discounts contingent on each hospital reserving 10 percent of inpatient and 25 percent of outpatient services for low-income individuals, free of cost.
Unfortunately, private hospitals often flout these rules. Last year, New Delhi’s government fined five of the largest institutions roughly $100 million for failing to treat the poor, including Max — the hospital where I received care. It wasn’t the first time the judiciary found that private medical facilities were ignoring state requirements. In 2009, the Delhi High Court fined Indraprastha Apollo Hospital — where Konczak was treated — for violating the terms of its land agreement.
In theory, these penalties may be significant enough to deter future violations (Max Healthcare reported approximately $400 million in gross revenue last year). But Rupa Chanda — an economist and health care expert at the Indian Institute of Management Bangalore — says between judicial delays and corruption, major hospitals could find ways to avoid the full cost.
“The influential will pay their money and get out of it,” she says. “These requirements are not working.”
An incomplete system that leaves millions of people uninsured. An enormous urban-rural divide. A government that indirectly subsidizes high-quality private facilities that many cannot afford. The more one looks at India’s medical system, the more it starts to look like the American one.
Even the stories of these countries’ underserved populations overlap. Dayal’s mother and Konczak were treated in dramatically different situations. But despite poor health, both spent hours traveling to New Delhi because the hospitals near their homes could or would not provide them with adequate care.
The comparison might be even more apt were it not for the Affordable Care Act (ACA), which extended health insurance to nearly 20 million people in the United States. According to experts like Cohen, that’s already leading to a decline in medical tourism, as more people find themselves with adequate coverage at home.
The tax bill that recently passed Congress, however, eliminates the ACA’s individual mandate, and the Congressional Budget Office estimates that the change will increase the number of uninsured Americans by 13 million. Experts say the rising number of uninsured people will, in turn, produce an upsurge in foreign health care travel.
Konczak is a good example of the ACA’s impact. After returning to the United Stats, he eventually managed to purchase “a little bit of insurance” — a $600-a-month major medical plan. Once the ACA was implemented, however, he used Ohio’s marketplace to buy more substantive and affordable insurance that he imagines would have enabled him to do valve replacement surgery much closer to home.
“My health insurance cost monthly went down to $130,” he says. “I almost cried.”
India has no ACA analogue, but its public hospital system was partially designed to provide less affluent residents with affordable and accessible treatment. Like the United States but unlike, say, Belgium or Slovenia, India’s constitution does not list health care as a fundamental right. But it does declare that the government shall regard raising “the standard of living of its people and the improvement of public health as among its primary duties.”
The medical tourism industry highlights these countries’ flaws, and it showcases some of the shortcomings of health care worldwide. Releasing the stress on fractured systems could help ensure a fairer distribution of resources. But it’s hard to see how moving patients to India’s overburdened system makes global health care any more just.
Issues of fairness weighed on Konczak during his trip. It’s nearly impossible to visit India without witnessing stark poverty, and even as he was lying in the ICU, Konczak says he was perturbed by what he saw.
But he didn’t go to India to save the world. He went to save his life.
“It bothered me,” Konczak says. “But also, I’m dying.”