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No borders, no nations, no user charges

It was recently proposed that, here in the UK, foreigners should start having to pay towards their health care because of the apparent budgetary pressure from ‘health tourists’. Let’s be clear upfront; this isn’t a problem. If you believe the media, ‘health tourism’ costs the NHS around £30m per year. That’s less than 0.03% of the NHS budget. And the evidence suggests immigrants don’t use much health care anyway. Nevertheless, at some point in the future, this issue may really need addressing.

The case for treating everyone

The moral case seems obvious; everybody has an equal right to health care. If you think nobody has a right to health care, that’s fine too, but why should foreigners’ health be of less value? Economics, arguably, has a great cosmopolitan and egalitarian tradition. Most economists have been driven by their discipline to accept humans as being equal; even if they’re immigrants. This perspective, I suspect, extends to health economists in the UK.

The NHS constitution does not discriminate against foreigners, so it would presumably need changing if user charges for immigrants are introduced. It states that “public funds for healthcare will be devoted solely to the benefit of the people that the NHS serves“, but does not state who is included in “the people”. I’d like to think it includes anyone who happens to be within our borders at their time of need. Surely it should at least include NHS employees; many of whom are immigrants. If we decide not to treat foreigners for free it means that we do not value their health gains equal to ours. Indeed, the implication here is that any health care they receive is at the expense of a native. If this is the case then we health economists will need to adjust our cost-effectiveness analyses to shift any observed benefits for immigrants to the cost side of the equation.

I totally buy in to the moral case for open borders. It matters not to me whether you were born in England or not; nor does it matter to me whether or not you pay taxes. What’s more important to me is that you are willing to pay taxes, and I know plenty of born-and-bred Brits who would readily shirk their tax-paying responsibilities given the chance. For me an immigrant or a tourist has as much right to health care as an unemployed native. One cannot oppose treatment of immigrants on the grounds that they do not pay taxes without also opposing treatment for the unemployed. Case closed.

Moral arguments aside, plenty of services provided by the NHS also resemble public goods. The spread of infectious disease is an obvious risk of discouraging foreigners from seeking treatment. Furthermore, poor health may prevent or discourage immigrants from entering the labour market. It seems possible, if not likely, that charging immigrants a nominal fee for their health care would cost more than it saved. Hopefully we’ll see more evidence either way in the future.

The case against treating everyone

I can’t fathom a moral objection. Xenophobia might be to blame for the recent policy proposal, but I’ll leave it to others to try and figure out the moral arguments against treating everyone. Practically, however, and it pains me to say this, in the case of the NHS we could potentially have a problem. If a health care system is funded through national health insurance or taxation, the system can’t afford to insure the global population. Milton Friedman would probably agree on this point. The availability of welfare is likely to attract migrants who hope to receive it. Rational agents with health care needs would flock to the UK for treatment.

The budgetary pressure of ‘health tourists’, in the extreme, could dramatically reduce the average health expenditure per NHS patient. More care for ‘health tourists’ leads to less care for natives, and it seems difficult to justify reductions in the quality of care. Just to reiterate, this isn’t a problem right now. The tiny nugget of the budget that goes towards treating ‘health tourists’ does not jeopardise the quality of care provided by the NHS. I am speaking in hypothetical terms here of a situation which hopefully will never arise, but for which we should have a solution.

The solution

I don’t know. Obviously every country in the world should provide high quality universal health care that is free at the point of delivery; regardless of one’s nationality. This might happen some day. Let’s hope it does. In the meantime let’s stop legislating for problems that don’t yet exist.

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Angela Devine
Angela Devine
11 years ago


Thanks Chris for an interesting post. It looks like Rachael already addressed most of the points I was going to make (thanks Rachael!), but I have one more. As an immigrant, my employer pays for my visa and I would imagine (or at least I hope) that they would have to pay for my health insurance too. Universities employ a large proportion of international workers and are largely funded by government bodies, so I can see this becoming something where public funding is moving from one body (universities/research councils etc) to another (the NHS) in many settings.

Also, does this mean that I can stop paying my National Insurance? I don’t think I’m going to benefit from those payments (unless I stay in England the rest of my life) and I’ve yet to find a way to stop paying for it.

It’s already become very difficult for immigrants to get to or stay in the UK. I don’t think there’s a need for further barriers.

11 years ago

“Obviously every country in the world should provide high quality universal health care that is free at the point of delivery”
Obviously? Why?
I find it desirable that everybody could enjoy a high quality health care that is is affordable to her or him but why that health care should be FREE at the point of delivery and, more important, why should it be provided by the “country”.
Why don’t let everybody seek the quality, the universality and the affordability and let the market find the better solution(s)?

11 years ago

Thank you for the thought provoking post Chris. As an Aussie trying to scrape together enough money for her next Visa I obviously have a biased view on the issue.

Obviously, also as an Aussie I note the hypocrisy of pointing fingers at the UK about racist policies dressed up as logical, common sense. Compared to Australia this place is a free bar. I think it is important in analysing this policy though to remember how the NHS is financed. As you’ve pointed out Chris there is a strong moral feeling that everyone should have access to health care, regardless of their ability to pay. Because the people who use the most health care are the elderly and those from lower socio economic groups we get around this fact that by a means tested system of financing i.e. taxation. Other countries use a combination between private insurance for those that can afford it and publicly financed health care for those that can’t, but the UK has opted for this system, and so be it. Regardless, currently those who cost the most in the UK are those who don’t currently pay for it (but may well have done in the past).

The levy that the government is suggesting is being imposed on VISAs. Most VISAs are either working VISAs or student visas. Let’s leave the student issue aside for the moment, except to say that they use minimal health care and pay exorbitant fees to be able to study here. People on working VISAs pay taxes because, well, they work – it is as simple as that. And I agree with that. I’ve come to this country to live and work and I am happy to contribute to the society I live in.

So my problem is that basically I already am, and have been for the past 8 years, paying for the health care of others (I’ve been to the GP like twice). To levy a fee for a service I barely use and am already paying for, doesn’t seem to make sense.

The more interesting issue is people coming from developing countries who seek asylum or otherwise (I have to admit I’m ignorant as to the other VISA route for this group if they aren’t applying for working VISAs and if so, see above). These people are more likely to access health care services… than me. Evidence suggests that they don’t access it enough though and in fact I’m aware of research commissioned by the National Institute for Health Research trying to improve access particularly for those with communicable diseases as this is, obviously, a public health issue. I’m not sure the levy being proposed though is aimed at this group. Particularly if they are seeking asylum, the UK has an international, moral and human rights responsibility to take this group in, regardless of their ability to pay.

So from what I can figure out, the policy being proposed is yet another way for the government to “look like” they are doing something about the “immigration problem” and people who don’t pay their way, similar to the issue about people from the EU coming to the UK and claiming welfare (they don’t – excellent article about this here ). Oh, and at the moment, as noted in the Guardian article, immigrants and visitors don’t have free access to the NHS unless you have a VISA, and again we go back to the circulatory issue, those that currently pay taxes have access to the NHS, except students, but I’m pretty sure they aren’t here for health tourism. If they can afford the uni fees chances are they can afford some form of private health care back in their own country.

Sorry, I didn’t answer your original question Chris – yes I think everyone should have access to health care. Your question though about if immigrants should receive NHS care on the same terms as British citizens, I’m not sure. I think there should be some rules in place for those not working and on very short stays, as there already is, but I don’t think a levy is the right way around it.

Sam Watson
Sam Watson
11 years ago

If only political decisions were made on the basis of rounded, empirical arguments! Governments (particularly failing ones) are prone to scapegoat disenfranchised groups, in this case immigrants, but the poor and unemployed are other good examples.

I agree and believe that any ethical argument defending a position which denies foreigners care has to be grounded on the fact that foreigners are less deserving. That could either be due to a system where merit is based on contribution or a system where non-citizens have less intrinsic moral worth than citizens. The former case could be either due to absolute level of contributions, in which case the rich are more deserving than the poor, or due to a zero contributions/ any contributions threshold. The latter seems more likely. You could argue that buying things is a contribution (through VAT for example) but many would reject this. One solution could be to just ask foreigners for a small, nominal amount of money when they require care. But, if it were the case that the point of ethical significance was having made any contributions, then we should also ask the young and unemployed for money prior to treatment. The latter case where citizens have greater moral worth than non-citizens is clearly wrong and asking a doctor to treat these people differently is unfair.

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