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.

What do you think? Vote in the poll and share your thoughts in the comments box below