I have been eager to learn more about health policy in Nepal. But tracking down good information about Nepal’s government has been surprisingly tough. In part, because I don’t speak Nepali. But also because little such information exists.
Nepal is currently transitioning to a federalist system from one dominated by a central government. Powers will be shared with local levels, like in the United States. But as far I — or anyone else here — can tell, the final product is a big question mark. It’s under wraps. The “transition” period is set to end when the new fiscal year starts in July. So whatever they’ve been planning, they’ll have to share it soon.
However it looks, though, the fledgling government has big ambitions. Sudim, a research intern at G.T.A., showed me the outlines of its plan for universal health insurance. The government intends to create a national single-payer, in a form blending those of Britain and Canada. The federal government will raise taxes on its citizens, more on the rich (it seems), fund a national insurance, and reimburse care in the existing system of public and private hospitals and clinics.
The current system is out-of-pocket. Health insurance does not exist, so people pay whatever the price is for services. As a result, many people cannot afford them. Some “essential” medicines and services are provided by the government for free, but insurance would make for more equitable care and better outcomes.
The insurance looks like it will have “packages” for different services. But many details are fuzzy, like the tax scheme. (The government website for it has mostly empty pages.) But the plan is a decade in the making, and the government has apparently already tested it in 25 districts. The big rollout is next. This means that Nepal could well beat the United States to a single-payer system. Yes.
This is inspiring. Single-payer care is our best bet for lower prices and equitable care, and many developed countries already have it. But if the prospect of a developing country’s tackling single-payer makes you suspicious, you’re not alone.
The two concerns that came to my mind were cost and political feasibility, which go hand-in-hand. If the plan costs too much, will people willingly pay for it?
Take America. We spend an insane amount of money on health care: about $9,500 per person in 2015. That’s well over 16 percent of our G.D.P., or one-sixth of the American economy.
Now, switching to single-payer care wouldn’t cost more. You already pay for insurance. It would just come from the government instead. There’s even good reason to expect a single-payer to lower medical costs.
But the harder part is politics. To fund the insurance, a national single-payer would mean raising taxes, and Americans hate nothing more than taxes. Our unwillingness to reform our ragged health care system suggests that we hate taxes even more than death itself. (And the possibility of more money in our pockets!)
In Nepal, however, these worries don’t seem as relevant. We might worry that the cost of a single-payer would overwhelm the government, but spending on health here is very low. How low? Only $44 per person in 2015, if you can believe that. (If we adjust for purchasing power parity in the United States, it’s about $130.) I estimate that that’s only around 6 percent of G.D.P. Remember: We’re at 16.
To be sure, when people get access to more services, we should expect them to spend more, at least in the short term. And Nepal’s health spending has, indeed, spiked in the last two decades. It was only $9 per person in 2000. But even if it doubled again, it would be just above the relative spending of most developed nations.
(Cost concerns could be further minimized if the government decides to cover only certain health problems or procedures with its “packages.”)
Alright, but how about political capital? Surely, people will riot from the tax hike! Well, maybe not. Nepal’s government has ballooned in spending in recent years, from somewhere in the neighborhood of 20 percent of G.D.P. in 2014 to about 40 percent last year. The United States spends about one-third.
In other words, Nepal’s government has doubled in size! This fiscal year, it spent $9 billion, or about $300 per person ($1000 adjusted for purchasing power). Covering all health care would mean raising government revenue by just 15 percent. Since Nepalis seem quite comfortable with increased government spending, after a 100 percent increase in just two years, what’s 15 percent more?
So this looks like smooth sailing, right? Welcome, single-payer!
Well, there’s one more thing.
A few weeks ago, I went to a dinner with Deepak, the president of G.T.A., and two businessman friends of his. Over spicy Newari food, named for an ethnic group in the Kathmandu Valley, we discussed government and politics. One businessman raised a concern that hadn’t occurred to me: that Nepal’s government has the reputation of being, er, less effective than it could be.
He expressed extreme cynicism about it, actually. The people don’t trust it, he said; they don’t expect it to advance the country. There are two major parties, Communist and Congress, but unlike the polarization that Americans have come to expect from our parties, these two are apparently quite similar — above all, in their reputation for misusing funds. Their positions on policy don’t matter, the businessman insisted, because their predilection for corruption overrides all else.
Due in part to this mistrust, at least two people have told me that many Nepalis don’t pay their income taxes regularly or fully.
Now, hold on, these descriptions may be overblown. That they’ve come even from the well-educated is concerning. But remember that the American government is, in the minds of many, a “deep state” of corruption and ineptitude. It’s not. And, of course, many Americans believe that tax fraud is rampant. It’s not.
But there’s one crucial difference: infrastructure. You can’t hide most money from the American government. The I.R.S. can and often does find it, and much revenue comes from alternate taxes. Such infrastructure is weaker in Nepal.
How do I know? At least one Nepali told me, explicitly, that he does not pay his income taxes. And yet, here he is, unconcerned about the consequences.
When someone tells you, point blank, that he doesn’t pay income taxes, it’s hard to be optimistic about everyone else’s paying their taxes. As a result, it’s much harder to trust that the government can collect the funds it needs for a national health insurance.
Can it do so? It’s certainly possible. Can it find alternate sources? Also possible. It could borrow. When the government doubled in size, its deficit jumped from 1 or 2 percent of G.D.P. to 6.4 percent. But that’s larger than the relative size of America’s. And while our government has a great credit rating, Nepal’s is unrated. What happens if its wells of foreign and domestic lending start running dry?
And let’s say that the government does pull off the political backflip of establishing single-payer care. If Nepal is anything like the United States, where tax fraud happens almost exclusively among the very rich, the system may find itself struggling to provide the equitable care that it promised.
Also, if you’re hoping that the partial rollout could shed some light, I haven’t found any documents in English on it. Maybe it’s going swimmingly. Maybe it’s not.
So will Nepal beat the U.S. to single-payer health care? Only time will tell. I’m rooting for them. Whatever the outcome, it is so refreshing to see a government working to implement ambitious, meaningful health policy.
Which brings me to my last question: Why can’t we? One of our parties is actively trying to dismantle our program for increasing access to health insurance and medical services. We’re moving backward. Imagine what it would be like to have a government that wanted to guarantee health care for all its citizens.
Nepal can. It does. And it’s inspiring.
I’m sorry. I promised a break from the American government. But I’m sorrier that a government with resources like ours isn’t as ambitious as Nepal’s.