India has the largest number of poor in the world, and also one of the world’s most privatised healthcare systems. The country’s state and central governments together spend no more than 1.15% of GDP on healthcare, much lower than low-income countries (forget OECD countries that spend 6% at least). During a pandemic like COVID-19, one would have thought the central government would begin to implement its own National Health Policy commitment to raise public health expenditure to 2.5% of GDP by 2022 (instead of 2025, as the NHP promised). However, far from it, even the stimulus package has nothing for public health (except Rs 15,000 crore for PPEs, testing, etc).This begs the question: if governments are so dependent upon the private sector, does it have any recourse when practices turn unethical or greed takes an unhealthy hold? Sadly, in most of India, neither the centre nor states (and hence citizens) have any recourse against such greed – out of choice or under private pressure, it seems. Healthcare is under the State List in the Constitution, and only 11 of India’s states and all UTs (except Delhi) have enacted The Clinical Establishments (Registration & Regulation) Act, 2010 (henceforth CEA, 2010). As per the Clinical Establishments (Central Government) Rules 2012, under the abovementioned Act, The clinical establishments shall display the rates charged for each type of services provided and facilities available at a conspicuous place. But not many in Delhi do that. Would you buy a fridge if you don’t know its price in advance?The clinical establishments shall charge the rates for each type of procedure within the range of rates issued by the Central Government in consultation with State Governments. Compliance to standard shall ensure that unnecessary operations are avoided. But many private hospitals provide and charge as they please.Cancellation of registration, would occur at any time, if conditions for registration are not complied with. But if the law is not in place in most States of India, there is no fear of cancellation facing hospitals/providers.What is the result for patients when there is no CEA in a state? Let us give a concrete example from our lives in October 2020 – what happened to my son-in-law and his medical insurance company – over a 15-day stay at Max Super Specialty Hospital in Saket, Delhi. Also read: India’s Healthcare Should Not Go Down the Dangerous US Model PathAfter contracting dengue fever, which was spiking in Delhi due to the absence of spraying against mosquitoes in Covid times, his platelet count fell from 163,000—the bottom end of normal–to 10,000. He developed a hemorrhagic rash and bled from the tongue at which point we went straight to Emergency (Max Saket). After 23 chaotic hours in the emergency ward, where he received two transfusions, his platelets fell again to 2,000 and he was admitted to the ICU. We were informed there were no spare beds due to the 80% of beds allocation for COVID-19 that the Delhi government was trying to impose on private hospitals. In the intensive care unit (ICU), doctors suspected that he had a condition called Immuno Thrombocytopenia Purpura (ITP), which is when the immune system attacks red blood cells after entering the bloodstream from the bone marrow. A biopsy of the marrow was done and A+ blood donors sought through family and friends. Several kind souls volunteered to donate, and a transfusion helped take his platelet count up from 15,000 to 85,000. We were elated. However, subsequent blood tests showed a declining trend. At this point, he had been hospitalised for nine days, all spent in the ICU. His insurance company requested medical justification for this. They had been given estimates and had approved expenditure of a few lakhs of rupees but the running bill at the hospital climbed to Rs 7,74,214 by October 5. The room rent of Rs 22,500 per night was twice the cost of an executive suite at the Taj Hotel.Since steroids and other medication had not worked, there was a change of treatment to intravenous immunoglobulin IVIG, a kind of plasma. In two days, his system responded and his platelet count thankfully rose to 160,000. The bill over the same two days had rocketed to Rs 13,05,092. How could this be, the insurance company asked? The cost of the IVIG was Rs 3 lakh. Everything was itemised down to each tablet—Rs 1.53 for folic acid and Rs 1.50 for an antibiotic. We noticed there were five different consultants billing Rs 1,650 each with three to four consultants billing each and every day! One consultant showed up on the bill 14 times, yet showed up at the patient’s bedside just once. Aside from the extortionate room rent, there was a mysterious one-off charge entitled ‘Medical Supervision’ — this was item 560 on a bill with 580 items on it. Medical Supervision was Rs 199,706. The insurance company flatly refused to authorise it and haggled with the hospital on everything it felt was overcharged. This resulted in a reduced bill of Rs 11,25,080 of which the insurance company agreed to cover Rs 9,56,756. ‘Medical Supervision’, still unexplained with no breakdown given, was shifted to a list of costs that the patient would have to pay. Also read: Does India Need a Digital Health Mission?We demanded a breakdown of the ‘Medical Supervision’ component which had been reduced to a one-off lump sum of Rs 1,10,000 since the Insurance company had queried it. Even after a meeting of the hospital finance department, we were told that no breakdown could be provided so we were left with no option but to pay up and go home. We complained bitterly at the high-handed manner in which the bill was presented without justification. We pointed out the number of consultants billing for the same advice and the one that had billed 14 times. We got nowhere. However, sadly, the private healthcare system is designed to fleece individuals and insurance companies alike with impunity, emboldened and encouraged by the sheer lack of accountability or any redress in these desperate times. Several questions arise from the perspective of citizens. First, why have only 11 states passed the CEA? Why is Delhi, the only UT that has not adopted the CEA (the Delhi Health Bill 2019 on the subject is pending, with Covid raging)? Are states that enacted the law, actually implementing it, or succumbing to private provider pressure? Finally, what sense of responsibility should corporate and for-profit health providers have at a time of national crisis? Santosh Mehrotra is a human development economist, and a former Secretary, Government of India. Michael Ward is a writer, lyricist and film producer.