Paper short abstract:

I aim to bring fresh insights on healthcare access for India’s uninsured 'missing middle,' focusing on chronic disease and provider choice. By sharing findings on affordability, equity, and policy gaps, I hope to spark discussions on strengthening UHC frameworks in fragmented mixed health systems.

Paper long abstract:

This study posits implications on health, equity, and policy by investigating healthcare provider choice among India’s "missing middle," a population excluded from both public health insurance schemes and employer-based coverage. Chronic diseases—requiring long-term care and risking significant financial burdens—pose a critical challenge to this group, raising broader questions about healthcare equity and state accountability. Two hypotheses are examined: (1) chronic diseases drive private healthcare utilization due to perceived quality disparities, and (2) disease severity shifts preferences toward public care as affordability becomes a decisive factor. The study uses data from the National Sample Survey (2017–18) to analyse healthcare access among those suffering from chronic diseases. Using the linear probability model with fixed effects, findings reveal that chronic diseases show increased public care utilization with reduced private care preference. Additionally, disease severity significantly reduces private care choice, underscoring financial vulnerabilities linked to chronic disease and seeking private care. These insights are pivotal for global debates on universal health coverage (UHC). India’s fragmented healthcare landscape reflects broader tensions between privatization and state obligations. Extending government health insurance to the missing middle and strengthening public health systems are essential for fostering inclusive development, that provides health as a human right.