If you’re not port-forwarding, only peers that are port-forwarding can download from you. And you can only download from peers that are port-forwarding. There can be times where a torrent only has a few seeders, but they are not port-forwarding, and if you’re not either, you won’t be able to download the torrent.

Also if they can’t afford that, surely they have state medical insurance

Ha! No, depending on the state, there are tons of barriers, means-testing, work requirements, mandated classes they might not be able to attend (due to childcare/lack of transportation), etc.

Even after the ACA, ER visits are still all the healthcare many people get.