A recent parliamentary panel report has suggested an array of doable measures to help make the Central flagship health insurance scheme achieve the ultimate goal of Universal Health Coverage (UHC). ARCHANA JYOTI shares details

The panel’s suggestion to widen the ambit of the Ayushman Bharat Pradhan Mantri Jan Arogya Yojana (AB-PMJAY) to cover lower middle-income group who fall under the Above Poverty Line (APL) category, just above the poverty line but are in dire need of funds, stems from the fact that the financial burden of diseases leads to cross the poverty line.

Many senior citizens residing in places like shelter homes and old age homes do not fall under the BPL  and face financial problems while availing treatments. Their inclusion in the scheme would help them access affordable and quality treatment, said the panel in its 151st report which was tabled recently in Rajya Sabha.

Under AB-PMJAY  the government provides the benefit of cashless hospitalisation for secondary and tertiary care to nearly 10 crore families or 50 crore beneficiaries, identified based on their socio-economic background.

The  parliamentary standing committee on health and family welfare also suggested the government expand the scope of the scheme to include some sections of children and senior citizens, who may not have health insurance and fall in the Above Poverty Line (APL) category.

The panel has cited a document by NITI Aayog, ‘Health Insurance for India’s Missing Middle’, which suggests that even after the implementation of the PMJAY, at least 30 per cent of Indians (more than 40 crore) still lack any form of health cover.

Adverse health events can lead to financial hardship and even push them into poverty, the report said, adding that this group of Indians is characterised by informal employment, unstable incomes, and a lack of social security.

As per the Economic Survey 2022-23, almost half of all health spending in India is still paid by patients themselves directly at the point of treatment, although this has dropped as the government’s share of spending on health went up significantly after 2013-14.

In fact, rising non-communicable diseases (NCDs) coupled with increasing health bills in the private sector have resulted in a significant spurt in health spending in the country. While out-of-pocket expenditure (OOPE) remains the major source of health care financing in India (two-thirds of the total health spending), the financial burden varies enormously across diseases and by the economic well-being of the households.

Further, the panel led by Rajya Sabha member Bhubaneswar Kalita has suggested the government to rely on tax incentives and disincentives to improve health insurance coverage among corporate employees.

In what could come as a major relief to a large number of workers in the private sector, the panel has recommended measures such as ‘employer mandate’ — making it a must for an employer to provide health insurance to each employee.

The panel has also taken  exception that insufficient funds were released and there was poor utilization.  “The central government has in the last five years (2018-19 to 2022-23) released Rs 17,000 crore towards PMJAY. Of this, Rs 6,180 crore was released in the previous financial year.”

It also observed that the average sum of Rs 6,000-Rs 7,000 crore allocated as the central government’s share of the scheme each year is not sufficient for 33 states and Union Territories, advising that the same be increased.

“For this purpose, other old/peripheral schemes of the government in the healthcare sector may be subsumed or integrated with PMJAY so that the unutilised funds, resources, and manpower involved in those schemes may be utilised for its efficient implementation,” said the report.

The central flagship which was launched in September 2018 to achieve UHC as recommended in the National Health Policy 2017 and the SDGs has been rolled out in rural and urban areas for over 10.74 crore families, with further expansion of the beneficiary base to 12 crore families based on National Food Security Act (NFSA) data. (See box for more features of the scheme)

However, while the scheme is a welcome move, more needs to be done. The panel while preparing reports did extensive research, held a series of discussions with several representatives from the health sector to get the best picture. As per the report, the panel found that the  quality of public healthcare facilities, including Primary Health Centres, Community Health Centres, district hospitals, and tertiary care hospitals, varies widely.

Also, rural areas face significant challenges in terms of shortages of healthcare providers, infrastructure, and medical supplies. Urban areas have relatively better infrastructure and services compared to rural areas, but they are often concentrated in metropolitan cities, leading to overcrowding and long waiting times, notes the panel.

“The private healthcare sector in India offers a wide range of services, from primary healthcare to high-end specialised treatments, but it can be very expensive and inaccessible to a large portion of the population.”

A significant proportion of the Indian population faces challenges in accessing affordable healthcare, leading to financial strain and even catastrophic OOPE, noted the panel and suggested that “Lack of health insurance coverage is a significant factor contributing to affordability issues. While government-sponsored insurance schemes exist, coverage is often limited, and many people remain uninsured. “There is a need for more healthcare infrastructure, an increase in the healthcare workforce, and reforms to reduce out-of-pocket expenses. India's healthcare access and affordability landscape is complex and marked by disparities.”

In developing countries, financial constraints, coupled with the unpredictability of illness episodes, only a minority of the population resort to the ex-ante methods of insuring to meet the health shocks. The poor people who struggle to meet daily subsistence food consumption are incapable of insuring themselves from unexpected illnesses, as per the panel.

In 2018, only about 14.1% of the rural and 19.1 % of the urban populations had insurance coverage. Therefore people resort to ex-post coping mechanisms like using income savings, selling livestock or assets, and borrowing from family, friends or money lenders to smoothen consumption expenditure.

The Committee has strongly called for increasing the Government's health expenditure from the present 2.1 percent of GDP on the lines of the objectives of the National Health Policy 2017.

The Committee after intensively studying the experiences of Thailand, China, and Latin American countries found that provisions of the Affordable Care Act of the United States also known as Obama Care for inclusion in Ayushman Bharat.

“By including some sections of the persons falling in APL category, the provisions for 'employer mandate' to provide health insurance to the employee and his family, subsuming of specific schemes for children and senior citizens, tax incentives and disincentives to corporate regarding healthcare are some of the measures worth including in the Ayushman Bharat Scheme and PMJAY,” it said.

Since the outgo of funds is immediate in insurance mode, the Government should push for payment of the premium of insurance in installments, preferably monthly/quarterly installments, the panel has suggested.

To sum up, if strengthened and restructured further, the AB-PMJAY can be an important milestone in achieving the UHC.  For, the goal of the UHC is to ensure that all the people receive the health services they need without financial hardship.