​Work in progress, Pg6

Key Highlights:

• The 80th round of the National Statistical Office's household social consumption (health) survey reveals a threefold increase in health insurance coverage since the launch of PMJAY in 2018.
• Hospitalization rates have not recovered to 2014 levels, indicating that insurance coverage does not guarantee access to hospital beds.
• The proportion of the population reporting ailments has doubled, with a decline in infectious diseases and an increase in non-communicable diseases.
• The median out-of-pocket expenditure (OOPE) has dropped to ₹11,285 per hospitalization, but the potential for significant financial burden remains high.

Detailed Insights:

• Previous surveys identified out-of-pocket expenses (OOPE) as a major cause of poverty, but the 80th round indicates that healthcare is becoming more affordable due to the public sector absorbing primary and secondary care costs.
• Reimbursement rates under PMJAY and state-funded schemes are often below market rates, leading private hospitals to bill patients separately for diagnostics and ancillary services.
• The Ayushman Bharat network, providing free medicines and diagnostics, is underfunded relative to the needs of managing chronic diseases, where the private sector dominates.
• While the poor have nominal coverage, they are often excluded from the practical benefits, while the insured middle class faces rising catastrophic costs.
• The next phase of healthcare reform should focus on strengthening public sector hospital capacity to compete with the private sector for tertiary care.

Key Concepts Involved:

• PMJAY (Ayushman Bharat Pradhan Mantri Jan Arogya Yojana): A national health insurance scheme providing financial protection to poor and vulnerable families for secondary and tertiary care hospitalization.
• Out-of-Pocket Expenditure (OOPE): Direct payments made by individuals at the point of receiving healthcare, excluding any prepaid health insurance or government subsidies.