The rise and risks of health insurance in India , Pg6

Key Highlights:

• PMJAY (Pradhan Mantri Jan Arogya Yojana) and State Health Insurance Programs (SHIPs) aim to provide health coverage up to ₹5 lakh per household annually, focusing on in-patient care.
• In 2023-24, PMJAY covered 58.8 crore individuals with a budget of approximately ₹12,000 crore, while SHIPs had a combined budget of at least ₹16,000 crore.
• A study found PMJAY increased private hospital utilization without significantly impacting overall hospitalization rates.
• The National Health Authority (NHA) reported pending dues under PMJAY alone amounted to ₹12,161 crore.

Detailed Insights:

• Health insurance schemes in India, like PMJAY and SHIPs, offer relief to poor patients by expanding healthcare options but are not a substitute for a robust Universal Health Care (UHC) framework.
• These schemes predominantly support for-profit medicine, with about two-thirds of the PMJAY budget spent in private hospitals, reinforcing a poorly regulated, profit-driven healthcare system.
• Health insurance tilts the system towards hospitalization, potentially overshadowing the urgent need for investments in primary and outpatient care, crucial for accessible treatment and reduced hospital visits.
• Despite high coverage figures, utilization problems persist, with only 35% of insured hospital patients able to use their insurance in 2022-23, indicating hurdles, especially among disadvantaged groups.
• Targeted health insurance leads to discrimination between insured and uninsured patients, with private hospitals sometimes discouraging insurance use due to higher commercial charges for uninsured patients.
• Healthcare providers face issues like low reimbursement rates and long delays in payments, leading to hospitals suspending services or withdrawing from schemes like PMJAY.
• Health insurance schemes are prone to corruption and abuse, with the NHA recommending action against 3,200 hospitals for fraudulent activities under PMJAY, highlighting a lack of transparency.
• India's public expenditure on health remains low at 1.3% of GDP in 2022, compared to a world average of 6.1%, indicating a need to address the deficit and transform public sector healthcare standards for achieving UHC.

Key Concepts Involved:

• Universal Health Care (UHC): Ensuring quality healthcare access to all community members, regardless of their ability to pay.
• PMJAY (Pradhan Mantri Jan Arogya Yojana): A national health insurance scheme providing financial protection for healthcare expenses to eligible beneficiaries.
• State Health Insurance Programme (SHIP): State-level health insurance schemes modeled on PMJAY, offering similar benefits within specific states.