Increasing coverage, growing distress, Pg8

Key Highlights:

• NSS 80th round data (Jan-Dec 2025) reveals increased health insurance coverage but not a significant rise in hospital care utilization.
• Out-of-pocket (OOP) expenditure on hospitalization sharply increased between 2017-18 and 2025, especially in the private sector.
• Government-financed health insurance (GFHI) schemes like PMJAY saw a 2.5-fold coverage increase between 2017-18 and 2025.
• There's a notable shift from public to private healthcare for hospitalization and childbirth between 2017-18 and 2025.

Detailed Insights:

• Despite increased insurance coverage, hospitalization rates remain below 2014 levels, indicating coverage isn't translating to care access.
• Rising OOP expenses occur even in public hospitals due to unavailability of medicines, diagnostics, and high non-medical costs.
• 57% of GFHI enrollees needing hospitalization sought care in private hospitals, often without receiving fully free care as promised.
• GFHIs, while targeting socio-economically backward sections, are disproportionately utilized by relatively better-off individuals.
• Increased fiscal strain from GFHIs leads to delays in reimbursements to private providers, impacting scheme effectiveness.
• GFHIs effectively subsidize private sector healthcare using tax money, enabling private sector access to previously unreachable markets.
• The Ayushman Arogya Mandir (AAM), aimed at comprehensive primary care, remains underfunded despite showing promise.

Key Concepts Involved:

• Out-of-Pocket Expenditure (OOP): Direct payments made by individuals to healthcare providers at the point of service.
• PMJAY (Pradhan Mantri Jan Arogya Yojana): A government-sponsored health insurance scheme providing coverage for hospital care.