Dipa Sinha 
The government has recently announced an extension of the Ayushman Bharat–Pradhan Mantri Jan Arogya Yojana (AB-PMJAY) scheme for all old persons above 70 years of age. The AB-PMJAY was so far available only for the bottom 40% of the population, thereby covering about 12 crore households (based on the deprivation lists according to the Socio-Economic Caste Census, SECC 2011 and some additional groups such as anganwadi workers and ASHAs).
With this development, all old persons except for those who are getting health benefits from other government schemes, will be eligible for the health insurance under the PMJAY. The benefits remain the same, i.e. a cover of up to Rs 5 lakh per year per household towards hospitalisation expenses. While it is welcome that the government is acknowledging geriatric health needs bringing attention to issues of an ageing population, it needs to be examined whether the publicly funded health insurance (PFHI) schemes is the best route to achieve access to health for the aged.
There is abundant research on the experience of PFHIs in India, many based on earlier state schemes and few recent ones since the launch of the PMJAY, which raise a number of issues. The PFHIs, including PMJAY, include only inpatient expenses, whereas a significant proportion of out-of-pocket expenses is on outpatient care and within that on medicines. The latest National Health Accounts (2019-20) for instance estimates that of the current health expenditure (CHE) in the country, 19.3% is on outpatient curative care and an additional 22% is on over the counter and prescribed medicines.
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As far as hospitalisation is concerned, issues of equitable access to accredited hospitals across the country, continuing OoPE despite being covered by PFHIs, problems of cherry-picking of cases and unnecessary procedures in private hospitals etc. which have been seen in the context of these insurance schemes remain. Further, it has also been seen that such insurance schemes tend to escalate overall healthcare costs for the economy. With an ageing population, these are issues that need to be considered before expanding insurance-based healthcare for the elderly rather than direct provision of services through public hospitals.
The American model, where through the Medicare and Medicaid programmes health insurance is provided to the elderly and the poor while the rest of the population depends on private health care usually financed through employer-provided or privately purchased health insurance is a case in point. America has one of the highest health expenditure to GDP ratios in the world at 16.6% compared to about 11.3% average for EU countries and yet has greater exclusions and poorer health outcomes overall. The government health expenditure in America, despite the lower coverage is 9.62% compared to the EU average of 8.38% (despite most countries in the EU having wide-ranging public health systems with varying financing models compared to the mostly private health care model of the US).
Further, while the extension of PMJAY to all people above 70 years might ease the burden of hospitalisation to an extent for some people, the pressure of outpatient expenses remains even on those who are covered. The Longitudinal Ageing Study in India (LASI) conducted in 2017-18 shows that 7.7% of those above 60 utilised inpatient care over the last one year and 29.3% of them utilised outpatient care in the one month prior to the survey.
The mean out-of-pocket expenditure (OoPE) of those above 60 years of age on inpatient care for the last hospitalisation during one year prior to the survey was Rs 8028 in public hospitals and Rs 31,933 in private hospitals. Private hospitals are much more expensive and almost 60% of all hospitalisations among those above 60 were in private hospitals (43.7% among the poorest). There is hence a huge gap in access to good quality and affordable inpatient care in government hospitals.
For outpatient care, in one month prior to the survey the expenditure was Rs 1,149. Therefore, while the out-of-pocket expenses are indeed higher per episode for hospitalisation cases, the burden of outpatient care expenditure is also substantial and affects a larger number of people. The old age pensions that poor old people receive through the social security schemes of the government hardly covers for even just the outpatient curative care expenses.
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Most states give old age pensions of only Rs 1,000 or less per month (with the central government contributing Rs 200 for those in the 60-79 age group and Rs 500 for those above 80). Over 55% of the old people are covered by these schemes but most other old people are not covered by any employment-related sector pensions given the very high levels of informal employment in India.
The burden of chronic diseases which require care and attention is also high amongst the elderly. These expenditures are not accounted for in the usual health expenditure surveys which capture data on hospitalisation and recent out-patient visits. According to the LASI survey, for example, among those aged above 60, 34.6% self-report having cardiovascular diseases, 32% hypertension or high blood pressure and 14.2% diabetes or high blood sugar. More than half report eye or vision related problems, 26.7% are underweight. There is a need for comprehensive health, nutrition and social security services designed for the elderly.
There is the National Programme for Health Care of the Elderly (NPHCE) which needs to be supported with adequate budgets and support. Its success, however, depends on the overall strengthening of the public health system at all levels from the primary to the tertiary. It is well known that the public health expenditure as a proportion of the GDP in India remains very low. The shift in priorities towards insurance schemes weakens the system further and in the long run is taking us away from building an equitable, good quality health system for all. We must pause and rethink the direction in which we want to take our health system so that we achieve universal health care with inclusion of the most marginalised.
Dipa Sinha is a development economist.