Govt must take direct responsibility of citizens’ healthcare, not leave it to insurance based system

Schemes such as Ayushman Bharat have serious limitations, while premiums charged even by insurance companies run by State are beyond reach of middle class families, hitting elderly the most

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Representative image
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Dr Arun Mitra

The COVID-19 pandemic exposed weaknesses in our healthcare system. Complications of the disease apart, unprecedented number of people lost their lives due to lack of basic needs like oxygen, ventilators, medicines and hospital beds. Over and above, exorbitant cost of treatment became a real constraint in the treatment of cases requiring hospitalization.

A patient requiring ventilator, for instance, had to pay around Rs. 20,000 per day as ICU charge in private hospitals which people were constrained to flock to in the absence of proper government facilities in most places. After adding the cost of medicines and other items, the patient had to shell out nearly Rs.40000 per day. This is an amount beyond the capacity of our people who are already in deep economic crisis as a result of lockdowns, loss of jobs and livelihood.

According to Pew Research Centre, the number of people earning less than $2 has doubled from 5.9 crore to 13.4 crore during the pandemic and as per a study by the Centre for Sustainable Employment at Azim Premji University, 23 crore people earn less than Rs. 375 per day.

Elderly people have been the worst hit by COVID-19, being retired and dependent on their children even for day to day living. Despite the fact that senior citizens have contributed through their life to nation building, healthcare for them remains a big challenge. The National Health Policy 2017 laid emphasis on the need for palliative and rehabilitative care for all geriatric illnesses, but in practice, hardly any steps have been taken.

To meet health needs, the government’s focus is on insurance based healthcare instead of health as state’s direct responsibility. Ayushman Bharat has serious limitations. It provides healthcare coverage to only 40% of the population, that too for indoor care only. This means 60% of the population is left out of this insurance scheme. It is also a well-known fact that 70% of out of pocket expenditure on health is on outpatient care. This affects the geriatric group in particular because a person in this age group is faced with diseases of chronic nature, for which he/she has to pay frequent visits to outpatient clinics.

Moreover, there are several conditions to get benefit of the Ayushman Bharat scheme, some of which are simply illogical. People not entitled to it include those who own a two/three/four wheeler or a motorised fishing boat; those who own mechanised farming equipment; those who have Kisan card with a credit limit of Rs. 50000; those who work in government-managed non-agricultural enterprises; those with a monthly income above Rs.10000; those owning refrigerators and landlines; those with decent, solidly built houses; and those owning 5 acres of more of agriculture land.

Several other healthcare schemes include Rashtriya Swasthiya Bima Yojna (RSBY) for Below Poverty Line (BPL) families, Aam Admi Bima Yojana for rural landless household, Janashree Bima Yojana (JBY) for below poverty line and marginally above poverty line, and Universal Health Insurance Scheme (UHIS) for health care to poor families. But these schemes provide very minimal healthcare facilities for hospitalization only.

Employees’ State Insurance Scheme (ESIS), Central Government Health Scheme” (CGHS) and Ex-Servicemen Contributory Health Scheme (ECHS) are better in this respect and provide both OPD and indoor care without any limits. Under the ESI scheme, total beneficiaries number around 3.2 crore employees or about 13 crore of their family members. The other two schemes provide benefit to about 50 lakh employees. During the peak of the second wave of COVID, most of the ESI hospitals were converted to COVID hospitals. As a result, beneficiaries were not able to get treatment for other illnesses for which they had to go to the private hospitals and pay from their own pocket.

In the absence of any suitable healthcare schemes by the government, a big chunk of our population which is in unorganised sector is left with a choice to opt for health insurance coverage either by the public sector or private sector insurance companies. However, premiums for insurance are steep and even middle income group people find it difficult to go in for it.

A big paradox is that whereas an elderly person is more likely to be taken ill, insurance companies increase the premium exorbitantly with age of the insured. The rate of premium of these companies has increased tremendously in the last five years.

For example, under the Mediclaim policy of New India Assurance Company Limited, a public sector unit, the premium for those in the age group of 66-70 for a sum assured Rs.1 lakh increased from Rs. 5600 in 2016 to Rs. 19866 in 2021, an increase of 354%. For a sum of Rs 2 lakh, it went up from Rs. 10630 to Rs. 28218, an increase of 265% in the last 5 years. For a sum assured of Rs. 5 lakh, it increased from Rs. 24230 to Rs. 42120, a rise of 173% during this period.


For senior citizens who have either no income of their own or have very meagre income and are dependent on their children, it is impossible to pay such high insurance premium.

The pandemic has exposed this myth of insurance based health care system. No company will cover it if the expenses increase beyond the sum assured. COVID patients requiring ventilators had to spend much more than this amount. So they had to either borrow money or sell their assets.

Further, the companies have stopped dealing with cases directly and have appointed TPAs. This has been done only to put blocks on getting reimbursement from the companies though raising of frivolous objections.

Therefore, only a comprehensive universal health care system can meet the needs of our people. The government should strengthen primary healthcare. They should open its advanced tertiary care centres where facilities for palliative and rehabilitative care are available.

Insurance companies should be made to compulsorily cover OPD care cost as well for the insured. The irony is that tariff of the government owned companies is more than the private sector companies in some cases.

(IPA Service)

Views are personal

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