Ayushman Bharat is a nice name for a scheme that promises health insurance to nearly 40 percent of Indian population. Any such intent that offers insurance cover of Rs 5 Lakh to 10 crore families must be welcomed. There are questions on the availability of funds for the scheme. However, such questions apart, it’s the viability of the scheme and its operational aspects that need to be discussed well before it is actually launched.
The scheme aims to cover nearly 50 crore Indians, who belong to the lower half of the economic strata. As per the latest data, nearly 45 crore people, which is almost 93 percent of the total Indian labour force, work in the unorganized sector. Also, out of a total of 12 crore farmers, 75 percent are marginalized farmers, with less than one hectare land holding. Another 15 crore people work as landless agricultural labourers. So, it can be safely presumed that the scheme would primarily cater to this section of Indian population that comprises of unorganized labour, farmers, landless farm labourers, tribals and Dalits.
The health issues faced by this target population relate to lack of nutrition, unhygienic living conditions, occupational health hazards and lack of timely attention and treatment. Therefore, it is imperative to ensure that majority of diseases inflicting them do not fall outside the fine print of the insurance companies, which are expected to roll out the scheme.
It is a common knowledge that the medical insurance companies have a detailed set of fine prints in their schemes. Often, any critical illness diagnosed within the first 90 days is not covered by most insurance schemes. Also, pre-existing illnesses are usually not covered for first few years. Similarly, senior citizens have limited medical cover, especially if they go in for first time insurance coverage.
Most of the labour force in the unorganized sector works in inadequate working conditions. It is well known that persons working in various hazardous and taxing industries have a high incidence of chronic diseases. Silicosis, silico-tuberculosis in glass industry and flour mills; incidence of cancer in ship breaking industry in Alang; pleural plaque, lung cancer, asbestosis, mesothelioma due to asbestos; respiratory diseases in tobacco industry; lymphocyte changes due to exposure to benzene, toxicity due to mercury; musculoskeletal problems due to long hours of wrong posture in various industry etc. are all well documented.
A large population targeted by the Ayushman Bharat scheme is inflicted with one or more such diseases. It must be ensured that such people are not kept out of insurance cover, as the diseases pre-exist at the time of launch of scheme.
A similar challenge exists for farmers also. Rampant and ill-informed use of pesticides and fertilizers is a major cause of chronic illness related to cardio-vascular and respiratory diseases. The carcinogenic impact of excessive use of pesticides is now well acknowledged. But as a recent case in Maharashtra suggests, it is very easy to pass the onus of unsafe use of pesticides on to the farmers.
Last year more than 40 farmers lost their lives in Amravati-Yavatmal region, when they inhaled pesticides that were sprayed in fields. But the Special Investigation Team (SIT) formed to probe it, primarily held the farmers themselves as guilty. Led by the Divisional Commissioner of Amravati, the SIT concluded that the farmers didn’t take adequate measures to protect themselves. It is quite possible that the insurance companies may take a similar stand and refuse to cover chronic illness attributed to lack of safety norms observed by farmers.
Therefore, as the scheme rolls out, the government must ensure that all pre-existing chronic illness and the occupational diseases caused due to work are fully covered by the insurance scheme. It must not remain limited to common diseases like TB, heart diseases, diabetics etc. and to accident injuries. The incidence of the occupational diseases is widespread and cannot be ignored.
The government must also ensure cashless hospitalisation for the beneficiaries of the scheme. It is a common experience that reimbursements are a tricky business in medical insurance. Reimbursements may prove extremely cumbersome for the poor. In remote areas especially, hospitals are far off and travelling for administrative requirements for reimbursements may huge cost money and time. In any case, for a government that’s known for its penchant for cashless transactions and direct cash benefit, the cashless medical insurance must certainly be an automatic choice.
In this context, the government may well study the learnings from previous health insurance schemes in the country. One of the successful health insurance schemes in India was in Andhra Pradesh by the Congress government led by YSR Reddy. Known Aarogyasri scheme, it provided cashless facility for treatment of 938 listed diseases and health problems in any government or private hospital in the state. The scheme was for the BPL population of Andhra Pradesh. The present Telangana government has since relaunched the scheme.
It is also apt to recall the experience of previous two health schemes by Modi government that were launched with great promise. In 2015, Finance Minister Arun Jaitley had announced Prime Minister Jeevan Jyoti Bima Yojana, with natural and accidental death coverage of Rs 2 lakh. A premium of Rs 330 per annum was charged from beneficiaries. Till December 2017, 19 crore 77 lakh persons had enrolled in the scheme, but the claims were paid only to 78,541 persons. Also, the banks claimed that the amount they received as premium was not sufficient to cover the service costs.
Another insurance scheme launched in 2015 was Prime Minister Suraksha Bima Yojana. It was linked to Jan Dhan Yojana bank accounts and for an annual premium of Rs 12, it provided accidental death & disability coverage of Rs 2 lakh. In this scheme too, total number of beneficiaries enrolled in two years were 10 crore, but the claims were paid to only 9,705 persons till April, 2017. In this case, too, general insurers have urged the government to hike the premium due to rising loss ratio. Both the schemes no more figure in any promotion campaign of the Modi government.
It is probably the failure of both the schemes, which has now prompted the government to launch Ayushman Bharat scheme. The high cost of medical treatment is indeed a big challenge for common people. The general health services and government hospital system has deteriorated over the years. So, there is a great political incentive to cater to the need of people and if the scheme succeeds, the electoral dividend would certainly be quite high. Hence, it is even more important that government does due diligence before launching this flagship programme. If the intent is to start it only for visual appeal and headlines management, it may soon boomerang. Therefore, all measures must be taken to ensure that an ambitious step does not fail. Ayushman Bharat must grow into an effective, cashless and all-encompassing health scheme for the poor of India.