The Union government has approved the inclusion of all senior citizens above the age of 70 under the Ayushman Bharat scheme. The Union cabinet took this major decision on Wednesday (September 11).
The scheme is based on an insurance model that provides a cover of Rs 5 lakh every year on a “family basis”.
An eligible citizen can avail the insurance cover at any private or government hospital that is empanelled under the scheme only when she is hospitalised for treatment.
The premium is paid by the Union and state governments. The Union-state contribution to the scheme is in the ratio of 60 to 40.
As per Wednesday’s announcement, all senior citizens above the age of 70 in a family will be covered.
However, the cover of Rs 5 lakh will be divided among such citizens in a family – it will not be available on an individual basis.
Such citizens will be issued cards by the government, which has claimed that the expansion of the scheme will benefit six crore citizens.
Earlier, the scheme was only available for families belonging to lower socio-economic strata – those in India’s bottom 40% – on the “family basis”.
Each eligible family, irrespective of the number of people in it, has a cover of Rs 5 lakh. The scheme covers family members of all age groups belonging to the disadvantaged groups, as per the existing model.
A press release issued by the government today added that those citizens older than 70 who belong to the lower socio-economic strata and who are already covered under the scheme will get a top-up cover of Rs 5 lakh.
That is, such senior citizens belonging to the lower strata and who are already eligible for a Rs 5 lakh cover will now get additional support worth Rs 5 lakh on account of their age, over and above what they can already avail.
The government has clarified that the additional cover will apply only to senior citizens and not all members of the family.
Those senior citizens older than 70 who have insurance cover from a private company can also avail the Ayushman Bharat scheme now. A pre-existing cover will not make such senior citizens ineligible.
A significant chunk of citizens in the 70+ age group are also already covered under various schemes like Central Government Health Scheme (CGHS), the Ex-Servicemen Contributory Health Scheme (ECHS), Ayushman Central Armed Police Force (CAPF) – depending on their employers.
The government has said that such citizens can avail either their existing schemes or the newly extended Ayushman Bharat scheme. Such citizens will have a choice to opt for one scheme. They are not eligible for more than one government scheme – that is, the ones they already avail as well as Ayushman Bharat.
“[As many as] 55 crore individuals corresponding to 12.34 crore families [have already benefited]. The scheme has covered 7.37 crore hospital admissions including 49% women beneficiaries,” the health ministry’s press release stated.
“Initially, 10.74 crore poor and vulnerable families comprising the bottom 40% of India’s population were covered under the scheme. Later, the government of India, in January 2022 revised the beneficiary base under AB PM-JAY [Ayushman Bharat] from 10.74 crore to 12 crore families,” the government added.
The scheme also covers 37 lakh ASHA workers and anganwadi workers irrespective of their age and socio-economic status.
Ayushman Bharat’s flaws
However, one of the major drawbacks of the Ayushman Bharat scheme is that it can only come into play when a patient is admitted to hospital – as is the case with all private insurance schemes.
On the other hand, it is the out-patient department (OPD) services that form the bulk of the medical services sought by people, according to several analyses.
Almost 40%-80% of expenditure on health is on OPD services in India, according to a study published in the International Journal of Preventive Medicine. Therefore, people are forced to spend huge amounts of money out of their own pockets for such visits to doctors, apart from what they spend on buying medicines and availing diagnostic services.
Last year, a report by the Comptroller and Auditor General pointed to large-scale corruption in the scheme. One of the many things it brought to light was the fact that private hospitals empanelled under the scheme pocketed insurance money even for those patients who had already died before seeking treatment.
The report also revealed that the scheme has also led to scenarios where the population burden on every empanelled hospital varies widely between states.
For example, it said that on average, for every one lakh population there are 1.8 empanelled hospitals in Bihar. On the other hand, 26 hospitals had been empanelled under the scheme per lakh population in Goa.
This puts the population of poor states like Bihar in a disadvantaged position. Such disparity among states was visible throughout the country.
(This article was first published in The Wire)
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