Prime Minister Narendra Modi is expected to launch the Ayushman Bharat Pradhan Mantri Jan Arogya Yojana (AB-PMJAY) for senior citizens on October 29, according to sources.
Last month, the Union Cabinet, chaired by the Prime Minister, approved a significant expansion of the world’s largest public health insurance scheme, which provides cashless coverage of up to ₹5 lakh per year for hospitalizations. This expansion will cover all senior citizens aged 70 and above, regardless of their socio-economic background.
The central government will fund 60% of the scheme, while states have the flexibility to expand or modify it to include other age groups. Some states have already done so, covering additional beneficiaries at their own expense.
Prime Minister Narendra Modi. (Narendra Modi- X)
The Union health ministry estimates that the decision will benefit approximately 45 million families (60 million senior citizens). Currently, 123 million families are covered under the scheme. The expansion is also expected to benefit women, as 58% of India’s population over 70 are women, with 54% of them being widows, according to government data.
Families already enrolled in the Ayushman Bharat scheme with senior citizens will receive an additional shared top-up cover of up to ₹5 lakh per year. Middle- and upper-middle-class families not currently covered due to their socio-economic status will also benefit from this shared coverage if they have senior citizens in their households.
The additional top-up of ₹5 lakh will be specifically allocated for senior citizens within covered families.
Eligible seniors will need to apply for the benefits, although those already covered under other government health insurance schemes, such as the Central Government Health Scheme (CGHS), will have the option to choose between plans. People with private insurance will also be eligible to join the scheme.
A new card will be issued to eligible beneficiaries. The initial budget for the expansion is ₹3,437 crore, with provisions for further coverage expansion based on demand.
Statement from Official
“There is a major event planned for October 29th wherein several big-ticket health projects will be either launched or announced that includes the Pmjay for senior citizens that was recently approved by the Cabinet,” said a senior central government official, requesting anonymity.
History of AB-PMJAY
In 2017, an Indian version of the Global Burden of Disease Study reported on significant diseases and risk factors across all Indian states from 1990 to 2016. This study sparked considerable interest in government health policy by pinpointing major health challenges that the government could tackle. A significant portion of the population remains underserved by the Indian healthcare system, which largely depends on out-of-pocket payments from patients to finance care. These expenses often prevent many individuals from accessing necessary healthcare services. In 2018, the Indian government revealed that over six crore Indians were pushed into poverty each year due to these out-of-pocket medical costs. Despite the presence of various regional and national healthcare programs, much more work remained to be done.
In February 2018, the Indian government introduced the Ayushman Bharat Yojana as a universal healthcare plan during the Union budget presentation. The Union Council of Ministers approved the initiative in March. During his Independence Day speech in 2018, Prime Minister Narendra Modi announced the launch of a major national health program set for September 25, coinciding with the birthday of Pandit Deendayal Upadhyaya.
In June 2018, the application process for hospitals began through an "empanelment process." By July 2018, the Ayushman Bharat Yojana suggested that beneficiaries access services via Aadhaar but also provided alternatives for those without the identity card. The AB PM-JAY was officially launched on September 23, 2018, in Ranchi, Jharkhand. By December 26, 2020, the scheme was extended to the Union Territories of Jammu and Kashmir and Ladakh. The program has been described as "ambitious."
Characteristics
The PM-JAY scheme offers several key features: it provides health coverage for 10 crore households, benefiting around 50 crore Indians; each family is entitled to a coverage of ₹5 lakh per year for medical treatment at both public and private empaneled hospitals; it facilitates cashless payments and maintains paperless records through healthcare facilities; eligibility for benefits is determined using criteria from the Socio Economic and Caste Census 2011; there are no limits on family size, age, or gender; all pre-existing medical conditions are included; it covers 3 days of pre-hospitalization and 15 days of post-hospitalization care, including diagnostic services and medication costs; the scheme is portable, allowing beneficiaries to seek medical treatment at any PM-JAY empaneled hospital nationwide; and it includes access to free COVID-19 testing.
In India, there has been a shift towards an insurance-based healthcare system rather than strengthening essential primary, secondary, and tertiary healthcare in the public sector. The chronic underfunding of public health compared to the private sector, coupled with the Indian government's market liberalisation of private health insurance in the late 1990s, has led to greater health disparities, as private insurance is primarily affordable for wealthier communities. In the mid-2000s, government-funded health insurance emerged as a novel approach to healthcare financing, enabling individuals to avoid catastrophic out-of-pocket expenses. Under this model, the state pays premiums to private insurers, allowing eligible individuals to receive free treatment at any public or private institution participating in the PM-JAY scheme. The Indian government recognized that out-of-pocket costs were driving people into poverty and that government hospitals were inadequate in protecting against catastrophic health expenses. The alternative of government-funded health insurance allows lower-income individuals to access private healthcare without incurring additional costs.
The Ayushman scheme has led to an increase in revenue for government hospitals and improved facilities for patients. Many who were once reluctant to visit government hospitals due to inadequate amenities now choose these facilities, trusting them for treatment under the Ayushman scheme.
Challenges
When the Ayushman Bharat Yojana (Ayushman Card) was launched, questions arose about how to align its initiatives with existing health development recommendations from NITI Aayog. A significant challenge in implementing a national healthcare scheme is the need to upgrade infrastructure to integrate it into a modern national system. Although the Ayushman Bharat Yojana aims to deliver quality healthcare, India still faces fundamental healthcare issues, such as a shortage of doctors, a high incidence of infectious diseases, and a national budget that allocates comparatively low central government investment in healthcare. Some of these challenges extend beyond the Health Ministry, encompassing areas like urban development and transportation. While many government hospitals have adopted the program, numerous private corporate hospitals have not, citing their inability to provide specialised services at the low government rates, even with subsidies.
Additionally, there have been instances of misuse of the Ayushman Bharat scheme by private hospitals through the submission of fraudulent medical bills. Reports indicate that surgeries have been falsely claimed for patients who had been discharged long ago, and dialysis has been recorded as performed at facilities lacking kidney transplant capabilities. In Uttarakhand alone, there have been at least 697 fraudulent cases, resulting in a ₹1 crore fine imposed on the hospitals involved. Preliminary analysis of high-value claims under PM-JAY shows that a small number of districts and hospitals account for a disproportionate share of these claims, with indications of an anti-women bias, as male patients appear to receive more coverage. Despite efforts to prevent malpractice, the potential for unscrupulous private entities to exploit the system for profit remains a significant concern within PM-JAY.
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