Can Ayushman Bharat reduce out-of-pocket expenditure?

In poor health part 3: Data shows that most health insurance schemes in India have not provided significant relief to beneficiaries

By Kundan Pandey
Published: Wednesday 19 September 2018
Ayushman Bharat
In 2004, the total OOP expenses per household were Rs 3,855 while it increased to Rs 4,955 in 2014. Credit:M eetaAhlawat /CSE In 2004, the total OOP expenses per household were Rs 3,855 while it increased to Rs 4,955 in 2014. Credit:M eetaAhlawat /CSE

Five days from today, Prime Minister Narendra Modi will launch Ayushman Bharat, a Central government scheme that offers Rs 5 lakh per family per year as financial protection for secondary and tertiary treatment.

Rs 5 lakh is also the sum Lakshmi, a domestic help from Ganganagar, a sub-urban area in Chennai, Tamil Nadu paid herself to seek treatment for tuberculosis (TB). This is, in spite, of the fact that she is a beneficiary of the Chief Minister Kalaignar Insurance Scheme.

Launched on July 23, 2009 and later revamped as Chief Minister’s Comprehensive Health Insurance Scheme on January 11, 2012, the Kalaignar Insurance Scheme is available to 1.34 crore families who have an annual income of Rs 72,000 or less and provides as security of Rs 4 lakh for four years (Rs 1 lakh every year).

But did the health insurance scheme help Lakshmi when she needed it the most?

Lakshmi. Credit: Adithyan P C/CSE

The 42-year-old was diagnosed with TB in 2014 but by the time she was diagnosed, her spinal cord was damaged and she was paralysed from the hip down. When she collapsed in January 2016, her family rushed her to a hospital. Several formalities later, they submitted the insurance card and yet she paid around Rs 5 lakh from her own pocket for pre and post-hospitalisation treatment. She sold all her belongings and is today under a debt of Rs 1 lakh. Her daughter, who was at that time in IXth standard, had to quit school.

Many beneficiaries like Lakshmi are forced to spend out of their pocket despite being insured under health insurance schemes.

An independent study of 1,176 households - 640 in urban slums in North Chennai and 536 in remote villages in Salem district show that those using insurance schemes are spending more money than those who are not.

Rajalakshmi Ram Prakash, a Chennai-based researcher on gender and health, who is pursuing her PhD from the Tata Institute of Social Science, Mumbai says that her study showed that on an average, the out-of-pocket expenditure (OOP) among those who utilised the state’s health insurance scheme was Rs 40,000. On the other hand, the same was Rs 30,000 for those who did not use the health insurance schemes.

Similarly, in Chhattisgarh, beneficiaries of health insurance scheme were found spending money from their pocket. The state launched the Rashtriya Suraksha Bima Yojna (RSBY) in 2009 and later expanded the scheme to all families living in the state in 2012. Around 12.5 million people in the state are enrolled under RSBY/MSBY (Mukhyamantri Swasthya Bima Yojna). A research paper published in a medical journal PLOS One in November 2017 highlights that 96 per cent of insured patients visiting private sector health centres and 66 per cent insured visiting public sector health centre were still paying money from their pocket.

A comparison of two surveys from the National Sample Survey Office, 2004 and 2014, also highlight that insurance scheme provide no significant relief. A report by Brookings, a global think tank says that OOP has increased in the last 10 years. In 2004, the total OOP expenses per household were Rs 3,855 while it increased to Rs 4,955 in 2014. The major change was noticed in in-patient care where every household was spending Rs 1,104 in 2004 while in 2014, it increased to Rs 1,842. This happened despite the fact that all health insurance schemes were focused in in-patient treatment only.

When comes to out-patient expenses per household in 2004, it was Rs 2,751 which increased to Rs 3,113 in 2014.

As per the report, percentage of households falling below the poverty line due to OOP health expenditure remains the same as seven per cent if compared to 2004 when none of these initiatives were rolled out.

The rural poor experienced more financial burden in 2014 compared to 2004. While the top four rural quintile groups have not seen any statistically significant change in OOP expenditure over 10 years, the poorest rural saw an extraordinary increase of 77 per cent in OOP during this time.

It should be a concern given the fact that all the government insurance schemes in the country have been targeting this segment specifically.

(This is the third article in a series which investigates government health insurance schemes in India. Read the first and second here)

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