Why Ayushman Bharat will not work

What could possibly be wrong with a health insurance scheme that aims to provide free and universal healthcare to every Indian?
Why Ayushman Bharat will not work

The world’s largest health insurance scheme is here, say the ads. Healthcare in India is going to be transformed, we are informed. See how the PM is helping the poor access affordable healthcare, exult his supporters. But is Ayushman Bharat worth the hype?

There are two types of government schemes. The majority of them are well thought through but poorly implemented; so the benefits do not reach the intended beneficiaries fully. But there are a few schemes that are daft even at the policy stage. They have little chance of working and if they actually worked well, would paradoxically be impossible to sustain. Ayushman Bharat falls squarely in the second category.

What could possibly be wrong with a health insurance scheme that aims to provide free and universal healthcare to every Indian? Nothing, except that free universal healthcare should already be available. In most parts of India treatment in government hospitals is either free or a nominal fee is charged. But accessibility and the quality of care are different matters. Also, secondary and tertiary care are in scarce supply in many states. But on paper free healthcare exists. So we are creating a scheme partly to do what an existing scheme, meant to do the same, is not doing.

Private sector infrastructure will be utilised for delivering the services, but some government hospitals will also chip in. The logic: government hospitals lack the infrastructure and as the government’s aim is to ensure accessible and affordable healthcare, how should it matter who provides the care?

It should. There can never ever be a substitute to strengthening public healthcare infrastructure in India and schemes like Ayushman Bharat and state health insurance schemes weaken the already critically ill public health space. There is a strong feeling among people that private healthcare is better than government healthcare and such schemes only reinforce that impression.

What is the problem if the private sector provides the service for a fee? They have the infrastructure and poor patients will benefit anyway. The problem is there is no regulatory mechanism in place to monitor the quality of service provided, its ethical necessity and of course whether the patient was made to pay more than what the scheme covered. And the rates under the scheme are low; hospitals say they cannot support the scheme long-term without revision of rates. Who is to check if hospitals are not cutting corners and putting patients’ lives at risk? The most vulnerable people are being led by the government to the mercy of the private sector with very little regulation.

The mind also boggles at the enormous scope for corruption that Ayushman Bharat and similar schemes can lead to. From the enrolment stage to approvals to payments, everything could have a price. The issue is also one of virtually killing off public sector hospitals. Unless you use the TN model of paying insurance money to government hospitals and doctors just to do the job they are already paid to do, who will now want to have a procedure or surgery done at a government facility? Alternately if we are to say that a set of 500 procedures will be done only at government facilities, then would that not take out a large chunk of patients from the insurance scheme?

Let us now look at budget allocations. Even to a non-economist, it is clear that the around Rs 3,200 crore allocated for the scheme this year will not even be enough to cover a small subset of the 10 crore families enrolled. If we assume that just 5 per cent of those enrolled claimed 20 per cent of their eligible Rs 5 lakh, the scheme will need Rs 50,000 crore. What would Rs 3,200 crore be able to accomplish? And we have not taken into account the running cost.

Next look at the so-called wellness centres to be opened under this scheme. How are they different from primary health centres? If they are just upgraded PHCs then that could be accomplished without the scheme. The interplay between state health insurance schemes and Ayushman Bharat will also be keenly watched. States may try to reduce their financial burden by pushing their patients through this scheme.
The IT backbone needed for such a scheme is humungous and it is doubtful if the government has thought through the complexities, especially of data privacy and security. We are seeing the mess unfolding in Aadhaar and this could be an even bigger disaster with confidential health information accessed without authorisation.

Finally, what if the scheme becomes successful with all the beneficiaries becoming aware of it? Simple: There would be no money to run it and it would collapse. Example: If the claim rate was even, say 15 per cent at an average of 10 per cent of the maximum limit, that’s Rs 75,000 crore needed each year. The claim rates are likely to be much higher as no one is excluded here unlike in private insurance where many who actually need the care are ineligible to be covered due to various exclusions including old age, pre-existing illness, etc.

So why the need to go ahead with such a scheme? Because, these schemes are seen to be vote catchers. In Andhra Pradesh, Y S Rajasekhara Reddy built a huge reputation for himself through Arogyasri, the pioneer among state health insurance schemes. There will no doubt be people who benefit and the photo ops help create a strong populist message. Such schemes also cater to the aspirations of the poor, who can receive healthcare at private hospitals they couldn’t earlier afford to go to. The criticism of Ayushman Bharat isn’t to say that people won’t benefit from it. Many of course will, but this is certainly not enough to justify its costs and the damage it will do in the long-term to public health infrastructure.
The government will realise its folly at some stage but for now it’s election time. And states haven’t realised their folly in years. There is never going to be a substitute to strengthening public health institutions. Technology can greatly help improve the quality of care that public hospitals can provide. That should be the way to go. And that is where the money must be spent.

Dr Sumanth C Raman
TV anchor and political analyst
Email: sumanthcraman@gmail.com

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