Context

• The Centre’s decision to extend the Ayushman Bharat Pradhan Mantri Jan Arogya Yojana (AB-PMJAY) with an additional Rs 5 lakh coverage for individuals aged above 70 is commendable.
• However, it raises several questions about its sufficiency, long-term sustainability, and policy gaps in the broader healthcare coverage.
• Therefore, it is important to critically evaluate the implications of this extension, focusing on how it addresses the healthcare needs of the elderly population, its financial viability, and the broader healthcare policy gaps that remain unaddressed.

An Overview of India’s Ageing Population and its Healthcare Needs

• India's demographic profile is rapidly changing and while life expectancy in the country has reached 70 years, the healthy life expectancy is significantly lower at 63.5 years.
• This gap highlights a growing burden of non-communicable diseases (NCDs), disabilities, and an ageing population increasingly requiring long-term healthcare.
• With private health insurance out of reach (especially for those engaged in informal labour [92% of the workforce]) for many elderly individuals due to exorbitant premiums, the government’s intervention is critical.
• Currently, only 20% of people over 60 years have health insurance coverage, contributing to high levels of impoverishment due to catastrophic healthcare expenditures (CHE), particularly among the elderly.
• The government's move to extend health coverage through AB-PMJAY, thus, appears timely and necessary.

A Critical Gap in the Announcement: Financial Burden and Insufficient Allocation

• While the government claims that the extension will benefit 4.5 crore families, preliminary estimates suggest otherwise.
• The allocated Rs 3,437 crore appears insufficient to cover all eligible beneficiaries.
• According to population projections and hospitalisation rates derived from the Longitudinal Ageing Survey of India (LASI), 5.6 crore households could be eligible for the scheme.
• After accounting for those already covered under employer-based schemes, the remaining 43.5 lakh families would need healthcare coverage.
• Using average hospitalisation costs derived from LASI data (Rs 32,804 per year), the scheme’s actual cost would be Rs 14,282 crore annually, over four times the current budget allocation.
• This discrepancy points to a serious financial shortfall, suggesting that the scheme, while well-intended, is not adequately funded to achieve its stated objectives.

Broader Healthcare Coverage Gaps in ABPMJAY Extension

• The Exclusion of Outpatient Care for Elderly
  • Outpatient care plays a critical role in preventive healthcare, early detection of diseases, and the ongoing management of chronic conditions.
  • In fact, outpatient services account for nearly 46% of total healthcare expenditure in India.
  • For elderly individuals, regular doctor visits, medical tests, and minor treatments are necessary to keep their health in check.
  • Most NCDs require periodic consultations with healthcare professionals, diagnostic tests, and adjustments in treatment protocols — all of which fall under outpatient care.
  • For example, a person with diabetes needs regular blood sugar monitoring, medication adjustments, and dietary consultations.
  • Similarly, individuals with hypertension need regular blood pressure checks and medication management.
• Risk of Out-of-Pocket Expense
  • By excluding outpatient services, the AB-PMJAY forces elderly individuals to bear out-of-pocket expenses for these essential services, which is particularly burdensome for those in lower-income brackets.
  • It contradicts the scheme’s goal of protecting households from catastrophic healthcare expenditures (CHE), as outpatient costs accumulate over time, potentially leading to significant financial stress.
  • Without insurance coverage for outpatient services, the elderly, who are more likely to have frequent healthcare needs, are left vulnerable to impoverishment despite having hospitalization coverage under the scheme.
• Exclusion of Long-Term Care
  • Another major gap in the AB-PMJAY is the exclusion of long-term care, a critical aspect of healthcare for the elderly.
  • With ageing, the prevalence of chronic conditions and disabilities increases, requiring continuous care over an extended period.
  • Conditions such as stroke, Parkinson’s disease, dementia, and severe arthritis often render elderly individuals bedridden or significantly disabled, necessitating long-term medical and caregiving support.
  • Many of these conditions are not curable but can be managed to improve the quality of life through sustained care.
• Risk of Decline in Health
  • The current AB-PMJAY scheme does not provide for long-term care services, leaving a significant gap in the continuum of care for the elderly.
  • This omission is especially problematic given that many chronic diseases, such as cancer, cardiovascular diseases, and respiratory conditions, require ongoing treatment and rehabilitation even after hospitalisation.
  • Without coverage for long-term care, elderly individuals are at risk of experiencing a decline in their overall health and quality of life once they are discharged from the hospital.
• Lack of Public Health Infrastructure and Over Reliance on Insurance
  • One of the central limitations of the AB-PMJAY extension is that it focuses too heavily on insurance-based coverage without addressing the critical need for improved public health infrastructure.
  • India’s public health spending has stagnated between 0.9% and 1.35% of GDP for the past seven decades.
  • The over-reliance on insurance-based schemes without strengthening the public healthcare system may lead to a more expensive healthcare model, similar to the one in the US, which has been criticised for its high costs and inequitable access.
  • By contrast, the Canadian and European models of healthcare view health as a public service and treat it as a human capital investment, leading to better health outcomes overall.

Ways Ahead to Address Healthcare Coverage Gaps

• Inclusion of Outpatient and Long-Term Care
  • To truly ensure the well-being of India’s ageing population, the AB-PMJAY must evolve to include outpatient and long-term care services.
  • The current focus on secondary and tertiary care is insufficient in addressing the complex and continuous healthcare needs of the elderly.
  • Policy reforms that integrate these services into the public healthcare system would not only improve health outcomes for the elderly but also help reduce the financial burden on families and the healthcare system.
• Investment in Public Health Infrastructure and Training Facilities
  • Furthermore, the government must invest in training healthcare professionals, including geriatric specialists, nurses, and caregivers, to meet the specific needs of an ageing population.
  • Infrastructure improvements, such as the development of geriatric care centres and the inclusion of home-based healthcare services, are also necessary to support the growing demand for long-term care.

Conclusion

• The extension of AB-PMJAY to cover older adults is an important policy intervention, but it is insufficient to address the healthcare challenges faced by India’s ageing population.
• The scheme's limited scope, financial inadequacy, and exclusion of critical healthcare services like outpatient and palliative care hinder its effectiveness in promoting healthy ageing.
• To truly support the elderly and ensure their well-being, India must significantly increase its public healthcare spending, improve healthcare infrastructure, and integrate preventive care into its healthcare policies.