The National Health Protection Scheme (Pradhan Mantri Jan Arogya Yojana) was launched in September 2018 amidst euphoria. But closer look at the blueprint released by the National Health Agency reveals that the patient could actually suffer many hardships. What is more saddening is that in spite of several studies analysing already existing government health insurance schemes, the newly christened PMJAY doesn’t reflect the important lessons learnt.
This analysis focuses on three issues.
Identifying poor families
First, let’s take the proposed methods of identifying beneficiaries. The NHA has stated that there would not be any (pre)enrolment process and instead, eligible households would be identified using the Socio Economic Caste Census data of 2011 (SECC).
Government documents say that ‘family letters’ would be sent to each household in the list with a QR code which lists the family member’s names. The NHA’s strategy is oblivious to ground realities whereby the poor (especially the urban) keep migrating and may not possess a consistent address, mobile number or a ration card, as laid down in Guidelines for Additional Collection Drive.
If family structures have undergone changes, the onus is put on the household to get the list corrected by providing birth or marriage certificates – provided one of the existing household members has Aadhaar. For those in the informal sector, it is not clear how the scheme would verify eligibility for the multiple jobs and transient nature of unorganised work.
Other research studies of different government health insurance schemes, including the author’s doctoral research, have highlighted exclusions of the most vulnerable sections from these insurance schemes because of outdated lists and lack of documents.
And even among those who could be eligible, the NHA is looking for ways to exclude people. Recently, the NHA issued a circular whereby households which own a landline or a two wheeler or a refrigerator would get automatically excluded.
Second, Modicare takes pride in labelling itself as a paperless scheme, but not for the patient. The Arogyamitra stationed at every empaneled hospital will verify the identity of the ailing person, his/her relationship to the family and whether he/she is entitled to receive the benefit by verifying documents. It is after this step, that hospitals initiate the preauthorisation process.
It is well known that the poor, due to financial and non-financial barriers, often delay seeking care and end up at the hospital in serious or critical conditions. It is impractical to imagine that the family will carry along the documents with them. The author’s own doctoral research in Tamil Nadu shows that a family member is likely to be sent back to fetch the letter, other identity cards or income certificate to complete just the Beneficiary Identification Process at the hospital.
The distances between residences, the hospital and offices can be extensive – especially for the rural and tribal populations, as none of the existing insurance schemes have improved the supply of inpatient services in underserved areas. Transportation and other indirect costs have been excluded in the proposed scheme as well.
Even though the government documents state that during emergencies, a Government ID proof is not compulsory, if it is not provided within the specified time, the beneficiary will have to pay for treatment.
Such procedures are set to burden anxious family’s with added expenditure besides costing valuable time for initiating treatment. Since patients need to pay for emergency cases if verification is not completed, private hospitals are often reluctant to admit patients without certified documents or insist on cash payments in advance. In this context, families may even – by choice or design – have to forego the insurance benefits because of expected delays and costs.
All things considered, patients may in fact prefer to just pay upfront to initiate treatment, and not avail the government’s scheme.
Thus, the hassle-free cashless feature promised in the scheme will not easily or likely be the norm. Similar findings on the failure of publicly funded health insurance schemes to provide cashless services have also been reported from Chhattisgarh and Maharashtra.
Impediments to ‘cashless’ service delivery
Third, NHPS promises to provide affordable and quality treatment care for the most vulnerable, but there is acute information asymmetry between the patient and the health provider on what exactly is included under that. In this environment, private providers have been found to “cherry pick” the cases which are profitable for them, giving them higher remunerations and denying treatments that are not high-end.
For example, during my doctoral research I came across the case of one 30-year-old woman living in rural Tamil Nadu who was told at the hospital that her leg surgery “costs only Rs. 35,000 and the CMCHIS card was meant for surgeries of one lakh or above”.
As private players cherry pick, with Rs 5 lakh now being promised under Modicare, hospitals would start focusing more on only those patients with requirements for high-end treatments than those presenting ailments requiring procedures whose package rates are less profitable. This is substantiated by research which has looked at the average claim of private hospitals for insurance, which is much higher than public hospitals.