Despite nudges from the regulator, the vast majority of India’s senior citizens remains unprotected by health insurance. Even within the affluent population, seniors face high policy rejection rates, are forced to endure long waiting periods on pre-existing conditions and face steep premia which make insurance unaffordable. Therefore, the Centre’s decision to expand Ayushman Bharat Pradhan Mantri Jan Arogya Yojana (PM-JAY) the state-funded health insurance scheme for disadvantaged citizens, to universally cover all citizens above 70 years of age, was much-needed. Six crore seniors are expected to receive free insurance coverage of up to ₹5 lakh a year, with the costs fully funded by the Central and State governments. Seniors in families already covered by the scheme will get an exclusive top-up of ₹5 lakh, while those in non-covered families will get a family cover of ₹5 lakh a year.

Warts and all, PM-JAY has managed to reduce the out-of-pocket healthcare costs borne by ordinary Indians. In the six years since its rollout, PM-JAY has expanded its coverage to 35 crore individuals and defrayed health care costs of up to ₹1.07 lakh crore, funding 7.8 crore hospital admissions. The scheme has also contributed to the upgradation of over 1.74 lakh primary health centres into Ayushman Arogya Mandirs for primary care, and empanelled over 30,500 private and public hospitals for secondary and tertiary care. But the scheme may need a few tweaks to cover healthcare needs of seniors.

For one, PM-JAY allows reimbursement of bills only on hospitalisation. In order to prevent misuse and over-billing, the Centre has specified a standard set of packages and tariffs. However, treatments availed by seniors will differ significantly from younger patients. There is a need to expand the existing list of packages and rates. Two, PM JAY-approved hospitals often turn away patients because of delayed payments of bills by the States. These delays need to be addressed. But most important, despite the availability of public hospitals, over 70 per cent of Indians turn to private hospitals, many of them providing poor quality healthcare. This has posed a challenge to the working of PM-JAY. Data show that of the 13,449 private hospitals empanelled with the scheme (barely half the total number of PM-JAY hospitals), a majority are small sub-50-bed facilities. There are complaints of patients being turned away in emergencies because of private hospitals being reluctant to provide treatment at PM JAY-approved rates. They are subjected to needless procedures as well.

The only solution is for States to beef up public healthcare infrastructure and for the Centre to create greater awareness so that patients seek out public instead of private hospitals. The government should also set up geriatric care facilities to reduce long waiting times. Given that the private healthcare system is all but broken in India, PM-JAY would be more effective if it were to rely on a well-developed public health infrastructure.