Jagadeeshwaran*, a spry 90-year-old, was rushed to a cardiologist as he complained of chest pain after climbing to the rooftop for household chores.
He had always believed that an active lifestyle would keep his health concerns — high blood pressure, diabetes and a cardiac stent — under control.
His daughter, though, was worried whether the pain had to do with his stent. Would another procedure be required, and will it be covered under the recently expanded Ayushman Bharat, she asked the cardiologist.
While Jagadeeshwaran was advised more tests to determine treatment, his daughter’s query wasr related to the Ayushman Bharat-Pradhan Mantri Jan Arogya Yojana (AB-PMJAY) — recently extended to all citizens over 70 years. The scheme offers a ₹5 lakh coverage, irrespective of income levels.
Though it’s early days yet, the expanded scheme addresses a much overlooked segment, and will need to avoid the inherent pitfalls of the existing scheme.
Pros and cons
Senior cardiologist Dr Sivakadaksham expects the scheme’s extension to help with age-related illnesses. “The incidence of cardiac failure is less than 1 per cent in the population below 60 years and 10 per cent above 70 years. It is not cancer that’s deadliest, it is cardiac failure which requires hospitalisation in ICU,” he says.
Calcific cardiac stenosis, common in people above 65, requires aortic valve replacement, which costs about ₹7 lakh in the private sector. If the Ayushman scheme covers it, then it will be a boon for this age group, he adds.
Experts, however, worry that challenges in the existing scheme could spill over into senior coverage. “While the PMJAY is projected as a step towards universal health coverage, it is not as comprehensive as it claims,” says Soumitra Ghosh, associate professor and chairperson of Centre for Health Policy, Planning and Management at Tata Institute of Social Sciences.
“There are leakages at multiple levels. From our field visits to coastal communities in Kerala, we found that access to hospitals empanelled under AB-PMJAY is difficult. Big hospitals are not interested, because they are not getting the money from the government,” Ghosh alleges.
There is also concern over the cost of outpatient treatments or consultations (not covered under the scheme), leading to additional out-of-pocket expenses.
Ramesh* (35) has been relying on the combined PMJAY-CMCHIS (Chief Minister’s Comprehensive Health Insurance Scheme) for his 68-year-old mother’s dialysis at a private hospital in Coimbatore.
While the dialysis cost is covered, Ramesh bears the cost of medicines, scans, blood tests, doctor fee, and so on — which adds up to nearly ₹4,000 a month. “Emergencies are particularly nightmarish,” he says, especially getting to a hospital in the middle of night. “We often end up paying as they don’t approve the use of ‘free’ treatment,” he says, exasperated.
Other challenges include the cumbersome application process for the scheme, delays in receiving the ID card for treatment, and the limited number of hospitals supporting the scheme.
Bridging gaps
Narendra Bharindwal, Vice President of Insurance Brokers Association of India, points out, “While PMJAY is undoubtedly a significant step toward universal healthcare, it remains inadequate as a standalone health insurance policy for senior citizens. The ₹5 lakh coverage pales in comparison to the actual costs incurred.”
“Chronic conditions like diabetes, hypertension, and cardiovascular disease require ongoing medical intervention, which often exceed the financial limits of PMJAY,” he says.
Private health insurance offers a comprehensive coverage for India’s ageing population, but the steep premiums, exclusions, and stringent eligibility criteria make them inaccessible to many senior citizens, he observes.
“Introducing government-backed top-up plans could be a game-changer. These would allow senior citizens to access extended coverage... the lower tariffs negotiated under Ayushman Bharat’s hospital network mean that its ₹5 lakh coverage often equates to a ₹10 lakh private policy. This cost-efficiency, combined with government-backed top-up option, would bridge the gap between Ayushman Bharat and private insurance, enhancing the scheme’s appeal and functionality,” says Bharindwal.
Ghosh, instead, calls for strengthening existing public health infrastructure. Government health and wellness centres, for example, can help prevent and manage costly conditions involving the heart and kidney, leading to better outcomes and averting expensive hospitalisation.
As Centre and State seek to cover those in the 70-plus age group, the need is to make healthcare comprehensive and affordable, without administrative stumbling blocks.
*Names changed