Why universal medical insurance is on the way

Dr KK Aggarwal

Universal health care (universal health coverage, universal coverage, universal care, or socialized health care) is a national health care system that provides health care and financial protection to all citizens of a country. It provides a specified package of benefits to all members of a society with an aim of providing financial risk protection, improved access to health services, and improved health outcomes. The health care does not cover everything for everyone.

The critical components are

·         Who is covered?

·         What medical services are covered?

·         How much of the cost is covered?

As part of Sustainable Development Goals (SDGs), United Nations member states have agreed to work toward worldwide universal health coverage by 2030.

In India with a population of 133.92 crores, Ayushman Bharat will cover 50% of the population (40% or 50 crore people in conventional scheme + additional 10 % people with income less than 8 lakh per annum). For them insurance premium will be paid and shared by the central government (60%) and state government (40%) from the central and state taxes collected from the people.

Another 32% of the population is medically covered by Employee State Insurance (ESI) (8% employees + 10% unrecognised sector); Railway (9%); Defence (1.1%), state health insurance schemes (1%), Municipal corporations (1%); CGHS (36,67,795 people) and PSUs (0.75 crore family beneficiaries) [1%] another 1% is covered through private companies (corporates).

The remaining 18% of the population comprises people with annual income of more than 8 lakh per annum who can easily afford individual private insurance.

To make universal coverage possible the options include:

·         The government should make it mandatory to have insurance for those not covered by any government, PSU or NGO scheme.

·         Like ESI, it should be mandatory to have the employee insured by the employer as part of his or her salary package.

·         Around 41% of the population has some life cover, which should provide some medical cover.

·         Any individual with salary up to Rs 21,000 per month is entitled for ESI insurance; this should also be allowed for all those will salaries less than Rs 8 lakh per annum.

·         Ayushman Bharat provides coverage for up to 5 lakh for the family. However, most packages are capped, and the average expenditure is only Rs 18000/- per admission. Till today in the last 4 months, only 10 lakh people have been treated with an expenditure of only Rs 1800 crores (@ Rs 18000/- per person). At this rate, the annual expenditure will be only Rs 7200 crore (shared by center and state in a ratio of 60:40). This amounts to very little for the country.

·         If required, the government can cover additional 18% of the population also. With this the government will be able to ensure coverage for 100% population and provide general ward basic and emergent treatment to all admissions

For this to happen the government must also ensure affordable health care by implementing one company - one drug - one price policy; incentives to open Ayushman-only hospitals by small healthcare doctor-owned setups and capping the prices of National List of Essential Drugs, devices, reagents, investigations, equipment and disposables.

The government should also make it mandatory for all establishments to provide 10% beds for Ayushman patients.

The cost of providing universal national immunization; “nationalizing” diseases and health issues of national importance like TB, AMR, Leprosy, cancer, dialysis and providing free treatments to all should continue via the national health annual budget, which itself should be raised by another 25% to be made around Rs 75000 crores. This budget should cover the proposed 1.5 lakh wellness centers.

To further improve the health budget, the total budget for environmental pollution (air, water, earth); budget for women and child health, mid-day school meal, Swachh Bharat, road safety, pharma sector, food industry etc. should be merged with an aim to reduce the disease burden.

The government should provide coverage only for general ward treatment. There will still be enough business left for private and national insurance companies for additional insurance coverage for private wards and diseases not covered under Ayushman Bharat.

Dr KK Aggarwal

Padma Shri Awardee

President Elect Confederation of Medical Associations in Asia and Oceania   (CMAAO)

Group Editor-in-Chief IJCP Publications

President Heart Care Foundation of India

Past National President IMA