'Extended health cover would give seniors more access to public, private hospitals': Expert speaks on AB PM-JAY expansion 

Ayushman Bharat cover: The Union government's recent decision to expand the coverage of the Ayushman Bharat Pradhan Mantri Jan Arogya Yojana (AB PM-JAY) to include senior citizens aged over 70, regardless of their income, is seen as a commendable step towards providing essential health coverage to approximately 60 million individuals.

Initially, Ayushman Bharat offered a health insurance cover of up to Rs 5 lakh to families living below the poverty line. Earlier this week, the scheme was extended to include all senior citizens, irrespective of their income levels. This comprehensive health insurance scheme offers a substantial coverage worth Rs 5 lakh per family and operates on a family-centric approach. 

The funds allocated for this expansion amount to Rs 3,500 crore, a figure deemed feasible considering the cost restrictions enforced by the government on medical procedures. Nonetheless, this development has led to apprehension among major private hospitals regarding the implications of the scheme on their operations. 

"The AB-PMJAY originally covered only economically vulnerable families in both urban and rural India. Introduced in 2018, the scheme provides health insurance coverage of up to Rs 5 lakh per family per year for secondary and tertiary care hospitalisation. This has now been extended to all senior citizens above the age of 70. This move strengthens social security for vulnerable seniors as it may not always be possible for them to have independent access to private health insurance. So, this move can provide critical financial relief for elderly healthcare and improve their access to necessary treatments," said Adhil Shetty, CEO, BankBazaar.com. 

Shetty noted a couple of points about the new scheme:

1. The program offers comprehensive health insurance coverage of up to Rs 5 lakh per family annually for secondary and tertiary care hospitalisations.
2.  This expansion plays a crucial role in enhancing the social security safety net for elderly citizens who may face challenges in obtaining private health insurance independently. 
3. By extending the scheme to cover senior citizens, it aims to alleviate the financial burden of healthcare expenses for the elderly and facilitate their access to essential medical treatments.
4. The top-up for senior citizens is separate from the family’s shared coverage.

"Under this clause, senior citizens aged 70 and above, who belong to families already covered under the AB-PMJAY, will receive an additional health insurance cover of up to ₹5 lakh per year exclusively for themselves. This top-up is separate from the family’s shared coverage, ensuring that elderly members can access healthcare without affecting the coverage limits of younger family members," Shetty added. 

5. The additional financial protection to elderly individuals aged 70 years and above is a boon for those who are already enrolled in private health insurance or the Employees' State Insurance (ESI) scheme. 

6. Through this program, eligible senior citizens will be granted supplementary health insurance coverage of up to Rs 5 lakh annually, effectively enhancing their current insurance benefits.

7. Beneficiaries will have the opportunity to utilise an extensive network of authorized public and private hospitals affiliated with AB-PMJAY, resulting in a more thorough healthcare protection. 

8. Furthermore, participants can take advantage of cashless hospitalization services, which help alleviate the burden of upfront payment costs.

"The seniors will receive an extra health insurance cover of up to Rs 5 lakh per year specifically for themselves, supplementing their existing insurance. They will have access to a large network of empaneled public and private hospitals under AB-PMJAY, meaning a more comprehensive healthcare coverage, as well as cashless hospitalization that reduces the financial strain of upfront payments," Shetty added further. 

Wider net

Under AB-PMJAY, the annual health coverage of Rs 5 lakh is expected to benefit approximately six crore individuals, constituting roughly 5% of the country's current population. As life expectancy rises and the number of elderly individuals increases in the coming three decades, it is projected that one-fifth of India's population will be over the age of 70 by the year 2050. 

Addressing the challenges brought about by the demographic transition involving the aging population requires significant reforms in welfare policies. Currently, about 20% of the elderly population can access safety nets like the Central Government Health Scheme (CGHS), Rashtriya Swasthya Bima Yojana, and employer-sponsored health schemes. Expanding the coverage of the nation's publicly-funded health assurance program would be a crucial step towards improving the quality of life for this specific demographic segment.

A position paper published by Niti Aayog in January 2024 emphasized the increasing importance of ensuring senior citizens' access to high-quality healthcare, especially considering the prevalent shift towards nuclear families.

The paper underscored the critical importance of having an adequate number of healthcare centers and facilities specifically designed for the elderly. These resources play a crucial role in shaping the health-seeking behavior of older individuals, in addition to offering them a sense of financial security. It is recommended that policymakers place a high priority on enhancing the healthcare infrastructure to address the unique needs of the growing aging population.