Universal health coverage - a distant dream or in our foreseeable future?

Universal health coverge - a distant dream or in our foreseeable future?

Inclusive health insurance is a term that gets thrown around a lot. The World Health Organization defines it as “ensuring that all people can use the promotive, preventive, curative, rehabilitative and palliative health services they need, of sufficient quality to be effective, while also ensuring that the use of these services does not expose the user to financial hardship.” It is an ideal situation—one in which healthcare is affordable and accessible to people of all strata in society. But how effectively can such an all-encompassing scheme really be implemented? And how much progress has India made so far towards making this a reality? An Insurance Regulatory and Development Authority report quoted in an article from The Hindu estimates that only 17% of the Indian population were covered by health insurance as of 2014. Availability is not the issue. A range of plans are on offer from both the public and private sectors, but they are either inaccessible to most of the population or unsustainable for the scheme providers, resulting in an appallingly low proportion of individuals who are actually insured.

Both public and private insurance plans should be self-financing in the long run. They should take advantage of the fact that a very small proportion of the population will actually incur major medical expenses, while ensuring a steady stream of revenue by making sure that everyone is paying for coverage regularly. So a smart plan would include a nominal monthly premium, from which the insurer would be able to cover pay-outs for treatment and also make a profit—incentivizing the patient, payer and provider to do their jobs well/effectively.  

In the public sector, there are four companies, all of which offer different versions of a Mediclaim Policy, but coverage is capped depending on premiums and even the ages of policyholders. The Insurance Regulatory and Development Authority of India, which is responsible for legislating public and private health insurance plans available in the country, recently closed a loophole that prevented older citizens from renewing their policies. Lifelong renewals were established in 2013.

In the private sector, there is a lot of choice, but I want to explore one in particular that could be called a (moderate) success story—Yeshaswini. Yeshaswini is a micro-insurance program, the brainchild of renowned cardiac surgeon and entrepreneur, Dr. Devi Prasad Shetty, and implemented by the government of Karnataka in 2003. It promised to cover all farmers (and peasants) in Karnataka for tertiary healthcare needs through a cashless model: every member of every family covered pays Rs. 5 per month (Rs.120 per year), and is thereby insured for any surgical needs that might arise. The plan was designed with the intention that that the insurer would be more than able to cover the payout-events when they arise, accounting for the fact that only 3% of the population will actually require a major surgery. Although the plan seemed simple enough, the implementation proved to be quite difficult. The state government of Karnataka was largely responsible for managing the large payer base, which resulted in a lot of delayed payments and administrative issues. Additionally, enrolling rural farming families required a fool-proof way of identifying and verifying eligibility before cards are issued. A unique identification system was still not within reach in Karnataka then, and regulating who actually used the Yeshaswini cards became a challenge. Patients who could easily afford to pay for services were using the subsidized insurance scheme, while those who needed it fell through the cracks. Additionally, the rates set by the Yeshaswini policy makers were much lower than the walk-in rates at the private hospitals. Many refused to accept patients covered by Yeshaswini. A study by the Harvard School of Public Health also supports a move away from solely publicly-financed healthcare: most public sector spending accounts for tertiary hospital care instead of preventive primary care, tipping the healthcare scales largely in favor of a wealthier urban population. The rural population’s needs are left unaddressed.

A public-private partnership seems to be the most practical and easily-implementable solution to this issue. Additionally, in a country like India, where 74% of healthcare expenditure is private (according to a 2015 India Brand Equity Foundation report), the contribution of the private sector to healthcare provision can hardly be ignored. The public and private sectors need to split their responsibilities to ensure that health insurance schemes in the country are truly inclusive.

Additional Reading:

1. https://www.who.int/health_financing/universal_coverage_definition/en/
2. https://www.ibef.org/industry/healthcare-india.aspx
3. https://www.thehindu.com/news/national/only-17-have-health-insurance-cover/article6713952.ece
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