The jumla called Ayushman Bharat

Pradhan Mantri Jan Aarogya Yojana (PMJAY), popularly known as Ayushman Bharat, is another jumla that the Prime Minister Narendra Modi-led NDA government threw at us.

We are not saying it just like that but will be backing up with facts.

Here is the post-mortem of Ayushman Bharat scheme which will prove that it is nothing but yet another jumla by the Modi government:

Claim: “This will be the world’s biggest health insurance scheme in the world and will benefit more than 50 crore people.” (PM Narendra Modi, Ranchi, Jharkhand, September 23, 2018) 

Reality: Households covered under the Pradhan Mantri Jan Aarogya Yojana (PMJAY) is lower than under the number of households previously covered by the Rashtriya Swasthya Bima Yojana (RSBY) (introduced by the UPA government) and various state health insurance schemes.

According to the National Health Authority, 11.2 crore households (equivalent to 56 crore individuals) were covered under existing state and central schemes in 2017-18. PMJAY covers 10.7 crore households (or 54 crore individuals). Some examples:

• In Maharashtra, 2.3 crore households were covered under the Rajiv Gandhi Jeevandayee Arogya Yojana (later renamed the Mahatma Jyotiba Phule Jan Arogya Yojana). However, only a third of those households (84 lakh) qualify for PMJAY. This way the Modi government pays only 22% of the premium of those covered by health insurance.
• In Chhattisgarh, 40 lakh households were previously covered under the RSBY and the Mukhyamantri Swasthya Bima Yojana (MSBY) but only 37 lakh households will be covered by PMJAY. This has forced the state government to dip into its own coffers to cover the excluded.

Claim: “The Modi government has set up a scheme called “Modicare” under which it has given these families Rs 5 lakh a year to pay for families that have grave illnesses.” (PM Modi, Nizamabad, Telangana, November 27, 2018) 

Reality: The claim that “Modicare” has provided each household insurance cover of Rs 5 lakh is a huge fraud. The cheapest equivalent private-sector plan in the market for a family headed by a 30-year old costs Rs 5,252 per year. Most plans are in the range of Rs 10-15,000. PMJAY claims to provide the same for Rs 1,100, with a central contribution of Rs 660.

In Chhattisgarh the state government calculated that the Rs 1,100 premium is enough to cover only Rs 50,000 and made insurance firms bid for only Rs 50,000 insurance cover. All claims above Rs 50,000 and Rs 5 lakh are paid by the state insurance trust, the Mukhyamantri Sanjeevani Sahayata Kosh Yojana, to which the centre contributes zero. The state government calculates the actual cost of providing Rs 5 lakh cover as Rs 2,000 per year. The claim that “Modicare” is giving Rs 5 lakh of insurance to the people is a classic jumla.

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Claim: “Earlier poor patients were left to die. They did not have access to adequate healthcare.” (PM Modi, Jaspur, Gujarat, March 04, 2019) 

Reality: Patients will not have access adequate healthcare under PMJAY because it excludes outpatient treatment, which 87% of ailing persons undergo.

Outpatients are people with health problems who visit hospital for diagnosis or treatment, but do not at the time require a bed or to be admitted for overnight care.

Outpatient treatment is a serious financial burden that accounted for 63% of the Rs 4,955 spent by households out of their pockets on health in 2014.

The Modi government’s lack of focus on primary healthcare reflects in its spending priorities. Under the National Health Mission, 1.5 lakh primary health centres and sub-centres are to be upgraded into Health and Wellness Centres. However, measly budget allocations of Rs 1,200 crore in 2018-19 and Rs 1,600 crore in 2019-20 show a lack of serious intent.

OTHER LOOPHOLES: 

PMJAY does not cover a wide range of diseases and treatments that afflict millions. Here is a sample of common medical conditions that are not treated by PMJAY:

• Diabetes. Diabetes is widespread in India and requires regular treatment and investigations like sugar and haemoglobin tests over many years. But these are not covered by PMJAY. Only if your disease worsens and you get complications like a diabetic foot that needs amputation then you can avail PMJAY funds.
• High blood pressure. High blood pressure, or hypertension, needs continuous monitoring and treatment, often over decades. However chronic treatment is not covered under PMJAY. PMJAY will only help you if you neglect your condition and develop serious complications like stroke, heart attack or kidney failure that require hospitalisation.
• Back pain. Lower backache is a common condition that requires investigation, oral drugs and physiotherapy for a few weeks. None of this is supported by PMJAY. But if the patient gets paralysed and is hospitalised, only then will PMJAY

So, until and unless your disease turns into a life-threatening one, you cannot avail the scheme. 

PMJAY incentivises fraud and overtreatment. Fraud, overtreatment and overdiagnosis are common risks in insurance-based healthcare. However the government is making no serious investments in the capacity to monitor and regulate these issues, even though the quantum of coverage is being ratcheted up to Rs 5 lakh.

The PMJAY model tender document prepared by the Modi government gives considerable leeway to hospitals and health providers to engage in fraud before serious penalties like de-empanelment occur. A hospital is permitted to commit ten offences (two offences each under five categories) before being de-empaneled (see Appendix A below).

In line with the Modi government’s autocratic instincts, it is hiding data about PMJAY’s activities. The Ayushman Bharat dashboard is inaccessible to the public and to researchers, and information is being tightly controlled to prevent any informed discussion about this programme that is ostensibly transforming public health in India.

In a further use of public funds for private benefit, the government on January 09, 2019 issued guidelines to provide private firms with land and upto 40% viability gap funding.