Prakash* and Seema Yadav* were crestfallen on being told by the doctor at a hospital in Bihar that their one-year-old had a congenital heart disease that needed surgery at the earliest. This cannot be done in Bihar, he said, advising the parents to take the first train out and get it done at a better equipped hospital in Delhi or Mumbai.

As the family dealt with the sadness of having to put their infant through surgery, Prakash was hopeful that the cost would be taken care of, as they were covered by the Centre’s Ayushman Bharat health insurance programme.

That comfort unfortunately was not to be when Seema and the increasingly unwell infant arrived in Mumbai, Prakash’s place of work. Public hospitals were bursting at the seams with patients and children. And private hospitals were beyond his pocket. And to his rude shock, Prakash discovered that his Ayushman Bharat (AB) card was not acceptable to them.

Eventually, Prakash was given the names of private and charitable health institutions that were on the Ayushman Bharat website as empanelled hospitals.

But here too, Prakash’s AB card was not accepted. Instead, he was told that only the Maharastra state insurance scheme would be applicable. Unfortunately, Prakash had not taken that cover as he had been told it was reserved only for those hailing from the State.

Falling through the cracks between Central and State insurance programmes, Prakash is now running from pillar to post, besides cobbling together ₹2 lakh and more, to get the baby’s surgery done in any hospital that would do it with the urgency it merits.

This harrowing experience is all too familiar in healthcare. But the added disappointment of falling in the insurance blindspot of different Government programmes is getting reported from other States too, say people working with hospitals and healthcare agencies across the country. This is a basic gap that the Centre needs to fix, as the Ayushman Bharat programme completes six months and continues its journey to get more hospitals on board.

Independent health researcher Ravi Duggal observes that instances are being reported of patients not getting the financial support they were entitled to for systemic reasons, including one Government cover not being recognised in another State. Private hospitals and doctors were reluctant to get onto the AB programme, as they find it badly designed, not capturing their realities in terms of costs. And for those on the scheme, there was the standard rumble on delayed payments, he says.

Unwilling to be named, the head of a charitable hospital keen on becoming part of the AB programme suggests that the Centre have different pricing, depending on whether the medical procedure is done in a rural area, a small city, or a large metro. The costs that a large hospital has to bear in a large city increase manifold — from the electricity cost to other inputs, nurse and supporting staff costs, to name a few, he points out. The reason why State health insurance works with fewer problems is because it has better pricing structures and payments, he says.

The roll-out of AB was not without its glitches and the Centre has been in dialogue with private hospitals and doctors to iron out differences on pricing, for instance.

Many healthcare specialists are uncomfortable with the insurance model that takes care of an individual only when hospitalised. They urge the Government, instead, to pursue a universal healthcare approach where out-patient treatments are also covered. But till such time, given that the AB juggernaut is on the roll, they say, the Government needs to ensure a mutual recognition of the different insurance covers across the country. “Can you recall a situation where a patient is turned away from All India Institute of Medical Sciences or Tata Memorial Hospital because they belong to a different State?” asks Indranil Mukhopadhyay, a health economist and Assistant Professor, OP Jindal University, on the absurd situation where different Government-run insurance programmes are not recognised within the same country.

‘Unnecessary complication’

As patients get enrolled in Government insurance programmes, premiums are paid to companies, but patients still don’t get the benefit of free healthcare, he says, despite payments being made. “We are complicating matters that are quite simple,” says Mukhopadhyay, bringing the attention back to basics in terms of investing in and upgrading primary health centres and public hospital infrastructure. Hospitals across the country should be empanelled to accept any Government-run health insurance programme, he says. The present system of discriminating between different Government-run health insurance programmes only takes the country one step away from offering universal healthcare to all its people.

*Names changed to protect identity of the patient family

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