Opinion: Dr George Paul
Will Modicare ensure quality healthcare?
Thursday, September 27, 2018

The state indemnifying the poor for health benefits is neither new, nor revolutionary. It was first implemented as the Rashtriya Swasthya Bima Yojana (RSBY) a decade ago (2008) and adopted by several states.

Kerala now has the CHIS which provides up to 1 lac insurance for the BPL. Additionally, it has a premium slab for BPL and APL which is unique. The poor have to pay a token premium of Rs 30 and the others the full premium.

Kerala, which also has a 92% enrolment was used as the template for the recently launched Ayushman Bharat scheme, as two former IAS officers, including Dinesh Arora a former Kerala Health secretary, are now members of the NITI Ayog. They cited Kerala as an example of successful implementation of the insurance scheme. Tamilnadu was not far behind when it rolled out the Kalaignar scheme in 2009 ( later to become the TN CM's Insurance scheme), followed by the Karnataka Government's Arogya Scheme etc.

Post-2008, all states in the South and some in the North adopted the policy of the state indemnifying the poor against health events. While the insurance was for 1.5 to 2 lacs in most states, the insurance payout exceeded this amount in several special situations. 

There are now some grave concerns about whether patients in the Southern states like TN are going to lose out because of the Ayushman scheme because the payout for individual procedures are far below what the state governments have already been providing. So, while the figure of 5 lacs per family looks impressive, the amount allocated for individual procedures are pathetically low and it would be impossible to deliver quality care as envisaged by the central government. 

As a maxillofacial surgeon, who has been operating under the TN state's Insurance schemes for the last 10-12 years, let me cite by example -- the TN CM scheme pays a total of Rs 18,000 for treatment of a facial fractures in an A2 category hospital, while the same procedure under the Ayushman scheme has a payout of only Rs12,000/.

A more complicated procedure called Arthroplasty for TMJ ankylosis ( jaw bone joints are frozen to the extent the patient cannot chew or eat) can be done in the TN state insurance scheme for Rs36,000. The procedure is challenging to both the anesthetist and surgeon and may take up to 4 hours to perform with considerable risks for everybody. The Ayushman Scheme offers only Rs 15000. It is impossible to do this procedure under General Anaesthesia ( GA) in a safe environment. The surgery involves admission in a hospital for at least 3-4 days.

It involves an anaesthetist, a surgeon, an operation theatre, technicians, nurses, advanced anaesthesia machines costing several lacs, anaesthetic gases and medicines for 4-5 hours, possibility of a tracheostomy ( or expensive equipment for inserting the tubes in a closed mouth), post-operative recovery or even an ICU, post-operative drugs, physiotherapy devices to prevent re- ankylosis etc. We have not taken into account the other standard requirements like infrastructure, investigations, and staff for logistics and paperwork. This amount is grossly insufficient and anybody who has done a bilateral TMJ ankylosis correction will agree.

There is an even more problematic allocation for an even more complex disease. The Ayushman insurance pay-out for surgical treatment for oral cancer and reconstruction is a paltry Rs6000/. This will not even cover the basic investigations. The TN scheme offers Rs 45,000 ( at least on paper). Even that is grossly inadequate.

Are we, therefore, looking at meaningful health care or a jugaad or a temporary illusionary fix for a health scenario that is abysmal, to begin with?  

What India needs is a meaningful universal health care provided by a government that really cares for its citizens and not their votes. When the state can take care of the health of the last of its citizen as in most European countries or even China, health policies would truly be transformational. Everything else is a delusion. When our elected representatives and bureaucrats chose to get treated by the system they so wholeheartedly promote, it will be the day when welfare health will truly be a reality.


(The writer is a well-known oral and maxillofacial surgeon with degrees in law and medical ethics. Views expressed are personal)


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