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In a major policy development, the Union Cabinet approved universalisation of health coverage under the Ayushman Bharat—Pradhan Mantri Jan Arogya Yojana (AB-PMJAY) to all Indians above 70 years of age on 11 September 2024. Earlier this year, Prime Minister (PM) Modi had announced at the launch of the BJP’s election manifesto that the government was determined to include every senior citizen above 70 years of age in the PMJAY scheme. However, with the latest Budget in July 2024 silent on the expansion, there were fears that the implementation of the expansion may get delayed at least by a year. According to government sources, this massive expansion of the scheme is to benefit around 45 million families across India. With upcoming elections in Jammu and Kashmir, Haryana and Maharashtra later this year, this move is expected to reap rich electoral dividends.
According to government sources, this massive expansion of the scheme is to benefit around 45 million families across India.
This expansion of the AB-PMJAY into non-poor households can be considered a first step of many to follow offering financial protection to the Indian middle class during health emergencies requiring hospitalisation care. An earlier paper from ORF at the launch of the scheme in 2018 had suggested offering AB-PMJAY policy to non-poor households at an affordable premium. In recent years, various media stories have appeared on plans to include 400 million non-poor citizens into the AB-PMJAY fold, but no concrete decision had been announced until now. What the current cabinet decision has done is subsidise the premium for the most vulnerable within the non-poor population, which is a commendable step.
As shown in Figure 1 exploring the 21st century demographic dynamics in India, the 70+ aged population has grown from 2.8% of the Indian population in 2001 to 4.3% in 2021, and is expected to double by 2031. According to a recent report by the NITI Aayog on senior care reforms, only around one-fifth of the elderly population (60+) in India is covered by health insurance, while nearly 78% remain without any pension coverage. As a result, a substantial proportion of healthcare expenses of the older population in India is financed out of pocket, putting their families at risk of increased vulnerability to financial crises.
Source: Data compiled from Elderly in India 2021 report by the Government of India
While around 20% of the 60+population is covered by insurance, latest data available at the population level from the Longitudinal Ageing Study in India (2017-18) suggests that there are substantial differences in insurance coverage among different age categories within the 60+ population. As Figure 2 shows, both 70-79 years and 80+ sub-populations in India had considerably lower health coverage as opposed to the 60-69 population. In addition, as the NITI Aayog report notes, many among the elderly reach old age without sufficient savings or pensions to live on or to support their long-term care. It is estimated that almost 70% of the elderly are dependent for everyday maintenance on family and relatives, putting economic pressure on the households. By offering universal coverage to the 70+ population of the country, the government of India is trying to change the status quo.
Source: Based on the Longitudinal Ageing Study in India (2017-18) reproduced from the India Ageing Report 2023 by UNFPA India.
The expansion of AB-PMJAY is part of a series of policy initiatives addressing issues of the elderly population. Major reforms within elderly care in India began with the National Policy on Older Persons (NPOP) in 1999, aimed at providing care and protection for vulnerable elderly individuals, along with the constitution of a National Council for Older Persons (NCOP). In 2007, the Maintenance and Welfare of Parents and Senior Citizens Act aimed at providing adequate medical facilities and security for the elderly.
Reflecting these two developments, the ministry of health and family welfare launched the National Programme for the Health Care of Elderly (NPHCE) in 2010-11 to address health issues specific to the elderly. In 2011, the National Policy on Senior Citizens expanded the focus of the NPOP to accommodate evolving challenges. The National Council of Senior Citizens (NCSrC), a more inclusive version of the NCOP, was established in 2012 to monitor these efforts. In 2020, the National Action Plan for the Welfare of Senior Citizens (NAPSrC) was introduced, further strengthening support systems with four key sub-schemes for senior welfare. Provision of adequate medical care to the elderly population was an underlying theme across these initiatives, and the current expansion is a substantial contribution towards addressing this major policy concern.
A look at the usage data of AB-PMJAY shows that the elderly population (60+) comprises of 14% of the more than 350 million Ayushman card holders, who have accessed the scheme. At the same time, almost-one-fourth of all authorised hospital admissions, amounting to 69 million, under AB-PMJAY from its inception in 2018, were of patients aged 60 or above. In line with the inclusion criteria of AB-PMJAY till now, these patients were from poor and vulnerable households. With the current expansion into the non-poor households, these proportions are going to go up in the years to come, offering respite to millions of families across the country.
Source: Data compiled from the AB-PMJAY Dashboard by the Government of India
The government of India plans to implement the expansion soon, and the existing AB-PMJAY structures will be used to roll out the scheme. However, concerns about awareness of government health insurance amongst the neediest remains an issue that may aggravate with age. A study based on a pan-India survey from 2021 found that although over 70 percent of households across India reported that they were aware of the PMJAY scheme, scheme awareness was lowest among households in the bottom two quintiles—precisely the population who need the most assistance. Access to mass media and new media could be a challenge among the elderly, and this existing problem may be amplified withing this age group. Awareness among the target populations remains a bottleneck within AB-PMJAY, despite information, education, and communication campaigns, which necessitates starting innovative interventions in low-awareness states.
Figure 5: Reasons for elderly not being covered under health insurance schemes (2017-18)
Source: Based on the Longitudinal Ageing Study in India (2017-18) reproduced from the India Ageing Report 2023 by UNFPA India.
Latest available data, although from the pre-PMJAY era, underlines these concerns. The Longitudinal Ageing Study in India (2017-18) found that a vast majority of the elderly in India is not aware of health insurance (Figure 5). A substantial proportion of the elderly population of India also found the existing health insurance schemes unaffordable. While making AB-PMJAY universal for the 70+ population is a welcome step to address the latter problem, the awareness deficit may prove to be a binding constraint. Mass campaigns with the help of local governments are needed to reach every household with elderly members who are over 70 years of age.
Interestingly, the Senior Citizen Health Insurance Scheme (SCHIS) launched in 2016 had offered a modest top-up cover of INR 30,000, in line with the then RSBY scheme to every elderly member of the RSBY household, with the additional cover in multiples based on the number of elderly members in the same household.
After the initial results of the implementation of the new scheme come in, perhaps it will be prudent to apply this clause to AB-PMJAY as well, given the increased vulnerability of households with more than one elderly member over 70 years of age, which are relatively low in number. In the future, AB-PMJAY needs to be offered for free to the population aged 60-69 years as well, in line with India’s elderly policy objectives. As discussed elsewhere, India’s journey towards health for all requires that the hundreds of millions of non-poor population at constant risk of health shocks are offered affordable ways to be part of the AB-PMJAY risk pool. The current expansion of the scheme into the non-poor households through enrolment of the 70+ population at zero cost to the household, will hopefully accelerate policy action on that pending decision.
Oommen C. Kurian is a Senior Fellow and the Head of Health Initiative at the Observer Research Foundation
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Oommen C. Kurian is Senior Fellow and Head of Health Initiative at ORF. He studies Indias health sector reforms within the broad context of the ...
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