Health Insurance Schemes in India: Bridging Gaps in Universal Health Coverage

India’s public health insurance — led by PM-JAY and State Health Insurance Programmes (SHIPs) — covers ~80% of the population. Budgets crossed ₹28,000 crore (FY24), with SHIPs growing 8–25% yearly since 2018.

Yet, only 35% of eligible patients use benefits. Coverage ≠ access. Access ≠ equity.

Why Insurance Matters

• Reduces out-of-pocket spending — key to poverty prevention.
• Decongests public hospitals by sharing load with private providers.
• Builds infrastructure — risk pooling incentivises hospital growth.
• Affirms healthcare as a right — not a privilege.

Structural Gaps Holding Back Impact

🔸 Private Bias: 51% empanelled hospitals are public — but get only 1/3rd of payouts. Profits flow to private chains.
🔸 Hospitalisation Focus: Neglects primary & preventive care — where 80% of health needs begin.
🔸 Payment Delays: ₹12,161 crore pending under PM-JAY — forced hospitals to suspend services.
🔸 Discrimination: Private hospitals avoid insured patients; public hospitals prioritise them.
🔸 Fraud: 3,200+ hospitals flagged for fake claims — eroding trust & efficiency.

Reforms for Real UHC (Universal Health Coverage)

1. Raise Public Health Spending → From 1.9% to 2.5% of GDP (NHP 2017 target).
2. Adopt Gatekeeping Model → Like Thailand — route patients via primary centres first.
3. Fund Non-Profit Hospitals → Like Canada — cap profiteering, ensure equity.
4. Clear Claims in 30 Days → Restore provider trust. No more crippling delays.
5. AI + Audits for Fraud Control → Real-time monitoring to stop false billing.