India rolled out its ambitious
Ayushman Bharatâ€“National Health Protection Scheme (AB-NHPS) on its 72nd
Independence Day, aiming to cover more than 10 crore families. Many scholars
have already criticized the program and the government's intention to focus on
health insurance rather than the systemic issues in India's healthcare
provision. They further argue that such an approach may benefit the private healthcare
industry more than the actual beneficiaries. Further, AB-NHPS is often compared
with 'Obamacare', therefore it is essential to differentiate between the two. I
will be delineating the differences between the AB-NHPS and Obamacare in the
United States, to demonstrate how it is wrong to compare them both. Finally, as
I explain below, the implementation of the scheme poses a challenge to the
respective state's authority on health-related subjects and health records
maintenance and privacy issues.
Is Modicare Similar to
Firstly, we have to straighten
out our thoughts on whether AB-NHPS aka Modicare is similar to Obamacare. As a
public health policy researcher with sufficient knowledge of both programs, I
can say with certainty that they are not the same. It is a political gimmick to
flaunt AB-NHPS as a healthcare reform like Obamacare.
The Patient Protection and
Affordable Care Act, 2010 (PPACA), also known as the Affordable Care Act (ACA)
or simply Obamacare, dealt with many issues beyond extending health insurance
coverage. Surprisingly, the term Obamacare was coined by opponents of the scheme and
not by the Democrats nor the then president himself. It will be interesting to
see who started calling AB-NHPS, Modicare.
The ACA was a healthcare
reform in the
real sense, as it attempted to address many crucial health system issues in the
United States. It not only looked into Medicaid expansion but also addressed
rising healthcare costs, incentivized medical professionals to serve in remote
areas, and expanded essential treatment coverage. It levied a tax on wealthy
individuals and medical devices, to provide subsidies for those who are insured
under the program. It made primary healthcare services
to the under-served population. Owing to existing frauds and loopholes in the
fee-for-service mechanism, it revamped the physician payment process and
brought the concept of value-based payments into practice. Obamacare also
mandated tax-exempted hospitals to conduct a community health needs assessment
(CHNA) every three years and develop implementation strategies to meet the
identified community health needs. Thus, ACA had the overarching objective of
improving accessibility, quality, efficiency, and accountability in the US healthcare
system. AB-NHPS, on the other hand, is geared towards improving financial
coverage with some systems overhauling long overdue under the Rashtriya
Swasthya Bima Yojana. Whereas the world has already moved towards a value-based
payment system, India's AB-NHPS still relies on a flawed fee for service (FFS)
payment system. Program implementers plan to rely on a robust IT system to
prevent frauds and overbilling. However, this approach may not prevent frauds
or skimming the system, as the fee-for-service approach itself incentivizes
healthcare providers to conduct more procedures, without paying much attention
to the quality of care.
Even with quality checks and a
robust IT system in place, fraudsters managed to bill the Medicaid authority in
the United States and siphon out money. Obamacare attempted to correct this
problem by implementing a quality-based payment system for physicians, instead
of paying them based on the number of procedures they perform.
The fee-for-service model of
RSBY earlier and now AB-NHPS have similar challenges. In the latest interview,
of AB-NHPS stated
that they are determining the package rates with the Indian Medical Association
and other stakeholders. The improved package rates may bring many healthcare
providers on board, but in time the program may have to deal with substandard
care, with the increased volume of services or the provision of unnecessary 'care'. With its limited scope, AB-NHPS comes nowhere close to Obamacare in
terms of envisioning healthcare reforms. India's other major health system
challenges are overlooked, and health insurance is given prime importance under
Cooperative Federalism or
Health is a state subject under
India's constitution, meaning states have the authority to decide on various
health issues in their respective jurisdiction. However, health-related
programs are often designed at the federal level and implemented vertically.
The sense of autonomy at the state level mostly depends on the whims of the
ruling political party. Unfortunately, the collective feeling of statehood
among the residents of a state doesn't translate into effective policy
formulation or a demand for state-specific health programs.
Besides, most states especially
the poorer ones are heavily dependent on federal coffers for money to run any
health programs. As a result, these states have few bargaining chips in any
national programs. Such states wholeheartedly accept vertical national health
programs even if they are not suited or tailored to their local conditions.
This phenomenon was seen with RSBY, where many non-Congress
readily accepted the scheme. Eventually, however, due to the flawed
implementation many states backed out and tried to run their own programs. The
given by the CEO of AB-NHSP
states that as of now, few states are on board with the AB-NHSP, for several
reasons. But it is unlikely that the states will refuse the centre's offer and
not participate in the program.
In the United States, many
states opposed the blanket implementation of Obamacare. 17 states out of 50
still haven't accepted the
expansion of Medicaid under Obamacare. In fact, several states challenged the
constitutionality of some of the ACA's provisions in the Supreme Court. The
feeling of state autonomy is dominant among the people and state-level
policymakers in the United States. All states have their own versions of
federally funded health insurance programs, with some federal oversight.
Under the AB-NHSP, by contrast,
the state's independence is likely to be restricted for the sake of uniformity.
It will be interesting to see in coming years how much the federal government
will be able to exert its power in the name of cooperative federalism, and how
states respond to this federal coercion.
What Will Happen to
Patient Data under AB-NHPS?
AB-NHPS envisages using
electronic medical records transferable from one hospital to another,
ostensibly to avoid the hassle for the patients of carrying huge medical files.
The Indian government has drafted the much awaited Digital
Information Security in Health Care Act 2018 (DISHA), under which patients' medical
records will be protected from commercial exploitation. DISHA prohibits health
institutions from sharing any identifiable health-related information with
vendors or insurance companies, or pharmaceuticals companies for that matter.
DISHA and the use of electronic
health records may well help AB-NHPS increase efficiency. However, the
integration and implementation of both will be a challenging task in coming
years, given the infrastructural and network insufficiencies in our digital
infrastructure. Small dispensaries, nursing homes, and maternity homes will
first have to develop the necessary infrastructure and provide necessary
training to their staff to comply with the rules under DISHA 2018. On the
patient's side, if a data breach occurs, from a lack of awareness they may find
difficult to exercise their right to appeal it and seek redress. Without strong
support, small healthcare facilities may choose not to participate in the
AB-NHSP network at all, given the penalties under DISHA. For the already
overburdened government institutions, maintaining digital health records and
complying with DISHA will become a daunting task. Ancillary healthcare
institutions such as laboratories and pharmacies will also have to comply with
the data protection rules.
It will be interesting to see
the actual implementation of DISHA 2018 under AB-NHPS, as many practical
aspects of daily health systems are not
overlaid under the act. Here again I will try to explain with examples
from the American healthcare system.
Patients' health records in the
United States are protected under the Health Insurance Portability and
Accountability Act of 1996 (HIPAA). Under this act, healthcare entities are
responsible for protecting patients' health information. In one case, a healthcare
provider left a voice message on the patient's phone giving details of her
disease and possible treatment plan, which was accessible to another family
member. This was considered a HIPAA violation as the patient hadn't given her
consent to notify her about her illness on that particular phone number, and
corrective actions were taken against the healthcare provider. In another case,
a medical facility charged a patient $100 to review his/ her own medical
records, which fee was revoked after the intervention of the federal agency.
Several other instances of issues with HIPAA compliance are given on the US
Department of Health and Human Services' website.
It is clear from these examples
that it will be a challenging task to implement electronic health
record-keeping and safeguarding patient rights under DISHA 2018 and AB-NHPS,
and the profit-oriented clinical establishment may take advantage of low
awareness and system loopholes to exploit indigent patients. One can well
imagine how electronic medical records can become a profitable business for
clinical establishments. Further, all clinical establishments will require
extensive training to build the necessary infrastructure to comply with this
mandate. The health ministry will have to formulate separate rules and
guidelines to meet the challenges, and all medical institutions and healthcare
providers will need extensive training to comply with the rules and avoid any
India has chosen the path of
health insurance to improve its healthcare coverage. By starting out on the
wrong foot and not learning from the mistakes of the other countries, the
system is likely to suffer from insufficiencies, and fail India's poor in
particular. The success of AB-NHPS will depend on how program quickly learns
from its mistakes and protect patient's rights, while making healthcare
Preshit Ambade is a
doctoral candidate at the College of Public Health, University of Arizona, USA.
His research interests include healthcare financing, health insurance, and
disparities in the health system.