“Social progress can be measured by the social position of the female sex” - Karl Marx


Implementation Challenges Facing The Ayushman Bharat Program

India rolled out its ambitious Ayushman Bharat–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 Obamacare?

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 accessible 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, the CEO 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 the program.

Cooperative Federalism or Central Coercion?  

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 ruling states readily accepted the scheme. Eventually, however, due to the flawed implementation many states backed out and tried to run their own programs. The latest interview 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 breach.  

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 affordable.  

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.  


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