As people grow older, the chances of their having multiple comorbidities rise. But ageing also marks a phase in life when there is loss of income or a higher dependency on family for financial support. When these two factors — poor health and lack of adequate financial support — come into play, they leave a devastating effect on the elderly.
Healthcare expenditure is one of the biggest challenges the geriatric population in India faces. As the India Ageing Report 2023 by the United Nations Population Fund India and International Institute for Population Sciences puts it: “The enormous burden of healthcare costs depletes savings, leading to distress financing and debts. Some of the major sources for financing in-patient and out-patient-related health expenditure are personal income, income at the household level (other than personal income), savings and contributions from relatives or friends. For in-patient care at private facilities, funding is mainly drawn from savings, loans and contributions from relatives or friends”.
According to the report, fever/pyrexia of unknown cause, chronic pain in joints/arthritis, high blood pressure, generalised pain, diabetes or related complications, breathing problems, problems with eyes, heart-related issues, gastroenteritis, and injuries or accidents were the top 10 reasons for accessing out-patient care.
Hospitalisation for fever/pyrexia of unknown cause, gastroenteritis, heart-related issues, breathing problems, ophthalmic surgery, abdominal surgery, diabetes or related complications, and stroke were the top 10 reasons for accessing in-patient care, it said.
Available insurance schemes
In India, both the Central as well as several State governments offer health insurance schemes. Private health insurance is also available. In late 2024, the Union government approved of health coverage for all senior citizens aged 70 and above, irrespective of income, under its Ayushman Bharat-Pradhan Mantri Jan Arogya Yojana (PM-JAY). There are a number of State-specific health insurance schemes as well, such as Tamil Nadu’s Chief Minister’s Comprehensive Health Insurance Scheme (CMCHIS). Some State schemes have also been integrated with PM-JAY.
Though insurance schemes are available, questions remain as to how accessible and affordable they are for the elderly.
The India Ageing Report collected information on the coverage of various health insurances schemes such as the Central Government Health Scheme, Employees State Insurance Scheme, Rashtriya Swasthya Bima Yojana, other Union and State government schemes, medical reimbursement from an employer, health insurance through employer and privately purchased commercial health insurances schemes. It found that the coverage of the health insurance schemes was highest in the age group of 60–69 (20.4 %). Elderly men (19.7 %) had a greater share of coverage than elderly women (16.9 %). A higher proportion of the elderly who were ‘currently married’, ‘currently working’ and/or faced limitations in conducting activities of daily living had health insurance coverage.
Low awareness (52.9 %) and non-affordability (21.6 %) were the primary reasons cited by the elderly for not availing of any health insurance. In fact, senior citizens residing in rural areas had very little awareness about health insurance schemes compared with their urban counterparts, the report observed.
Cost of healthcare
The elderly face numerous health challenges. “Chronic non-communicable diseases are common in older people. They need lifelong treatment. When financial constraints arise, drug compliance becomes poor; patients stop taking their medications and the disease progresses and complications arise,” S. Deepa, a senior geriatrician based in Chennai, points out.
G. S. Shanthi, senior consultant, geriatric physician, Kauvery Hospital, Chennai, adds: “Recovery from an illness takes a long time as you age. This is especially so, when the patient has multiple comorbidities such as diabetes, hypertension and cardiac ailments. Many times, patients are hospitalised for complications arising out of comorbid conditions, or they acquire an infection, or metabolic disturbances. Such patients require close monitoring initially until stabilisation. Such patients sometimes require non-invasive ventilation or ventilatory support and intensive care unit (ICU) admission. This increases the cost. The cost of medications and the duration of stay in the ICU could lead to an increase in hospital expenditure. Many of them want to come out of the ICU as soon as possible, taking into account the cost factor. We have seen instances of patients asking to be discharged against medical advice due to financial situations.”
Citing similar situations where elderly patients do not want ICU admissions, Prasad Mathews K., professor, geriatric medicine, Christian Medical College, Vellore, explains how his team copes in these situations. “During COVID-19, some of our geriatric specialists used to manage sick patients in the ward, due to a lack of adequate ICU beds then. We used to have patients on non-invasive ventilation in a regular ward. So, we started to follow a similar model of treating patients in the regular ward. When we looked at some data, we found that of 200 patients treated in this manner, 67% walked home. So, this was low cost and lifesaving for many,” he says.
Keeping the cost of care affordable is the main requirement in geriatrics, Dr. Mathews further adds: “As of now, from what we see, about 20% of our patients have some insurance cover. Treatments for stroke, cancers and major surgeries, however, are expensive,” he says.
The right direction
Dr. Shanthi notes that health awareness among the public has improved, and the availability and accessibility to healthcare is good in cities when compared to rural areas. “Some elderly people do have insurance coverage of their own, while for a significant number, their children would have them covered under their companies’ group insurance policy. However, the percentage of elderly having their own insurance cover is low, and that needs to improve,” she says.
Under insurance schemes such as CMCHIS, diagnostic imaging such as CT scans, MRI scans and costly medicines are also covered. Also, advanced procedures like angioplasties, coronary bypass surgeries and replacement of joints are offered under this scheme, benefiting many elderly, she adds.
As a person grows older, private insurance becomes more and more expensive. Dr. Mathews says: “The premium amount becomes higher, making it difficult for many to afford. The amount reimbursed also varies. In some instances, we have seen that private insurers reimburse only 75% of the claim amount. Though there are certain hitches, Tamil Nadu government’s CMCHIS is good, as it covers most ailments such as treatments for myocardial infarction and oncological procedures,” he notes.
Dr. Deepa says that since treatment is free in government hospitals in Tamil Nadu, the impact of insurance on healthcare access is difficult to measure; however, it would have a definite impact on care-seeking behaviour, and continuity of care, in the private sector.
“What we have observed is that many patients who get admitted do not have insurance cards. This is due to factors such as low awareness, difficulty in getting cards or their illness may not be covered under the package even if they have a cover,” she adds. Explaining the point by using a specific day’s pre-authorisation census of a unit, she points out that of 16 patients who were admitted, only two were eligible. While 10 did not have insurance cards, four others had the required documents, but their condition was not covered in the package.
Gaps in policies
There are also a number of drawbacks with insurance policies, Dr. Shanthi says. “One, palliative care is not covered, and it is high time that this is taken into consideration. If palliative care is included, many will benefit as it could cover the cost of medicines, nursing care and so on,” she says.
“What happens weeks after discharge?” she asks. “If a person has sustained a fracture and was discharged after surgery, he/she will require physiotherapy for a month or more. This applies to persons who have suffered a stroke too. Persons who have suffered neurological ailments may be bedridden or have restricted mobility. They need to have caretakers. In all these cases, most of the time, people have to spend out of their pockets. Also, there is no policy to include end-of-life care/palliative care or care for the bedridden. Yet another instance is of elderly persons who will need oxygen support at home. They buy or rent oxygen concentrators, and this repetitive expenditure too, is heavy for people. Experts and policymakers have to put their minds together to offer solutions to such problems.” she says.
Preparing for costs
Doctors stress the need, in the current landscape, to be prepared for future healthcare expenses. “Precautions must be taken for future health expenditures. Insurance policies that can cover the maximum cost of treatment should be taken. It will be helpful for elderly people if insurance companies offer policies with significant coverage for paramedical services during the post hospitalisation period,” Dr. Shanthi suggests.
Dr. Deepa too emphasises the need for persons in their middle age to save a portion of their income for future health-related issues. “People can avail of public health facilities. Awareness should be created about insurance schemes, and procedures to get enrolled in government insurance schemes should be simplified for older people,” she says.
The best solution, according to Dr. Mathews, is to improve government hospitals to enhance access to healthcare for the elderly across the income spectrum. “Tamil Nadu and Kerala have done it. Ours is an ageing population, and governments could focus on vaccination for the elderly so that pneumonia and influenza can be prevented, resulting in decrease in morbidity. So far, governments have concentrated exclusively on children. Now, they should ensure that the elderly are kept healthy,” he says.
This article was first published in The Hindu’s e-book Shades of Grey: Geriatric Care and its Social and Economic Facets.
