Mamata govt forced to walk tight rope with flagship health insurance scheme

Swasthya Sathi has got an overwhelming response. It has, however, thrown up two major challenges for the government — additional budgetary burden and reluctance of private hospitals to provide low-cost treatment

coronavirus, India, US, medicare, insurance
The private hospitals have demanded rate revision, claiming the rate fixed by the government is too low.  For instance, the cost of open heart surgery under the scheme has been fixed at ₹80,000 whereas private hospitals generally charges anything between ₹2 lakh and and ₹3 lakh for the procedure. | Photo: iStock

For 22-two-year-old ailing BJP worker Raju Pal, the West Bengal government’s flagship health insurance scheme, Swasthya Sathi, came as a blessing from the political ‘adversary.’

Pal, a resident of Barasat in North 24 Parganas, has been suffering from kidney ailments for several months. His family wanted to take him to Chennai or Vellore in Tamil Nadu for better treatment. But the lower middle class family could not arrange the money needed for the treatment there.

When all hopes were lost, local TMC leader and Barasat municipality administrator Sunil Mukherjee ensured that the family immediately received the Swasthya Sathi smart card needed under the scheme for cashless treatment at the Christian Medical College (CMC), Vellore.

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The CMC, along with the Delhi’s All India Institute of Medical Sciences (AIIMS), is among the hospitals from outside the state enlisted in the scheme.

More than 1,600 private and government hospitals in the state are empanelled under the scheme, touted as a political masterstroke of Chief Minister Mamata Banerjee, who also holds the health portfolio, ahead of the assembly elections to be held in less than four months.

The health insurance scheme, which was officially launched in December 2016 for only a targeted group, has been extended from December 1, 2020, to all residents of the state.

It provides a basic health cover for secondary and tertiary care of up to ₹5 lakh per annum per family. The health card is issued to a senior woman member of a family.

The overwhelming response the scheme has received so far has compelled even its staunch critics such as BJP state president Dilip Ghosh to change his stance.

“I’m not against the scheme. I’m against the fraudulent TMC government. If I get the chance, I’ll also apply for a Swasthya Sathi card,” Ghosh was quoted as saying by media after members of his extended family at Gopiballavpur in Jhargram district collected their smart cards standing in queue earlier this week.

The overwhelming response, however, has thrown up two major challenges for the government — additional budgetary burden and reluctance of private hospitals to provide low-cost treatment to such a huge eligible population under the government’s health scheme.

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The state’s health budget for 2020-21 is less than ₹12,000 crore. Some critics point out that if 5 per cent of the state’s over 10 crore people seek the benefits of the scheme, the burden on the state’s exchequer would be ₹50,000 crore a year.

The state’s health secretary Narayan Swarup Nigam, however, recently claimed that the budget would not be a constraint. He argued that not more than one per cent of the population needs hospitalisation at once. Considering that the national average for per person expenditure in hospitals is around ₹15,000-₹20,000, Nigam said the current budget allocation would be sufficient to run the scheme.

The annual expense for the scheme will be approximately ₹2,000 crore, according to the government’s estimate. Government sources said any further increase in expenses under this head will be extremely pinching for the state’s exchequer.

Private hospitals on the other hand are putting pressure on the government to increase the price of treatment packages under the scheme. They say the current rate is not economically viable for them.

Some hospitals have even refused to admit patients with Swasthya Sathi card despite the state government’s warning that refusal could lead to cancellation of licence.

A private nursing home at Baghajotin in South Kolkata allegedly did not provide cashless facility to Swasthya Sathi card holder Sikha Rani Sen on Friday (January 15). Her son Kanu Sen claimed that the nursing home compelled them to deposit cash for admission.

Earlier, Mohammad Gaffar (70) died after several hospitals at Siliguri in Darjeeling district allegedly refused to admit him with the cashless facility. Following Gaffar’s death, senior state minister Gautam Deb held meetings with managements of private hospitals in the town on Thursday to sort out the rate issue.

To resolve the issue, the government is considering forming a committee comprising representatives of private hospitals and government officials soon, sources said.

An indication of this was given at a meeting between representatives of the private hospitals and nursing homes with government officials chaired by Chief Secretary Alapan Bandyopadhyay last week.

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The private hospitals have demanded rate revision, claiming the rate fixed by the government is too low.  For instance, the cost of open heart surgery under the scheme has been fixed at ₹80,000 whereas private hospitals generally charges anything between ₹2 lakh and and ₹3 lakh for the procedure. Similarly, for coronary angiography charges are capped at ₹9,000 whereas at present private hospitals on an average charges ₹15,000 for the same.

Under the scheme, for replacement surgery like hip or knee the rate has been capped at ₹85,000, including the implant cost, while for common surgeries like gallbladder the rate is fixed at ₹19,500.

According to Association of Hospitals of Eastern India (AHEI), the price structures under the scheme is almost one-third or even lower than the normal charges of the private hospitals.

“The rates under Swasthya Saahi are a bit unrealistic. Even smaller nursing homes will not be able to sustain providing services at these rates,” said Rupak Barua of the AHEI.

Private nursing homes and hospitals sources say their problem will further aggravate as they expect following the massive enrolment under the scheme the large chunk of their patients will be the health insurance card holders.

At present only around 5-7 per cent of the patients are admitted under the scheme and hence their subsidised treatment can somehow be managed, sources said.

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For the TMC government, the success of the scheme is very crucial ahead of elections and so it will have to soon find a way to assuage the rate concerns of the hospitals with its limited financial resources.

The arm-twisting and threats of licence cancellation can only be counterproductive, even many TMC leaders admit in private.

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