Affording Care

July 2025

We often celebrate the remarkable advances in healthcare with enthusiasm. Fuelled by new technologies like machine learning and artificial intelligence, there is a widespread belief that these innovations will revolutionize healthcare within the next decade, ushering in a new era of treatment options and cure. This optimism is to help us look beyond today’s uncomfortable truth: “Even in the 21st century, nearly one-seventh of the global population still lacks access to even basic primary healthcare”. The contrast between high-tech breakthroughs and the continued absence of essential services for billions of people is stark. As Julio Frenk and his colleagues aptly observed in The Lancet, “There are glaring gaps and inequities in health both within and between countries, underscoring our collective failure to share dramatic healthcare advances equitably.” This quote captures the reality we must confront: progress in healthcare means little if it does not reach everyone.

The Three Barriers to Universal Health Coverage

Achieving universal health coverage depends on overcoming three deeply interconnected barriers: availability, accessibility, and affordability. While each represents a distinct challenge, their overlap often compounds the difficulty of delivering equitable healthcare. These challenges are particularly pronounced for the elderly population-a segment of our population that faces a higher burden of chronic diseases, disabilities, and sensory-motor decline including vision loss, thereby in need of sustained care.

Healthcare services may become available and geographically accessible over time, but the cost of treatment and hospitalization can remain a significant obstacle-especially for the elderly with limited incomes or without family support. Therefore, addressing affordability holistically is essential to ensure that the promise of healthcare extends to all, particularly to this vulnerable and growing segment of our society.

Tackling the Affordability Crisis

I have previously written about how LVPEI’s pyramidal model has been instrumental in improving access to eye care across our network. In this note, I will focus on this critical dimension of healthcare delivery, especially in the context of an aging population.

To address affordability, LVPEI pioneered a second key innovation: a cross-subsidy model. Under this approach, patients who can afford to pay, help offset the costs for those who cannot. This model has been pivotal in ensuring that no one is turned away from any of our centres, regardless of their financial circumstances or the complexity of their medical condition.

Yet, as widespread as this model is, affordability challenges persist, particularly for older adults. Our paying patients use a myriad means to address affordability, and a section of our patients opt for health insurance to cover for their eye care costs. With an average of 8,000 patient consults each day-over 2.4 million annually-LVPEI’s vast data offers a rare window into how elderly patients manage healthcare costs. It lets us examine real-world choices, or “revealed preferences,” that show how patients navigate their financial constraints when accessing care.

Insurance and Elderly Eye Care

A recent study led by my colleagues, Dr. Brijesh Takkar, Mr Ragukumar Venugopal, and Dr. Raja Narayanan (now at the Flaum Eye Institute, Rochester, USA), published in The Lancet Regional Health – Southeast Asia, explored how insurance influences cataract surgery among elderly patients at LVPEI.

Their findings from 10 years of data were revealing:

• Out of nearly 40,000 patients aged 70 and above, only 3 in 20 had any form of health insurance.
• This number declined sharply with age, especially for those over 80.
• Among patients aged 85 and above, less than 10% had insurance.
• Even government health schemes like Ayushman Bharat reached only 3.33% to 4.21% of patients in the 70+ age range.

This study shows that our existing health insurance mechanisms are either inaccessible, unaffordable, or not perceived as beneficial by the elderly. These numbers also underscore a troubling reality: despite public insurance efforts, many elderly Indians-particularly the oldest-remain financially vulnerable when it comes to healthcare.

The study also highlighted stark gender disparities. Elderly men were more likely to have insurance (19.11%) compared to women (12.43%). When they had to pay for care, more women ‘chose’ cheaper options for surgery than men. More women have vision loss than men precisely for these kinds of social reasons, so, multiple levels of vulnerability intersect in these age-groups.

Ayushman Bharat: A Positive Shift

The 2018 launch of Ayushman Bharat, India’s flagship universal health coverage program, marked a turning point. Since its introduction, there has been a 20% increase in insurance uptake among the elderly visiting LVPEI. Interestingly, some patients who initially opted for fully subsidized, free care at LVPEI chose to use their Ayushman Bharat coverage instead after its launch. This reflects growing public trust in government health insurance.

However, these positive developments are marred by undue delays between diagnosis and surgery for those using insurance, compared to those paying out of pocket. This lag likely reflects administrative processes in claim approvals, pointing at an area that needs reform.

Broader Public Insurance Coverage

This study shines a light on the financial and social vulnerabilities of India’s aging population. With elderly individuals projected to make up 22% of India’s population by 2050, and with many likely to face visual impairment, the findings serve as a canary in the coal mine for broader healthcare challenges.

It’s clear that public insurance coverage needs to expand, particularly for the ‘oldest old’ and elderly women, who face multiple layers of disadvantage. Ensuring their inclusion in health financing schemes will not only improve access but also health outcomes, and protect families from financial distress.

LVPEI’s dual approach-access through our pyramidal model, and affordability through cross-subsidy-provides us with both a distinctive delivery system and invaluable insights into healthcare behaviour. Our mission, “so that all may see,” carries a deeper meaning: it is about restoring vision with equity, and also illuminating the world with knowledge.

Studies like this remind us that universal health coverage is not just a policy goal it is a moral imperative. If implemented with focus on inclusion and equity, it can transform lives.

-Prashant Garg