India’s Elderly Deserve Full Health Coverage, Not Partial Promises (2025)

India has a vast population, largely in rural areas, constituting low- and middle-income households. The country ranks 130 out of 193 nations on the Human Development Index (UNDP, 2025). Sixty per cent of the population—81.35 crore people—depend on free foodgrains under a government scheme, revealing how citizens struggle to access even basic needs. Rising medical inflation, weak public health infrastructure, and the increased burden of non-communicable diseases have aggravated this struggle manifold. The government spends just 1.84 per cent of GDP on health, significantly lower than South Africa (4 per cent), Brazil (4.3 per cent), and Thailand (3.6 per cent).

India is witnessing one of the most significant demographic transitions of the 21st century. The proportion of elderly persons—individuals aged 60 years and above—is rising rapidly. Today, the elderly constitute approximately 10 per cent (104 million people) of India’s population. By 2050, they will reach nearly 19.5 per cent (319 million), according to NITI Aayog (2024). A sharp decline in fertility rates below 2.0, particularly in southern and western States, and increasing life expectancy (69-72 years) have created new healthcare challenges. Nearly 75 per cent of the elderly suffer from one or more chronic health conditions. Only 18 per cent (NITI Aayog, 2024) have any form of health insurance. Ensuring equitable access to affordable healthcare for senior citizens is not just a policy concern but a moral imperative.

The healthcare burden

As the average lifespan increases, so do complications—chronic diseases, declining physical mobility, reduced income, and social isolation. The Longitudinal Ageing Study of India (LASI) 2020 found that 75 per cent of the elderly suffer from at least one chronic illness. The list includes cardiovascular disease, hypertension, cancer, bone and joint disease, diabetes mellitus, and chronic lung and heart disease. The National Sample Survey 75th Round confirms this pattern: hospitalisation rates among the elderly were 8.5 per cent, rising to 14.3 per cent for those aged 80 and above. Among those with no surviving children, 21.3 per cent required hospitalisation—a figure that highlights the vulnerability created by weakened familial and social support networks.

Most elderly people are either retired or dependent. Their limited or nil income worsens these challenges. The mean out-of-pocket expenditure for inpatient care in private facilities stood at Rs.31,845, compared with Rs.4,452 in public facilities—an eight-fold difference. This disparity places considerable financial strain on elderly individuals and their households, often pushing them into debt. Many cannot afford treatment in private healthcare facilities or delay seeking care altogether.

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Against this backdrop, the Union Cabinet decided in September 2024 to include six crore senior citizens—approximately 4.5 crore families—aged 70 years and above under Ayushman Bharat Pradhan Mantri Jan Arogya Yojana (AB PM-JAY). The move extends Rs.5 lakh annual health coverage to new families with senior citizens not previously covered under PM-JAY. Already eligible families receive an additional Rs.5 lakh coverage. For a population segment historically excluded from health insurance, this intervention can substantially reduce financial vulnerability and increase access to hospital-based care.

But the age cap raises questions. Until recently, India’s health insurance ecosystem offered limited options for older people. Most insurance plans imposed upper age limits—capping at 65 years—along with high premiums, long waiting periods, and blanket exclusions of pre-existing conditions, which are almost universal among the elderly. As a result, only 18 per cent of the elderly had any health insurance coverage before the expansion, leaving the vast majority without financial protection. The BJP Lok Sabha Election Manifesto 2024 promised coverage for senior citizens under PM-JAY. This appears to have triggered regulatory reforms. The Insurance Regulatory and Development Authority of India lifted the age cap for purchasing insurance, reduced waiting periods, and mandated coverage of pre-existing conditions—correcting long-standing exclusions.

The policy gap

The healthcare challenges persist despite these changes. In India, non-communicable diseases strike a decade earlier than in developed countries. While these diseases typically affect individuals aged 55 years or older in many developed nations, their onset occurs at 45 years of age or above in India (The Lancet Global Health, 2018). Patients and their families bear a significant portion of healthcare expenses directly. Despite the decline in out-of-pocket expenditure (OOPE) in recent years, India’s OOPE stands at 45.1 per cent of current health spending (National Health Account 2021-22)—much above the global average of 17.23 per cent. This burden falls heavily on low-income and middle-class families. Many use distressed sources to finance healthcare. The societal shift towards nuclear families and the relocation of younger family members worsen the challenges. Seventy per cent of the elderly population depend on others for everyday maintenance.

Approximately 5.5 crore Indians slip back into poverty every year, reducing expenditures on other necessities and lowering household welfare. Life expectancy has risen, reflecting improved healthcare. But the quality of life in old age remains poor—marked by a high burden of non-communicable diseases, high out-of-pocket spending, and limited health coverage. The entire family bears this burden. When an elderly parent falls ill, a 35-year-old child often faces the choice: pay for treatment or fall into debt. This is not an abstract policy problem. It affects millions of families every year.

International organisations, including the World Health Organization, define elderly as “aged 60 years and above” for healthcare deliberations. Japan, with a life expectancy of 85 years, considers 65 years for elderly benefits. In India, the National Policy for Senior Citizens 2011 specifies 60 years to define senior citizens. Rashtriya Swasthya Bima Yojana also used 60 years for coverage of senior citizens. The current policy shows a gap in design and a missed opportunity in social protection. Restricting AB PM-JAY to senior citizens aged 70 years and above does not align with international standards or India’s own policy definitions.

Including all citizens aged 60 and above under AB PM-JAY would align the scheme more closely with Universal Health Coverage (UHC) principles. It would address both financial vulnerability and disease burden in a rapidly ageing society. But would this be feasible? According to the NITI Aayog (2024) report, India has 10.4 crore senior citizens aged 60 years and above. The recent expansion covers approximately six crore individuals aged 70 years and above. This leaves approximately 4.4 crore senior citizens in the 60-69 age group. The scheme already covers over 40 per cent of the population. An additional 2.64 crore senior citizens need coverage. Based on the Ministry of Health and Family Welfare’s estimation—which calculates an average of 1.33 senior citizens per family—this translates to around 1.98 crore families. The financial implication: Rs.1,249 crore to Rs.1,500 crore per year.

Is this amount prohibitive? The Cabinet of the government of India approved the extension of Ayushman Bharat PM-JAY in January 2022 for five years—from 2021-22 to 2025-26—with a financial outlay of Rs.42,489 crore. However, the Ministry of Health and Family Welfare, government of India, submitted a budget estimate of only Rs.26,900 crore for the period from 2021-22 to 2024-25. The ministry utilised Rs.20,083 crore till January 9, 2025. The government allocated an additional Rs.2,165 crore as the Central share for covering senior citizens aged 70 years and above under AB PM-JAY for the financial years 2024-25 and 2025-26. Two questions emerge: Can the existing budgetary provision accommodate the remaining senior citizens? If not, is the estimated financial implication of Rs.1,249-1,500 crore disproportionately high? The unutilised budget suggests otherwise.

Implementation challenges

AB PM-JAY’s implementation varies significantly across Indian States. Southern States like Kerala show high uptake. Others lag because of infrastructural gaps and digital literacy barriers. Geriatric care services, particularly at the primary level, remain underdeveloped. Only a handful of public hospitals have geriatric departments. The scheme’s success depends not just on financial coverage but also on the service delivery capacity of government institutions.

Awareness poses another challenge. Many elderly beneficiaries remain unaware of their entitlements under PM-JAY. Others cannot navigate enrolment and hospital processes. Without targeted outreach and support, especially in rural and remote regions, coverage remains symbolic rather than impactful.

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Countries such as Sweden, Japan, Germany, and Thailand offer lessons. They have pioneered integrated models of elderly care that encompass health insurance, social pensions, community-based services, and institutional long-term care. Sweden has established a comprehensive model that integrates health and social services, with a strong emphasis on individualised care. The Esther Model ensures coordinated and continuous care through Esther nurses. The Senior Alert programme monitors health risks and promotes proactive interventions. Japan’s long-term care insurance system mandates contributions from both citizens and the government, ensuring sustainable and inclusive elderly care. Germany combines contributory schemes with strong home-care infrastructure. Thailand has expanded primary care outreach through trained community health workers. These models embed ageing within broader social protection frameworks.

India’s recent move to bring senior citizens under AB PM-JAY holds transformative potential. It could become a model for age-responsive universal health coverage. But success depends on investments in infrastructure, human resources, and decentralised care models.

With an average life expectancy of 71 years in India, the expansion of AB PM-JAY to cover senior citizens aged 70 years and above creates an impression of inclusivity while excluding millions who need protection most. The government’s commitment to the elderly population and its vision for UHC will be reflected genuinely only when it adopts a comprehensive approach—including all senior citizens aged 60 years and above while ensuring timely, affordable, and compassionate care. The government must complement this move with targeted investments in geriatric care, better insurance literacy, and robust last-mile service delivery. Only then can we say that our health system prepares for those who built the nation, not just for the young.

Aamir Mustafa and Aabin Manoj have been engaged in efforts toward advancing Universal Health Coverage in India.