Reaching the Missing Middle: Ensuring Health Coverage for India's Urban Poor

Abstract Abstract—India has seen impressive investments in government-funded health insurance but still severely underfunds the health sector. The government of India has a critical role in ensuring effective health coverage to the “missing middle”: the urban poor. The urban poor have been excluded from benefits targeting eligible populations below the poverty line. Lack of access to public facilities and qualified primary health care providers in urban areas often results in treatment delays or patients relying predominantly on out-of-pocket payments to informal providers. The urban poor are also excluded from affordable health insurance markets. Illiteracy and poverty in the slums result in limited access to goods and services and unequal participation in social life, as well as in overall social exclusion. The government of India, in its 2018 union budget, announced a flagship National Health Protection Scheme (NHPS) that will provide health insurance benefits of up to INR 500,000 (7,692 USD) per family per annum. This article explores current and future opportunities to fill an important gap in access to health services, specifically targeting the urban poor by providing health insurance schemes that include primary health services for this population. Current public health insurance schemes providing exclusively hospitalization benefits are unsustainable; part of the solution is keeping people healthy and out of the hospital. Primary care integrated into health insurance improves population health management and is associated with higher patient satisfaction, fewer hospitalizations and emergency department visits, lower claim costs, and overall reductions in morbidity and mortality. There is no single solution to finance health services for the urban poor. This population mostly belongs to the informal sector, which encompasses workers whose jobs are not recognized formally and from whom no taxes are collected. However, the new NHPS could play a major role in expanding safety nets for the urban poor by providing financial risk protection and improving social inclusion. The government could use the introduction of the new scheme to shape approaches aimed at increasing opportunities for the urban poor through investing in public health facilities, subsidizing and fostering public–private affordable health insurance, and enhancing access to information, voice, and respect for rights.