The India Health Insurance Experiment (HIE) is a large-scale randomized controlled trial (RCT) involving over 11,000 above poverty line (APL) households in the Indian state of Karnataka. The purpose of this study is to evaluate the health and financial benefits of expanding access to Rashtriya Swasthya Bima Yojana (RSBY) to cover economically vulnerable households that are APL.
While RSBY covers BPL (below poverty line) households, APL households still face challenges in accessing affordable health insurance and suffer financial catastrophe due to health care spending. This long-term project started in 2013 and has measured short-run effects of RSBY coverage, and is currently collecting data to measure long-run effects 4 years after intervention. As the Indian government works to expand universal health coverage through the National Health Protection Scheme (NHPS), the results of the HIE currently inform and will continue to influence national health policy.
Why this study
The purpose of this study is to evaluate the health and financial benefits of expanding the Rashtriya Swasthya Bima Yojana (RSBY) to an economically vulnerable population ineligible for coverage under the current insurance scheme. The study also aims at providing a rigorous evaluation of RSBY, a program that had enrolled 150 million BPL beneficiaries as of the start of this project with the intention of expanding coverage to 300 million individuals.
The study conducts a RCT involving over 11,000 APL households from the districts of Mysuru and Gulbarga respectively.
Households are randomized to one of four treatment or control groups:
- Treatment GROUP A will receive free inpatient insurance coverage under the RSBY scheme.
- Treatment GROUP B receives an income transfer equal to the insurance premium for RSBY and the opportunity to buy RSBY insurance at the same premium the government pays. The income transfer given to GROUP B is intended to net out the income effect of the premium subsidy implicit in the provision of free insurance to the treatment group.
- Treatment GROUP C is given the opportunity to purchase RSBY at the same price the government pays to measure the value they attach to the insurance product and observe any effects in the use of RSBY when households pay for the benefit themselves.
- GROUP D is the no-intervention control group.
Each of these groups is intended, by itself or in combination with another group, to mimic different policy approaches to achieve universal coverage—from free insurance for all, to subsidized premiums, to a public option in the insurance market—or to serve as a concurrent control group. The difference in outcomes between the treatment and control groups will measure the causal effects of health insurance and separately identify the causal effects of premium subsidies.
In addition to the quantitative data collected, the team has conducted ethnographic research of households— both within and outside the sample. This qualitative data primarily focuses on how much households value health, health care, and health insurance, and their experience of using RSBY.
Results from enrollment in 2015 show higher uptake within study households (79 percent) compared to RSBY uptake in Karnataka for RSBY-eligible households (60 percent). Overall, even the treatment group simply given the option to purchase RSBY for the full premium amount demonstrated comparable uptake rates to BPL households where only a Rs. 30 enrollment fee was required. The higher enrollment rate may be a product of enrolling above BPL households or of going door-to-door to help people enroll.
Ongoing analysis of midline data collected at 18 months post-intervention will provide insights on the effect of RSBY coverage on utilization, household finances, and health status. Data collected during the end line will supplement this analysis and allow for longer-term effects to be measured at 4 years after intervention.