Understanding Low Health Insurance Enrollment and Use among Vulnerable Populations in Tamil Nadu: A Qualitative Study

Despite the rollout of public insurance schemes, vulnerable populations in India have low enrollment and use of insurance and continue to experience catastrophic healthcare spending. Our study aims to identify and understand the reasons for under-enrollment and under-use of Tamil Nadu’s Chief Minister’s Comprehensive Health Insurance Scheme (CMCHIS) among two key vulnerable populations: tribal populations and those living in urban slums. We constructed a conceptual framework that characterizes insurance enrollment and use as dependent on awareness and understanding, perceived value, hassle costs, and quality of scheme implementation. Based on this framework, we conducted 83 qualitative interviews across three different urban slums and rural tribal sites in Tamil Nadu and used a combination of inductive and deductive coding to identify the main themes and their relationships with each other. We found low awareness and understanding of the scheme. Many respondents never heard of the scheme; surprisingly, this was true even among those who were enrolled and possessed an insurance card.. Among unenrolled individuals, individuals reported being discouraged from enrolling due to the substantial time costs involved, with participants reporting the loss of one or two working days to complete the process, compounded by bureaucratic hurdles and the need for travel. Consistent with our conceptual framework, we found that much of the awareness gaps and high hassle costs could be attributed to the poor implementation of the scheme within the state. Many individuals also reported being charged by empanelled private hospitals for covered health expenditures, which may indicate private hospitals subverting the scheme and extracting additional payments from beneficiaries. Our findings suggest that poor quality implementation of public health insurance in Tamil Nadu drives low awareness and understand among vulnerable populations and creates significant hassle barriers to enrollment and use. Making insurance schemes transparent and easy to use will be critical for ensuring equitable insurance effectiveness and promoting universal health coverage.