Towards Complete Health Assurance: The Goa Model And The Road Ahead

Manorama Bakshi
Arjun Kumar

Goa’s Health Assurance Question

India’s journey towards universal health coverage has been marked by a gradual shift from fragmented, state-specific insurance arrangements to broader, more inclusive public assurance systems. As the country expands its ambition under national health protection frameworks, states have experimented with different models that balance fiscal capacity, administrative design, and population coverage. Within this evolving landscape, Goa offers a distinct case. The Deen Dayal Swasthya Seva Yojana (DDSSY) is not targeted narrowly at low-income groups but is instead structured around residency, extending cashless hospital care to a much wider section of the population.

However, broad eligibility does not necessarily translate into reliable access to care. Families can still encounter renewal and verification problems at the point of care; some hospitals have raised concerns over reimbursement and package rates; and the five-year residency requirement leaves recent migrant workers outside DDSSY. These gaps matter because the consequences of being uninsured–or finding that insurance does not work when it is needed–are ultimately borne by households through medical bills, lost savings and, in serious cases, debt.

For a state pursuing Swayampurna Goa and the broader vision of Viksit Bharat @2047, the key question is no longer just coverage on paper, but whether protection actually works when people need it. This article looks at how far DDSSY has gone in that direction, where it still falls short, and what it would take to close the remaining gaps.

From Targeted Assistance to a Residency-Based Model

Goa’s present health assurance system did not emerge all at once. Before DDSSY, the state’s principal financial protection mechanism was the Goa Mediclaim Scheme, a much narrower programme available to households with an annual income below ₹1.5 lakh and largely restricted to procedures that could not be provided in government hospitals. Patients also had to pay for treatment and seek reimbursement later, which meant that families still had to find the money upfront. DDSSY, introduced on 1 September 2016, changed this approach by making residency, rather than income, the principal basis for eligibility and offering cashless hospital treatment through both government and empanelled private facilities.

The underlying objective was straightforward: to reduce the burden of out-of-pocket medical expenditure (OOPE) while widening access to hospitalisation and surgery. Any person who has lived in Goa for five years or more can qualify under DDSSY, with the family unit covering the head of household, spouse, unmarried children, and dependent parents or in-laws. Government employees already covered by separate medical reimbursement arrangements are excluded to avoid duplication of public expenditure. Enrolment is managed through a family health card, with an annual registration or renewal fee of ₹200 for families of up to three members and ₹300 for larger families. Non-creamy layer OBC households, SC/ST households and persons with disabilities receive a 50% concession.

The benefits have also expanded over time. Following the July 2026 revision, annual cashless inpatient cover increased from ₹2.5 lakh to ₹4 lakh for families of up to three members, and from ₹4 lakh to ₹6 lakh for families with four or more members, with ₹6 lakh remaining the overall annual ceiling. DDSSY currently covers more than 447 medical and surgical packages and includes a separate outpatient medicine allowance of up to ₹15,000 a year for specified chronic conditions such as diabetes, hypertension, epilepsy, multiple sclerosis and cerebral palsy. Mental health and Ayurveda hospitalisation in public institutions and certain high-end diagnostic procedures referred by government doctors are also covered. There is no age restriction on accessing benefits.

DDSSY also operates alongside the national Ayushman Bharat-Pradhan Mantri Jan Arogya Yojana (AB-PMJAY), allowing eligible groups to benefit from interstate portability. DDSSY itself has a network of 11 government and 67 private empanelled hospitals within and outside Goa. Aadhaar-based identification and online platforms such as Goa Online support enrolment, verification and pre-authorisation. This combination of residency-based eligibility, cashless hospitalisation and a mixed public-private provider network is what distinguishes Goa’s model. It also sets up the more difficult question explored in the sections that follow: how well does this coverage work when people actually need to use it?

How DDSSY Works in Practice

Nearly a decade after DDSSY was introduced, its reach is substantial. In the 2025-26 fiscal cycle, around 1.81 lakh families, covering 6.6 lakh individuals, were enrolled in the scheme. This represents a significant change from the period before 2016, when financial protection was largely confined to narrower categories of patients under the Goa Mediclaim Scheme. The shift is important: health assurance is no longer treated solely as support for households below a particular income threshold, but as a service available across a much broader section of Goa’s resident population.

That expansion carries a fiscal cost, although expenditure has not followed a simple upward trajectory. Historical payouts under DDSSY have fluctuated considerably, from around ₹36 crore to ₹72 crore, depending on utilisation and claims processing. The scheme has operated with a baseline allocation of ₹65 crore, while the state spends about ₹50 crore annually on average. With the higher ₹4 lakh and ₹6 lakh coverage limits introduced in 2026, the annual requirement is projected to rise to around ₹75-85 crore or more. DDSSY continues to be administered through the Directorate of Health Services (DHS), with a Third-Party Administrator handling claims and payments made directly from state accounts.

The claims themselves tell a more interesting story. Most families do not come close to exhausting the maximum cover available to them. The median cost of a utilised package remains below ₹35,000, and more than 94% of families use less than ₹1.5 lakh in a year. Routine demand is concentrated in areas such as general surgery, orthopaedics and ophthalmology. The more expensive claims, however, arise from complex cardiac procedures, cancer treatment and high-end urological surgeries.

This distinction matters when considering whether the recent increase in the coverage ceiling is justified. A ₹6 lakh limit may appear high when compared with what most families actually claim, but insurance is meant to protect against risks that are uncommon precisely because they can be financially devastating when they occur. For households facing prolonged cancer treatment, major cardiac intervention or other complex care, the higher ceiling can make the difference between having meaningful financial protection and exhausting the available cover midway through treatment.

Goa has also been bringing this insurance system into the wider Ayushman Bharat Digital Mission (ABDM). The expansion of Ayushman Bharat Health Accounts (ABHA) is intended to make medical records, laboratory reports and prescriptions accessible across participating healthcare facilities rather than leaving them scattered across paper records and individual institutions.

Yet enrolment figures, expenditure and digital integration tell only part of the story. A health assurance system ultimately has to be judged at the point where a patient tries to use it. It is here, during verification, hospital admission, treatment and reimbursement, that some of DDSSY’s more persistent problems become visible.

Where Assurance Meets the Reality of Care

The reach of DDSSY is significant, but the experience of using it is not always as straightforward as the coverage figures suggest. One of the scheme’s strengths is that eligibility is based on residency rather than income. This has helped make publicly supported health insurance available across income groups and reduced some of the stigma associated with means-tested welfare. The inclusion of outpatient support for chronic conditions such as diabetes and hypertension is also important in a state where long-term treatment can place a recurring burden on household finances.

Some of the more persistent difficulties emerge at the point of care. DDSSY relies on digital verification for cashless treatment, and reports have documented instances in which portal or OTP failures have delayed authorisation, including for emergency procedures. A system designed to spare families from paying upfront can therefore become difficult to access precisely when time matters most. The problem is not digitalisation itself, but the absence of a reliable fallback when the technology fails.

Hospitals face a different set of pressures. Private empanelled providers have at times refused DDSSY cards or restricted beds available to beneficiaries, with delayed reimbursements and concerns that fixed package rates do not adequately reflect the cost of complex procedures cited among the reasons. These disputes have consequences beyond the relationship between the state and providers. When an empanelled hospital is unwilling to accept the card, it is the patient who is left looking for an alternative or facing an unexpected bill.

There is also a more fundamental question about who Goa’s model considers part of its universal system. DDSSY requires five years of residency, leaving recent migrant workers—including people employed in hospitality, construction and seasonal work—outside its coverage. The requirement may help contain the state’s fiscal exposure, but it also creates a difficult trade-off: some of the workers who contribute to Goa’s economy can live and work in the state without qualifying for its principal health assurance programme. For them, dependence on the public health system remains considerably greater.

These problems point to a broader issue. Expanding insurance is valuable, but coverage alone is not a measure of quality. Patients also need to know that the hospital treating them meets appropriate clinical standards, that poor outcomes can be identified, and that complaints can be raised without navigating another complicated administrative process.

Goa could strengthen this side of DDSSY by linking empanelment more closely to National Accreditation Board for Hospitals & Healthcare Providers (NABH) standards, while allowing smaller facilities a phased route towards higher accreditation. Clinical monitoring could also move beyond the number and value of claims to track outcomes such as hospital-acquired infections, 30-day readmissions and mortality following specialised procedures. The original proposal for independent medical audits would give the Directorate of Health Services a way to assess not simply how much treatment is being purchased, but the quality of that treatment.

Patient rights need similar attention. Verification should be rigorous enough to prevent misuse without becoming intrusive. The proposed shift away from practices such as photographs of surgical wounds or intimate body parts towards diagnostic records and authenticated clinical documentation would provide a more appropriate balance between claims verification and patient dignity. A grievance mechanism within Goa Online, allowing beneficiaries to report their experience of cleanliness, nursing care and discharge communication, could further make patient experience part of how provider performance is assessed.

For Goa, then, the next stage of universal health coverage is not simply about putting more people on the rolls. It is about making sure that the promise represented by the DDSSY card survives the journey from enrolment to the hospital bed.

Learning Across States: What Could Work for Goa?

Goa does not need to replicate the health assurance systems of larger states. Its smaller population, residency-based eligibility and existing public health infrastructure call for a model suited to its own circumstances. But experience elsewhere can still offer useful lessons, particularly where DDSSY faces gaps in protection, the range of treatments covered and the financing of public hospitals.

The first concerns protection against exceptionally expensive treatment. The recent increase in DDSSY coverage to ₹4 lakh for smaller families and ₹6 lakh for larger families provides a stronger cushion than before, but complex tertiary care can still exhaust these limits. Multi-stage cancer treatment, organ transplantation and prolonged neonatal intensive care are among the cases where costs can rise quickly. Rajasthan offers one possible approach: rather than substantially increasing the amount available for routine treatment, Goa could consider a higher top-up specifically for rare and catastrophic illnesses. This would preserve the existing structure for most claims while providing additional protection to the relatively small number of families facing exceptionally high medical costs.

There is also room to revisit what DDSSY pays for. Its 447 medical packages form a considerably narrower portfolio than those available under comparable schemes in Rajasthan and Tamil Nadu, which cover between 1,100 and 1,700 procedures, and Punjab, with more than 2,350. Package numbers alone do not determine the quality of a health assurance programme, and simply adding procedures would serve little purpose if they do not reflect Goa’s healthcare needs. A periodic review by clinical experts within the Directorate of Health Services (DHS) could instead identify genuine gaps—particularly in areas such as complex joint replacements, advanced interventions and cross-specialty day-care procedures—and draw selectively on the package lists used elsewhere.

Tamil Nadu offers a different lesson in the way insurance payments can support the public health system itself. Under the model discussed in the article, when an insured patient receives treatment in a government hospital, part of the insurance reimbursement is retained by the institution or department and reinvested in services. A similar arrangement within major Goan institutions such as Goa Medical College (GMC) could allow a share of DDSSY reimbursements to support equipment, departmental infrastructure and service improvements where the treatment was actually delivered.

These examples are most useful when treated as options rather than templates. Goa’s advantage is precisely that it does not have to reproduce the scale or complexity of larger state systems. The more relevant task is to identify where DDSSY leaves families exposed and borrow selectively from approaches that address those gaps without making the scheme unnecessarily complicated.

Closing the Remaining Protection Gap: What Would It Cost?

If Goa wants to move from broad health assurance towards genuinely universal coverage, the remaining gap is relatively small but not insignificant. The article estimates that around 8-10% of the population remains uninsured, either because of renewal lapses or because they do not meet the scheme’s documentation and residency requirements. Even among eligible families, DDSSY requires annual renewal and a registration fee of ₹200-₹300, adding another administrative step to remaining covered.

Removing these barriers would carry an additional cost. The first component is straightforward. With approximately 1.81 lakh to 2.2 lakh active families, absorbing the annual registration and renewal fees would cost the state an estimated ₹5-6 crore a year. Extending coverage to households that currently remain outside the system is estimated to require another ₹10-12 crore annually in premium support. If greater enrolment also leads to higher utilisation, the resulting claims are projected to add a further ₹20-25 crore to the scheme’s annual expenditure.

On these estimates, closing the coverage gap would require an additional ₹35-43 crore each year. Against Goa’s annual budget expenditure of more than ₹28,000 crore, this amounts to approximately 0.16% of the state budget. Put differently, the fiscal question is less about whether Goa can afford to extend protection and more about whether the additional expenditure can translate into coverage people can reliably use.

There is, however, an important distinction between making DDSSY free for those already eligible and making it genuinely universal. Absorbing the ₹200-₹300 annual fee would remove a financial and administrative barrier for existing beneficiaries. Reaching those excluded by the five-year residency requirement would require a separate policy decision about eligibility itself. That question cannot be resolved through additional funding alone; it requires the state to decide how broadly to extend its health assurance commitment.

Making Coverage Work Better

If Goa is to move closer to universal health coverage, the next phase of reform should focus less on expanding the scheme in principle and more on making it easier to access, more reliable at the point of care, and more responsive to the costs faced by hospitals and patients.

One priority is to simplify enrolment and renewal. Linking DDSSY records more closely with the electoral roll and Aadhaar could reduce repeated paperwork for eligible residents and allow coverage to be updated more automatically. But this should not be treated as a complete solution to the remaining coverage gap. People who do not meet the five-year residency requirement—and those who are not on the electoral roll—would still require a separate route into the system. Automatic renewal can solve an administrative problem; broader inclusion requires an explicit policy choice on eligibility.

A second priority is that verification should never delay treatment during an emergency. The proposed real-time e-KYC override could allow hospitals to begin urgent treatment when a patient presents valid identification, with OTP failures or minor documentation discrepancies resolved after the patient has been stabilised. This would directly address one of the most serious weaknesses identified in the current system: a cashless entitlement is of little use if digital verification delays treatment when time is critical.

Coverage also needs to be matched by available care. Goa should continue strengthening public facilities beyond its main urban centres so that patients do not have to travel unnecessarily for secondary and specialised treatment. Upgrading facilities at the taluka and sub-district level, alongside improving the availability of specialist staff, would make insurance more meaningful for people living farther from major hospitals.

Finally, the relationship with private providers needs attention. Faster and more predictable claims processing, less intrusive verification, and periodic revision of package rates to reflect actual clinical costs could reduce the incentives for empanelled hospitals to restrict DDSSY patients or refuse complex cases. Any move towards automated claims processing should therefore be accompanied by transparent rules, realistic reimbursement rates and safeguards for patient privacy.

These reforms do not require Goa to redesign DDSSY from the ground up. They require the state to close the gaps between eligibility, authorisation, treatment and reimbursement. That is where the difference between broad insurance coverage and dependable health protection is ultimately made.

When Health Assurance Works

Goa has come a long way from the narrower, reimbursement-based health protection that preceded DDSSY. A residency-based scheme, cashless hospital care and the recent increase in coverage limits have given a large section of the population greater protection against medical expenses. Yet the experience of DDSSY also shows that universal health coverage cannot be measured by enrolment or insurance ceilings alone.

The remaining gaps increasingly concern how the system functions at the point of care: whether a patient can secure timely authorisation, whether hospitals are willing and able to provide treatment under the scheme, whether those outside the residency threshold have a route to protection, and whether the care being financed meets appropriate standards. The estimated ₹35-43 crore in additional annual expenditure—around 0.16% of Goa’s budget—suggests that extending financial protection further is within the state’s fiscal reach. But funding alone will not resolve questions of access, eligibility and quality.

As Goa looks towards Swayampurna Goa and the wider ambition of Viksit Bharat @2047, the next step is therefore not simply to insure more people, but to make that assurance dependable. A health card fulfils its purpose only when it translates into timely, affordable and dignified care when a family needs it most.

About the Authors

Dr. Manorama Bakshi is Director & Head of Healthcare & Advocacy at Consocia Advisory, Founder & Director of the Triloki Raj Foundation, and a Senior Visiting Fellow at IMPRI.

Dr. Arjun Kumar is the Director of the IMPRI Impact and Policy Research Institute, New Delhi. He holds a Ph.D. in Economics from the Centre for the Study of Regional Development, School of Social Sciences, Jawaharlal Nehru University (JNU), New Delhi.

Disclaimer: All views expressed in the article belong solely to the author and not necessarily to the organisation.