The link between insurance and the outcomes of eye surgery is shaped by demographic differences – particularly gender, geography, economic disparities – and the quality of care received.
Published Jul 27, 2025 | 7:00 AM ⚊ Updated Jul 27, 2025 | 7:00 AM
With India’s population aged 65 and above expected to rise sharply by 2050, it underlines the need to expand insurance access, particularly among the elderly.
Synopsis: Elderly patients with health insurance are significantly more likely to experience better visual outcomes after cataract surgery compared to those without insurance, according to a large-scale study which analysed data from over 38,000 patients aged 70 and above across four states. The study highlighted the urgent need for expanding insurance access, especially for the oldest age groups and rural populations, to improve both eye health and healthcare equity as India’s elderly population grows rapidly.
Elderly patients with health insurance are significantly more likely to regain good vision after cataract surgery than those without coverage, according to a large-scale study conducted across four Indian states.
Published in The Lancet Regional Health – Southeast Asia, the study analysed data from over 38,000 patients aged 70 and above who underwent cataract surgery between 2011 and 2022. The surgeries were performed at various centres of the LV Prasad Eye Institute in Andhra Pradesh, Telangana, Odisha and Karnataka.
The researchers found that patients with insurance were 1.38 times more likely to experience favourable visual outcomes compared to uninsured patients. Among those aged 70–74, 74.2 percent of insured patients achieved good vision post-surgery, while the figure dropped to 61.9 percent among those without insurance.
These findings point to a significant gap in healthcare outcomes based on insurance status.
With India’s population aged 65 and above expected to rise sharply – from 8 per cent at present to 20 per cent by 2050 – and nearly half of all people aged 60 and above experiencing some form of vision impairment, it underlines the need to expand insurance access, particularly among the elderly, to improve not just financial protection but also overall health outcomes.
The study attributes the better visual outcomes among insured elderly patients to differences in the quality of care they received – not merely access to surgery.
“Higher proportions of elderly people using private insurance received foldable IOLs (Intraocular Lenses) – better lenses – as compared to those using government insurance (79.55 percent vs. 53.46 percent),” the authors said.
This gap in lens quality also revealed disparities along gender and age lines. “More elderly males (54.67 percent) received modern foldable IOLs compared to females (49.18 percent),” the authors said. “Implantation of foldable IOLs was less common for those over 80 years (44.49 percent vs. 53.08 percent).”
The preference for higher-quality care was so strong that some patients chose to forgo free surgeries in favour of insured treatment.
“A total of 189 (0.49 percent) patients converted from FS to insurance before undergoing surgery, even though they were initially offered the FS service,” the study noted. Of these, “forty-eight (25.40 percent) patients underwent a planned foldable IOL surgery, thus avoiding a rigid IOL in the case of FS service.”
The study also highlighted a troubling trend: as patients aged, both insurance coverage and visual outcomes declined. “The highest insurance uptake was observed in the age group 70–74 years, with 17.52 percent of the patients having insurance uptake,” the study noted. But this dropped sharply with age.
“In the 80–84 years age group, the insurance uptake was 10.88 percent; in the 85–89 years age group it was 8.50 percent; while in the >90 years age group, the insurance uptake was 7.14 percent for cataract surgery,” the study noted.
This decline was especially pronounced in private insurance. “The 70–74 years age group showed 3.17 times more usage of private insurance compared to government insurance (13.32 percent vs. 4.21 percent),” the study noted. But by the time patients were over 90, the gap had narrowed to “1.2 times more usage of private insurance compared to government insurance (4.07 percent vs. 3.33 percent).”
Government insurance coverage, meanwhile, remained persistently low across all age groups. “This increasing skew towards government insurance utilisation as compared to private insurance was noted without any proportionate change in the usage of government insurance (3 percent–4.2 percent) in all age bands,” the study noted.
The link between insurance and visual outcomes was further shaped by demographic differences, particularly gender, geography and economic disparities.
“We found insurance uptake to be higher in elderly males compared to elderly females. The overall insurance uptake was 19.11 percent in males and 12.43 percent in females,” the study noted. “The uptake remained lower for females across the analysed subgroups of age, socioeconomic status, residence and systemic morbidities.”
Geographic location also played a major role in determining both access to insurance and, as a result, vision outcomes. The study found that “rural residence had the lowest association with insurance uptake even in the multivariate regression (OR = 0.18, reference–metropolitan residence).”
Socioeconomic background showed a clear pattern that impacted how patients accessed and benefited from insurance. “Overall, 6,170 (16.07 percent) of all patients benefited from insurance uptake. Among these insured patients, 5,246 were from the lower middle class, 449 from the upper middle class (UMC), and 286 from the upper class (UC) socioeconomic categories,” the study noted.
Insurance use varied widely across economic groups. “Overall insurance usage was noted as 14.93 percent in LMC, 21.39 percent in UMC, and 29.64 percent in UC. The utilisation of government insurance was lower in all groups amongst the insured patients; 25.03 percent in LMC, 1.11 percent in UMC, and 0.7 percent in UC,” the study noted.
“Higher socio-economic status was also associated with better visual outcomes (OR = 1.42 and 1.79),” the authors said – further underscoring how wealth and class can influence both insurance access and quality of vision after surgery.
The rollout of Ayushman Bharat insurance schemes in 2018 marked a turning point in coverage and visual outcomes, the study found, with insurance uptake increasing between 2018–2022 compared to 2011–2017 (20.61 percent vs. 10.65 percent).
Patients who underwent cataract surgery after 2018 were far more likely to be insured.
“Patients who had surgeries after 2018 had the highest OR for insurance uptakes (OR = 2.65). This was much higher than all patient-attributable factors including presenting vision, systemic illnesses, gender, age, occupation and socio-economic status,” the authors noted. “This signifies the positive impact of the change in regulatory policy for insurance in 2018.”
However, while insurance improved access and outcomes, it came with longer waiting periods.
“It took a median gap of 6 days for patients without insurance to have surgery performed after being advised to opt for surgery. In contrast, for those with insurance, this median gap was significantly higher (13 days),” the study noted.
These delays were especially pronounced among government insurance beneficiaries.
“For these patients, it took a median gap of 18 days for surgery to be performed after the patients were first advised to opt for surgery. However, for the patients who were covered by private insurance, the median gap was significantly lower (11 days),” the study noted. “Government insurance approvals were found to be three times slower than those for private insurance approvals.”
Despite these barriers, demand for insured cataract surgery continued to grow
“From 2013 to 2022, there was a substantial increase in the number of patients undergoing cataract surgeries with insurance uptake. Starting with 19 surgeries in the baseline year, there was a peak (at 368.92 percent growth) in 2016, followed by a slight decline in 2020 (likely due to the COVID-19 pandemic), although the overall growth trend remained positive,” the study noted.
“By 2021, the number of surgeries doubled compared to the previous year, and this growth continued into 2022 with a 42.90 percent increase.”
The findings point to a critical vulnerability within India’s healthcare system – one that directly affects its oldest citizens.
“As the ‘oldest old’ may be financially dependent on their families, insurance coverage in this vulnerable group may be central to their ocular health. However, our data also revealed concerning disparities in the current situation, with the oldest individuals having limited insurance uptake (7 percent),” the authors said.
