Eight years after Ayushman Bharat– Pradhan Mantri Jan Arogya Yojana (AB-PMJAY) was launched to reduce the financial burden of hospitalisation on vulnerable families, the scheme has reached a scale few public health programmes have matched in the country.
Data speaks: More than 60 crore people now have access to annual health cover of up to Rs 5 lakh under Ayushman Bharat-Pradhan Mantri Jan Arogya Yojana (AB-PMJAY). As of September 21, more than 48.5 crore Ayushman cards had been created.
The scheme had funded 13.25 crore hospital admissions worth about Rs 2.03 lakh crore through more than 38,000 empanelled public and private hospitals. Union Health Minister JP Nadda posted the data on social media X.
But as the government marks the milestone, a recent editorial published in the International Journal of Molecular and Immuno Oncology has raised a larger question: how well does the promise of cashless healthcare work when a patient actually needs it?
While hailing the scheme as an attempt to protect families from the financial shock of serious illness, the editorial, titled "Ayushman program in India: Everyone is a hero", argues that the next phase of the programme should focus not only on expansion but also on making the system more reliable and easier to navigate.
Authors Dr Prashant Mehta, Department of Haematology Oncology and Bone Marrow Transplant, Amrita Institute of Medical Sciences and Research Centre, Faridabad, and Dr Purvish Parikh, eminent oncologist and haematologist and President of the Asian Geriatric Oncology Society, Mumbai, noted that for a family facing a serious illness, the real test begins at the hospital counter. Is the patient recognised as eligible? Is the required treatment covered? Can the hospital obtain approval without delay? Is the claim settled on time? And can the family understand the process without having to navigate a maze of paperwork?
That makes awareness an important part of the programme, they noted, asserting that having an Ayushman card does not automatically ensure that a beneficiary knows which services are covered, which hospital to approach or what to do when a claim is delayed or rejected.
The process can also be complicated behind the scenes, said Dr Mehta, the lead author.
Hospitals have to verify eligibility, match patient details, upload medical records, select the appropriate treatment package and, where required, obtain pre-authorisation. For patients and their families, these may appear to be routine administrative steps. But any delay at this stage can become significant when treatment is urgent.
This makes the people handling the system equally important. Ayushman Mitras, nurses, doctors, medical-record staff, coders and hospital administrators form the operational link between the scheme and the patient, as per the authors.
Another challenge is the balance between government spending and the actual cost of treatment, noted Dr Mehta.
AB-PMJAY package rates need to remain affordable for the public health system, but hospitals also need to be able to provide quality treatment within those rates. The editorial pointed to the need for regular and transparent revision of package rates, particularly as the cost and complexity of medical care change.
Timely reimbursement is equally important, the authors noted, pointing out that if hospitals face prolonged delays in receiving payments, it can create financial pressure and affect their willingness to participate in the scheme. At the same time, the government has to protect the programme from inflated claims, unnecessary procedures, duplicate billing and other forms of misuse.
The challenge, therefore, is to strengthen scrutiny without creating so many procedural hurdles that genuine patients are delayed, noted the authors.
The federal nature of India's health system adds another layer. AB-PMJAY operates across states and union territories, but healthcare infrastructure and administrative capacity vary. A beneficiary’s experience can therefore depend on where he or she lives and which hospital provides the treatment.
The editorial argued that stronger Centre-State coordination and portability are important if the programme is to provide a more consistent experience.
The government's own eight-year assessment shows that Ayushman Bharat has also expanded beyond hospital insurance. Ayushman Arogya Mandirs have recorded more than 500 crore visits, while the Ayushman Bharat Digital Mission and PM-Ayushman Bharat Health Infrastructure Mission are intended to strengthen other parts of the health system.
The expansion of the programme has also brought more groups under its umbrella. The government extended AB-PMJAY to all citizens aged 70 years and above in 2024, while additional categories such as ASHA and anganwadi workers and helpers have also been included, said the authors.
The larger question now is how these different components work together.
The authors said that for a patient, healthcare is not divided into government schemes, hospital packages, digital systems or insurance claims. It is one journey — from the first consultation and diagnosis to treatment, discharge and follow-up.
This is where the next phase of Ayushman Bharat could make a difference, said the authors.
The editorial has called for simpler processes, better grievance redressal, transparent payment timelines and more rational revision of package rates. It also argued for greater transparency in areas such as claim turnaround, rejection reasons and grievance resolution.
There is another delicate balance: tackling fraud without making genuine patients pay for it through delays or denial of necessary treatment. The authors highlighted another area to be worked on.
They concluded that the scheme’s next phase should focus on identifying and addressing the problems that cause the greatest hardship to patients, while preserving the gains made so far.
The authors summed up: “No public programme can cater to every problem. But a good programme can listen to problems, prioritise the most harmful frictions, and keep improving without losing its soul. ABPMJAY remains a remarkable effort by the government, the public, and the healthcare workforce."
“When we speak about it, whether in hospitals, in parliament, or in the media, we should be honest about shortcomings without erasing daily successes. Because in the quiet moments where a poor family receives timely care without financial ruin, the scheme is not a policy but a compassion made operational.”
