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Ayushman Bharat: A Healthcare Revolution at the Crossroads

When Ayushman Bharat Pradhan Mantri Jan Arogya Yojana (PM-JAY) was launched in 2018, it was hailed as the world’s largest government-funded health insurance scheme, promising Rs. 5 lakh of annual health coverage to over 50 crore vulnerable Indians. It was a bold initiative designed to alleviate India’s crippling out-of-pocket healthcare expenditure, which drives millions into poverty each year. Yet, five years on, Ayushman Bharat struggles to fulfil its transformative potential, particularly for migrant workers, rural populations, and the “missing middle.”

While the ambition behind Ayushman Bharat is undeniable, the scheme’s current design reveals structural gaps that disproportionately affect India’s most vulnerable, leaving many without access to the healthcare they were promised.

A Promising Vision Undermined by Flaws

Ayushman Bharat stands on two pillars: the Health and Wellness Centres (HWCs), aimed at strengthening primary healthcare infrastructure, and PM-JAY, which focuses on secondary and tertiary care hospitalisation coverage. On paper, it addresses both preventive and curative healthcare needs. However, in practice, significant limitations emerge.

Fieldwork conducted in November 2023 by PDAG for the Tata Trust project revealed that 82.6% of migrant households surveyed had no family member covered by any government health insurance scheme. In Rajasthan, the figure was 87.3%, while 77.3% of migrant households in Uttar Pradesh lacked coverage (Figure 41). These numbers highlight glaring gaps in outreach and enrollment, particularly among migrant families, despite the scheme’s vast coverage.

Even for those covered by some form of insurance, PM-JAY had less than 20% of migrant households registered, with schemes like Pradhan Mantri Jeevan Jyoti Bima Yojana (PMJJBY) and Pradhan Mantri Suraksha Bima Yojana (PMSBY) having seen higher enrollment rates (Figure 42). This suggested that while Ayushman Bharat aimed for comprehensive healthcare coverage, its penetration remained limited, with other schemes filling the void for vulnerable populations.

Migrant Workers: Falling Through the Cracks

Migrant workers are particularly disadvantaged when it comes to healthcare access. Their mobility, lack of stable documentation, and disconnection from social welfare systems often leave them outside the scope of schemes like Ayushman Bharat. While PM-JAY’s portability is a positive step, it relies on static identification systems like ration cards, which many migrant families do not possess.

In December 2023, the National Science Foundation’s project, operationalised by PDAG conducted fieldwork in Bihar (Gaya and Jamui districts) and found that the awareness of Ayushman Bharat was alarmingly low among migrant families. Many were unaware of the scheme’s benefits, and those with the Ayushman card faced difficulties accessing services. The distribution of cards was inconsistent, and ASHA workers struggled to raise awareness without adequate support.

However, the March 2024 phase of the NSF project, conducted in Bihar just before the Lok Sabha elections, reflected a significant shift. A mass registration drive in districts like Gaya and Jamui boosted awareness and coverage, ensuring that most eligible families had received their Ayushman Bharat cards. While this represents progress, it remains uncertain whether mere possession of the Ayushman card translates into adequate access to healthcare. Bureaucratic hurdles and complex processes continue to obstruct marginalised families from fully benefiting from the scheme.

In contrast, earlier Tata Trust project fieldwork in 2023 in Bahraich, Uttar Pradesh, revealed that 22.7% of households had at least one family member covered by health insurance (Figure 41). However, similar challenges regarding accessibility persisted, with many migrant households still facing significant barriers to fully availing themselves of the benefits.

The “Missing Middle”: A Critical Blind Spot

Perhaps the most glaring flaw in Ayushman Bharat’s design is its failure to cover the “missing middle”, nearly 30% of India’s population who are too affluent to qualify for government healthcare schemes but not wealthy enough to afford private insurance. The vulnerability of this group has been largely overlooked.

PDAG’s fieldwork shows that access to Ayushman Bharat in rural India often depends on social capital. Villages with a higher concentration of upper-caste households tend to have greater awareness and better access to healthcare schemes. Meanwhile, marginalised groups, like the Maha Dalits, remain uninformed and underserved, reflecting broader socio-economic and caste-based inequities that reinforce exclusion from public goods.

Outpatient Care: The Overlooked Dimension

While Ayushman Bharat focuses on hospitalisation, it neglects a crucial aspect of healthcare, outpatient care. For many families, especially in rural India, everyday healthcare needs revolve around outpatient services like consultations, diagnostics, and medications. These costs often surpass hospitalisation expenses, pushing low-income households deeper into debt.

Migrant workers are particularly disadvantaged by this omission. Field data from PDAG and Tata Trust’s study shows that migrant workers send an average of Rs. 22,118 back home during migration cycles, much of which covers healthcare expenses not supported by PM-JAY. Without outpatient coverage, their financial vulnerability only worsens. Expanding Ayushman Bharat to include outpatient services would significantly reduce the burden on families relying on these services for their healthcare needs.

The Climate-Migration-Health Nexus

The intersection of climate change and migration adds further complexity to India’s healthcare crisis. Climate-induced migration from states like Bihar, Jharkhand, and Uttar Pradesh is rising as environmental degradation renders rural livelihoods increasingly unsustainable. Migrants from these regions face not only economic but also healthcare vulnerabilities. Migrants often fail to receive the benefits of their PM-JAY cards, even when they possess them. Accessing actual benefits, such as treatment in hospitals, remains challenging for both marginalised communities in Bihar and migrant workers who travel from Bihar and Uttar Pradesh to other states.

While awareness of Ayushman Bharat has improved, the scheme remains poorly equipped to meet the healthcare needs of climate migrants. These migrants, who frequently relocate in response to environmental crises, often lack access to stable identification systems and are disconnected from the healthcare services they urgently need. Ayushman Bharat must evolve to incorporate climate resilience into its framework and address the unique vulnerabilities faced by displaced populations.

The Path Forward: Bridging Gaps for Comprehensive Care

To realise the full potential of Ayushman Bharat, critical reforms are necessary. While the March 2024 registration drive showcased improvements in enrollment, the actual test lies in ensuring that those registered can access the benefits of the scheme.

  • Expand Coverage to Include Outpatient Care: Outpatient services represent the majority of healthcare costs for rural and lower-middle-class households. Without coverage for these services, Ayushman Bharat will continue to fall short in alleviating the financial strain on families.
  • Reconsider Static Identification Requirements: Ayushman Bharat’s reliance on ration cards for enrollment must be rethought, especially for migrant workers. A more flexible identification system linked to Aadhaar or mobile numbers could ensure greater portability and access for those moving between states.
  • Sustained Political Will and Administrative Consistency: The mass registration drive before the Lok Sabha elections demonstrated that political will can improve awareness. However, such initiatives must be sustained beyond electoral cycles to have a lasting impact.
  • Address Social Determinants of Health: Ayushman Bharat must be part of a broader strategy that tackles nutrition, education, and environmental resilience. Without addressing these root causes, the scheme will remain reactive rather than proactive, limiting its long-term impact.

A Transformative Vision in Need of Realisation

Ayushman Bharat has the potential to transform India’s healthcare landscape, but its current design still falls short of addressing the full spectrum of healthcare needs. The structural gaps—from the exclusion of outpatient care to the challenges faced by migrant workers and the “missing middle”, must be urgently addressed if the scheme is to fulfil its promise of universal healthcare.

Recent fieldwork has shown improvements in awareness, but accessibility challenges remain significant. As India strives to meet SDG 3 (Good Health and Well-being), Ayushman Bharat must evolve into a robust, inclusive, and intersectional healthcare model.

The voices of those on the margins, from migrant workers in Bahraich to the marginalised population in Bihar, must shape the future of healthcare policy. If Ayushman Bharat is to become the transformative force it was envisioned to be, it must bridge these gaps now. The stakes are too high for half-measures. As India stands at the crossroads of healthcare reform, the time for bold, inclusive action is now.