India Ayushman Bharat at five years: coverage, claims, and the OOP question

From flagship launch to mass enrollment #

Pradhan Mantri Jan Arogya Yojana, the insurance pillar of the broader Ayushman Bharat program, was launched in September 2018 with a promise of 500,000 rupees of annual secondary and tertiary cover per family for the bottom 40 percent of households identified through the Socio Economic Caste Census. By the end of fiscal 2020, the National Health Authority had issued roughly 124 million Ayushman cards. Card issuance accelerated through the pandemic as states cleared backlogs and integrated state-level schemes such as Tamil Nadu's CMCHIS, Rajasthan's Chiranjeevi, and Karnataka's Arogya Karnataka. By April 2026, the cumulative card count exceeds 360 million across roughly 130 million unique families, and the eligible pool itself was widened in 2024 to include all citizens aged 70 and above, adding an estimated 60 million older adults regardless of income.

Empanelment kept pace, if unevenly. The empanelled hospital network grew from about 16,000 facilities in 2019 to more than 32,000 by 2026, split roughly 58 percent public and 42 percent private. Specialist procedure availability remains thinner in tier 2 and tier 3 districts, where private empanelment is sparse and public referral capacity strained. The scheme's identity layer, anchored to the Ayushman Bharat Health Account (ABHA) under the Ayushman Bharat Digital Mission, now reaches more than 750 million unique IDs, providing the rails for longitudinal claims analytics that earlier state schemes could never assemble.

Claims utilization: from authorization to actual care #

Cumulative authorized hospital admissions under PMJAY crossed 90 million by early 2026, with cumulative authorized claim value of approximately 1.42 trillion rupees, equivalent to about 17 billion U.S. dollars at prevailing exchange rates. Annual run rates have stabilized near 18 to 20 million admissions and 280 to 320 billion rupees of authorized value, with oncology, cardiology, and orthopedics accounting for close to half of paid value despite making up a smaller share of episode count.

Authorization is not the same as utilization. Internal NHA audits and CAG reviews suggest that 6 to 9 percent of authorized claims are downgraded, denied, or recovered after fraud and abuse triage, and that average paid value runs roughly 12 percent below authorized value once package downcoding and pre-authorization adjustments settle. Turnaround time has improved markedly: median claim adjudication moved from above 30 days in 2020 to under 12 days in most large states by 2026, although three states still report tail latencies beyond 60 days for high-value tertiary claims.

State-level uptake: a tenfold spread #

Headline national figures conceal a remarkable variance across states. Per-eligible-beneficiary claims utilization in 2025 ranged from above 0.18 admissions per person per year in Kerala, Chhattisgarh, and Tamil Nadu, to under 0.02 in Bihar, Uttar Pradesh, and the northeast. Authorized claim value per beneficiary similarly varied from above 1,400 rupees in Karnataka and Andhra Pradesh to below 250 rupees in Bihar. The drivers are well documented: density and quality of empanelled private hospitals, prior experience operating state insurance schemes, the strength of district health societies, and the share of beneficiaries who actually carry an active card.

States that converged early on PMJAY package rates and bolted on top-up cover, notably Gujarat, Maharashtra, and Karnataka, see private-sector claim shares above 65 percent of paid value. States that retained parallel schemes with higher reimbursement, such as Tamil Nadu and Telangana, route most volume through state rails while using PMJAY co-financing for tertiary cases. The lagging cluster, primarily across the Hindi belt and northeast, faces a supply-side bottleneck more than a demand problem, and incremental enrollment without empanelment investment will not close the gap.

Out-of-pocket spending: the headline that has not yet broken #

The National Health Accounts series produced by MoHFW shows out-of-pocket expenditure (OOPE) falling from 64.2 percent of total health expenditure in 2013-14 to 39.4 percent in 2021-22, with government health expenditure rising from 1.13 percent to 1.84 percent of GDP over the same window. The WHO Global Health Expenditure Database, using a slightly different boundary, places India's 2022 OOP share closer to 47 percent. Both series agree on direction but disagree on level, and the gap matters when claiming progress against the National Health Policy 2017 target of pushing OOPE below 35 percent.

The latest NSS 75th and 79th round household surveys, together with the Health Consumption Expenditure module of the 2022-23 HCES, suggest a more textured picture. Average inpatient OOP per hospitalization episode fell in real terms in PMJAY-strong states, particularly for cardiac and cancer admissions, but rose for outpatient care, diagnostics, and pharmacy purchases that sit outside the scheme's secondary and tertiary perimeter. Roughly 62 percent of household OOP in 2022-23 was outpatient, dominated by medicines and tests, exactly the categories PMJAY does not cover. Until primary care financing through the Health and Wellness Centre network and outpatient benefit pilots scale up, the OOP curve will flatten rather than collapse.

Provider payment redesign: the next lever #

PMJAY's package-rate model, with roughly 1,950 procedures grouped into bundled tariffs, has been credited with both the scheme's fiscal discipline and its provider friction. The 2022 and 2024 Health Benefit Package revisions raised tariffs for about 350 procedures, particularly in oncology, neurosurgery, and neonatal care, where prior rates had driven private withdrawals. Even after the revisions, structured surveys of empanelled hospitals find that 30 to 45 percent of high-end tertiary procedures are reimbursed below private payer rates, sustaining a quiet rationing of access at flagship facilities.

The NHA is piloting hybrid payment models that layer differential incentives for tier 2 and tier 3 districts, quality-linked top-ups for NABH-accredited facilities, and capitation-style payments for chronic disease management at Health and Wellness Centres. Early data from Andhra Pradesh and Meghalaya pilots show modest reductions in average length of stay and earlier referral for cardiac events. A diagnosis-related group transition has been studied but is unlikely before 2028 given the data infrastructure required to risk-adjust packages credibly.

Catastrophic spending: who is still being pushed under #

Catastrophic health expenditure, conventionally defined as OOP exceeding 10 percent of household consumption, fell from roughly 17 percent of Indian households in 2014 to about 12 percent by 2022 according to NSS-based estimates, with the steepest declines among the poorest two quintiles in PMJAY-strong states. Medical impoverishment, the share of households pushed below the poverty line by health spending, dropped from approximately 4.5 percent to under 3 percent over the same period, sparing an estimated 25 to 30 million people annually from poverty-inducing health shocks.

The protection is uneven. Households with members suffering chronic non-communicable diseases, particularly diabetes, hypertension, and chronic kidney disease, continue to face cumulative OOP burdens that PMJAY's hospitalization-centric design does not address. Cancer patients still report median OOP of 80,000 to 150,000 rupees per treatment course in tertiary urban centers despite scheme coverage, driven by drugs, diagnostics, transport, and informal payments. Closing this residual gap is the central health economics question for the second decade of Ayushman Bharat.

Three scenarios for 2026 to 2030 and the Salus view #

Salus models three trajectories. In the consolidation scenario, government health spending rises gradually toward 2.2 percent of GDP, PMJAY adds outpatient drug benefits in eight to ten states, and OOP share falls to roughly 34 percent by 2030, with catastrophic incidence near 9 percent. In the acceleration scenario, the central government honors the National Health Policy 2.5 percent of GDP target by 2029, primary care capitation reaches 60 percent of districts, and OOP drops to 28 percent with catastrophic incidence near 6 percent. In the stagnation scenario, fiscal pressure caps incremental allocations, package rates lag medical inflation, private empanelment shrinks in lagging states, and OOP plateaus near 38 percent.

The wedge between these futures is not enrollment, which is largely a solved problem, but the architecture of payment and the integration of outpatient and chronic care. Salus advises payers, providers, and state health agencies to model three priorities: a credible primary-care benefit financed through capitation rather than fee-for-service, a tariff revision cadence indexed to CPI-Health rather than ad hoc cycles, and a state-level performance compact that ties incremental central transfers to claims utilization in the lagging cluster. Get those three right and India's OOP question becomes answerable inside the decade rather than the generation.

Sources #

• National Health Authority Ayushman Bharat dashboard
• WHO Global Health Expenditure Database India
• Ministry of Health and Family Welfare India
• NSO NSS health survey
• IHME Global Burden of Disease India