Ayushman Bharat: Govt gets more ambitious with its health insurance scheme

The ministry had in 2022 included certain basic oncology treatments such as chemotherapy and radiation, as well as kidney and heart transplants and dialysis under the scheme called Ayushman Bharat–Pradhan Mantri Jan Arogya Yojna. 

While private hospitals typically charge ₹2.5 lakh to ₹10 lakh for such procedures, the government plans to include more complex treatments costing ₹20 lakh to ₹30 lakh, according to two ministry officials familiar with the plans.

These officials, who declined to be identified, did not specify what additional treatments and surgeries would be included in the updated list. “The ministry is reviewing the existing facilities… the changes are likely to be made after the election," one of them said.

When Ayushman Bharat was rolled out in 2018, it was meant to offer cashless treatment for secondary and tertiary care of up to ₹5 lakh per person in a year in both government as well as empanelled private hospitals. At the time, health insurance penetration in India was only about 35%, according to Statista.com.

As of September, about 600 million families earning less than ₹2.5 lakh in a year were issued Ayushman Bharat cards, helping provide timely and necessary medical care to individuals who otherwise weren’t able to afford such treatments. The scheme currently lists 1,109 packages and 1,949 procedures across 27 specialties.

Some of these, however, are not being availed as had been expected. 

With a budgetary allocation of ₹7,500 crore for FY25 for the Ayushman Bharat scheme, up from ₹7,200 crore for FY24, the ministry is looking to remove treatments not availed frequently and instead include more complex and expensive ones.

“Some of the treatments are not seeing enough patient count. In 2022, surgeries such as vasectomy were removed because there were hardly any takers for it. The ministry is still reviewing the packages that are not beneficial, both from a hospital’s perspective as well as in terms of demand from patients," said the second official.

“Surgeries such as knee replacements, hip replacements, and congenital heart diseases… are seeing good demand and helping many poor patients cut down on the cost of treatment," this official said.

The Union health ministry did not reply to queries seeking more information on the treatments and surgeries to be included under the Ayushman Bharat scheme.

But the government does intend to allow individuals covered under Ayushman Bharat to avail procedures not included in the scheme if they have a recommendation from the hospital treating them. This option is already available at the All India Institute of Medical Sciences in New Delhi.

“In cases where the treatment doesn’t meet the AB-PMJAY scheme and the family comes from a economically weaker category, we write to the ministry and get it covered by the scheme," said a senior doctor.

The ministry also plans to add more counters in government hospitals so more patients can register for the scheme.

But administrators of private hospitals complain about losses due to Ayushman Bharat, saying treatments listed under it are more expensive than the government’s estimates. 

Currently, patients can avail free treatment at 23,700 private hospitals empanelled under the scheme, with the government reimbursing the hospitals as per its estimate of treatment cost.

“The cost that the hospitals are incurring after implementing Ayushman Bharat is higher than what the government is offering. If patients need safety and care, there is a cost behind it and it varies from district to district," said Dr. R.V. Asokan, president, Indian Medical Association. “All the prices offered by the government are currently under the cost."

Funding for Ayushman Bharat is shared between states and the Union government in the ratio of 60:40. Uttar Pradesh, Madhya Pradesh, Gujarat, Chhattisgarh and Maharashtra have the highest number of beneficiaries under the scheme.

But some states such as Delhi, Odisha and West Bengal have not implemented Ayushman Bharat, preferring their own health schemes over Ayushman Bharat.