Ayushman Bharat Pradhan Mantri Jan Arogya Yojana: Why It Fails the Poor in Their Golden Years | Opinion

India’s Ayushman Bharat Pradhan Mantri Jan Arogya Yojana (AB-PMJAY) has sparked hope for senior citizens above 70, promising free health insurance with Rs 5 lakh annual coverage. Launched in October 2024, this ambitious scheme targets 6 crore seniors across 4.5 crore families, aiming to ease the burden of healthcare costs. For poor seniors, who often skip treatment to avoid debt, this sounds like a godsend. But beneath the surface, the scheme’s gaps—exclusions, state-level failures, and practical barriers—leave the poorest struggling. For many, this golden promise is a mirage, far from the lifeline it claims to be.

A Bold Vision with Blind Spots

On paper, AB-PMJAY is a game-changer. It covers 1,929 medical procedures, from heart surgeries to cancer treatment, with cashless care at empanelled public and private hospitals. There’s no waiting period, so chronic conditions like diabetes or hypertension are covered from day one. Seniors receive an Ayushman Vaya Vandana Card, and the ₹5 lakh cover is family-based, with an additional top-up for those already enrolled. For a poor senior, this could mean life-saving surgery without selling land or borrowing at crushing interest rates. The scheme’s portability allows treatment at any empanelled hospital nationwide, a boon for those who migrate or travel.

But the scheme’s focus is narrow—limited to secondary and tertiary care, meaning hospitalization for serious conditions. It completely ignores primary care, outpatient (OPD) visits, and routine diagnostics. For a poor 75-year-old widow in a village, this is a harsh reality. If she has arthritis or early diabetes, she needs regular doctor visits, medicines, or blood tests to stay healthy. AB-PMJAY won’t cover these. She must dip into her meager savings, rely on family, or skip care altogether. Small health issues can spiral into emergencies, landing her in a hospital—if she’s lucky enough to reach one. By then, the damage may be irreversible, or the costs, even with coverage, may still overwhelm her.

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Exclusions That Crush the Poor

The scheme’s long list of exclusions feels like a wall for the poorest. Routine dental care, like fillings or dentures, is excluded unless part of hospitalization. Treatments for HIV/AIDS, drug or alcohol rehabilitation, obesity, and mental health issues are not covered, despite being common among seniors. Organ transplants, often a last resort, are rarely included. Standalone diagnostics, like an angiogram to check heart health, are out unless tied to a hospital procedure. For a poor senior scraping by on a small pension or daily wages, paying for these tests or treatments is unthinkable. They’re forced to delay care, praying their condition doesn’t worsen.

The ₹5 lakh cap, while significant, is shared across the family. In a poor household with multiple seniors or chronic illnesses, this can vanish quickly. A single major surgery, like a heart bypass, can eat up much of the limit, leaving little for follow-ups or other family members. Treatment is also restricted to empanelled hospitals, which are often far from rural areas. A poor senior might spend hours traveling, paying for buses or autos, and losing income just to reach care. For someone surviving on ₹50 a day, this isn’t relief—it’s a new burden.

States That Turn Their Backs

The scheme’s absence in states like Delhi and West Bengal is a glaring failure. Political disputes have blocked AB-PMJAY’s rollout, leaving seniors there with no access to its benefits. In Delhi’s cramped slums or West Bengal’s rural villages, poor seniors rely on overcrowded government hospitals or private clinics they can’t afford. This isn’t just a policy gap—it’s a betrayal of the most vulnerable, caught in political tug-of-war. A scheme billed as universal should not exclude entire states, yet millions of seniors are left to fend for themselves, their health hanging in the balance.

Rural Realities: A Distant Dream

For poor seniors in rural India, AB-PMJAY is often out of reach. Over 26,000 hospitals are empanelled, but most are in cities or towns, miles from villages. Public transport is patchy, and private options are costly. Enrollment, while simple via the Ayushman app, assumes access to smartphones, internet, or help with Aadhaar-based e-KYC. Many seniors have none of these. Local health workers, meant to guide them, are overstretched. Awareness is low—some don’t even know the scheme exists. Fraud, though checked by anti-fraud units, adds distrust, with reports of hospitals overcharging or refusing care. For the poor, the scheme feels like a distant dream, not a reality.

The Human Cost of Gaps

These gaps aren’t just logistical—they’re deeply human. Picture an 80-year-old laborer with chest pain, unable to afford a routine heart scan because it’s not covered. Or a grandmother in a West Bengal village, ineligible because her state opted out, watching her health deteriorate. These are the faces of AB-PMJAY’s failures. The poor, who bear the double burden of poverty and illness, are hit hardest. Out-of-pocket healthcare costs push millions into debt each year, and while AB-PMJAY has reduced this for some, its exclusions and barriers leave too many behind.

When Will the Poor Truly Benefit?

The scheme can deliver for the poor, but only with bold fixes. First, it must cover primary care and OPD services. Regular check-ups and medicines can prevent hospital stays, saving lives and costs. Second, routine diagnostics, like blood tests or scans, should be included, even outside hospitalization, to catch issues early. Third, dental care, mental health support, and treatments for conditions like HIV/AIDS are not luxuries—they’re necessities for seniors. Fourth, the government must bring states like Delhi and West Bengal into the fold, ensuring no senior is excluded. Fifth, more empanelled hospitals in rural areas and door-to-door enrollment camps can bridge the access gap.

Beyond this, practical steps can make a difference. Mobile health vans, equipped for diagnostics and basic care, could reach remote villages. Partnerships with local clinics could offer subsidized primary care linked to AB-PMJAY. Awareness campaigns, using radio, local leaders, or street plays in regional languages, could ensure every senior knows their rights. These aren’t pipe dreams—they’re achievable with political will. Private insurance, often suggested as a supplement, is no solution for the poor; premiums are far beyond their means. The government must fill these gaps itself, making AB-PMJAY a true safety net.

A Promise Yet to Be Kept

AB-PMJAY for seniors is a bold vision, but it’s like a bridge with missing planks. Its exclusions, state-level gaps, and access barriers hit the poor hardest, forcing them to choose between suffering in silence or sinking into debt. The scheme has the power to transform lives, but only if it reaches the most vulnerable—those in villages, slums, and forgotten corners of India. Until these holes are plugged, millions of seniors will see their golden years marred by pain and poverty. India can do better. Let’s make AB-PMJAY a lifeline, not a letdown, for the poor who need it most.

(The author Girish Linganna of this article is an award-winning Science Writer and a Defence, Aerospace & Political Analyst based in Bengaluru. He is also Director of ADD Engineering Components, India, Pvt. Ltd, a subsidiary of ADD Engineering GmbH, Germany. You can reach him, at: girishlinganna@gmail.com)