On The Ground In Haryana: Ayushman Bharat Lifeline For Patients, But Doctors Say Unpaid Bills Are Crippling Hospitals

Meera, 55, was admitted to the S L Minda Memorial Multi Super Speciality Hospital in rural Hisar, Haryana, for three days after suffering multiple ailments for months.

After taking a series of tests and treatments for her ailments, she was cleared for discharge. However, she must still return in a few days for more treatment. She is diagnosed with gall bladder stones.

Swarajya met Meera's son-in-law at the Ayushman Bharat desk of the hospital as he was completing the discharge formalities. The 28-year-old, who works as a labourer, explained that the family consulted several doctors earlier but eventually came to this hospital.

A bill of Rs 17,000 was generated for her three-day treatment in the general ward, and it was fully covered under the Ayushman Bharat-Pradhan Mantri Jan Arogya Yojana (AB-PMJAY).

The family, otherwise dependent on government hospitals due to financial constraints, said that, based on a doctor’s suggestion, they sought treatment at a larger private hospital using the Ayushman Bharat card.

While a surgery is planned for a later date, since Meera is not physically ready for it yet, the upcoming procedure will also be covered under the scheme.

Ayushman Bharat's Health Impact In Haryana

Ayushman Bharat is India’s social health insurance scheme. It was launched by the Union government in September 2018. It provides health insurance coverage of up to Rs 5 lakh per family per year.

Under the scheme, 60 per cent of the cost is borne by the Centre and 40 per cent by the state, with the state government being the executive authority on the ground.

Nearly six years on, more than 35 crore beneficiaries have used their Ayushman Bharat cards, with approximately 14,000 private hospitals empanelled from a total of 30,000 healthcare facilities.

In Haryana alone, over 1,000 private hospitals are empanelled, with Hisar leading the state with 156 facilities.

The scheme has been successful in its goal of expanding access to quality healthcare for the poor and underprivileged, not just in government hospitals but in private medical institutions too.

If Meera were to receive treatment for her physical ailment without the support of Ayushman Bharat, her bill would have likely exceeded Rs 27,000.

Thankfully, according to Abhijeet, who mans the Ayushman Bharat desk at the hospital, a large number of patients are being treated under the scheme.

What's more, the level of care and treatment provided is the same with or without an Ayushman Bharat card.

"In the ICU alone, of the 23 patients, 17 are undergoing treatment under the scheme. Without this support, many wouldn’t even consider coming here. All patients receive the same level of care and attention as any private patient," Abhijeet said.

Mange Ram tells us that Komal, his 17-year-old niece, is suffering from kidney failure and has undergone dialysis twice in two days.

Though troubled since last four months, as Komal's condition worsened, they were able to bring her here for proper treatment under the health insurance scheme.

"These rounds of dialysis and her admission here would have been very expensive. Before this, we only went to local doctors, worried about the cost of private hospitals. Thankfully, with the card, we were able to come here for her treatment," he added.

Patients Happy, But What About The Doctors?

While the Ayushman Bharat scheme has enabled beneficiaries access to better healthcare, the doctors, who are the key point of contact and vital to the scheme's success, have faced challenges.

In Haryana, private hospitals have gone on strike twice this past year over unpaid claims totalling Rs 200 crore from the state government.

This raises a question: how has the scheme reached a stage where doctors feel that the situation is slipping out of control, as the state government continues to struggle with clearing payments to private hospitals?

Dr Ajay Mahajan, the president of the Indian Medical Association (IMA) in Haryana, tells Swarajya, “The Centre’s PMJAY is a blessing for the poor, providing access to costly treatments. We are grateful to be able to treat needy patients through this initiative.

“However, there are multiple execution issues. Initially, many doctors found the scheme unacceptable from the start due to the low rates offered by the government. In Hisar, one of the largest hospitals has not adopted the scheme. It was only small and medium-sized hospitals, which had fewer patients, which empanelled under the scheme to fill their capacity.”

The scheme allows people with an annual income below Rs 1.2 lakh to receive free treatment, depending on the specialties for which hospitals are empanelled.

While concerns about the rates persisted, the scheme operated relatively smoothly. However, over the past year, payment delays from the state government have caused disruptions.

“In August 2023, the Haryana state government expanded the Ayushman Bharat-Chirayu Haryana Yojana to benefit people with annual incomes of up to Rs 3 lakh. With this expansion and the higher income threshold, the number of patients surged dramatically, straining the healthcare infrastructure and finances, both for private hospitals and the state government,” Dr Mahajan says.

As per the government’s statement, "By extending coverage to families with annual incomes up to Rs 3 lakh, and offering treatment up to Rs 5 lakh, it aims to ensure that more people can access quality healthcare services without the burden of high medical costs."

“As private doctors and hospital operators, there is a limit to how long we can stretch our resources to treat patients without timely payments,” Mahajan adds, highlighting the growing frustration among healthcare providers.

Under the payment terms of the Ayushman Bharat scheme, the Centre and state share costs in the 60-40 ratio. As long as this arrangement was in place, the payment process was relatively smooth.

However, for the Chirayu scheme, the state government bears 100 per cent of the cost. This unfortunately strained the state's finances, causing delays in payments.

“The State Scheme Has Diverted The Actual Purpose”

Initially, the Ayushman Bharat scheme covered families with an annual income of up to Rs 1.2 lakh based on the Socio Economic Caste Census (SECC) data.

To improve inclusivity, the Manohar Lal Khattar-led government expanded the income limit to Rs 1.8 lakh through the Chirayu Haryana Yojana, and further raised it to Rs 3 lakh in 2023. Families can access the scheme by paying an annual premium of Rs 1,500.

Through this expanded scheme, nearly half of Haryana’s population is now eligible for free medical treatment in both government and private hospitals. So far, over 1.03 crore Ayushman-Chirayu cards have been issued, including 74.33 lakh Chirayu cards and 28.89 lakh Ayushman cards.

“While the number of beneficiaries has increased, the price slabs and treatment costs allocated to hospitals have remained unchanged. The state government started delaying payments, adding to growing claims,” says a doctor who has a private practice and is empanelled under the scheme.

He adds, “The scheme was initially intended for the truly needy, and all of Haryana’s doctor fraternity were united in duty to provide care to those unable to afford costly medical treatments. But the purpose of the scheme has been lost now.”

Many doctors feel that the state-level expansion of the scheme was politically motivated rather than genuinely aimed at improving access to healthcare.

Several small and medium-sized clinics and hospitals have payments in crores stuck with the state government, which claims that it lacks the budgetary capacity to manage the financial burden of these expansions.

More than 90 per cent of the patients in these facilities are covered by this health scheme, even those who don't appear to be in need of it. While doctors say they treat these patients just the same, the expansion has pushed those who are truly in need of healthcare to the back of the line, where they were before the introduction of this scheme.

"Many patients arrive in expensive cars, use the card for treatment, and even request additional facilities, sometimes informally offering to pay extra for them. This is not how a scheme of this scale can function effectively," says a medical practitioner.

What Needs To Be Done Now?

Under these schemes, the price slabs for treatments are set to minimum levels by the government, not accounting for inflation over the years.

“For several surgeries, these fixed rates only cover the bare minimum, impacting the quality of treatment, even if the number of patients has increased,” says Dr Dinesh Pahwa, a surgeon from Hisar.

"I received a patient for intestinal surgery, and the rate slab is Rs 30,000 for the entire process, including beds, medicines, and the surgery itself. However, just the essential antibiotics alone can cost Rs 30,000 when we perform this treatment," he says.

In many such cases, doctors sometimes incur losses just to maintain the quality of care.

While he supports the scheme’s overall vision and how it has enabled more patients to reach him for critical surgeries, he is worried about its long-term sustainability due to the funding challenges.

“To ensure the scheme is truly inclusive for a larger population, there needs to be a significant increase in funding. Ayushman Bharat is still the largest health insurance scheme in the world, but it requires much more financial support based on the scale to function effectively,” he says.

As per reports, the budget allocation for Ayushman Bharat in 2023 was around Rs 14,000 crore, compared to MNREGA at Rs 90,000 crore and PM-Kisan at Rs 58,250 crore — nearly one-fifth of these schemes.  

In percentage terms, Ayushman Bharat constitutes around 0.3 per cent of the annual budget, compared to 2 per cent for MNREGA and 1.4 per cent for PM-Kisan.

"Additionally, the existing cost-plus approach — where costs are calculated, a margin is added, and this becomes the price — should be reformed to account for the opportunity cost, ensuring fair pricing while maintaining quality care," says Dr Prasanna Tantri, Associate Professor and Executive Director of the Centre for Analytical Finance at Indian School of Business.

"As these price caps are often resulting in a compromise on quality, this has affected healthcare, as hospitals and doctors struggle to provide adequate services at such rates," he says.

Many private hospitals say the current rates don't even cover basic, reasonable care.

Impact On The Upcoming State Election

This issue has become a factor in the upcoming state election, which is promising a tough battle among political parties.

Doctors are concerned about the fate of their pending payments under the state-funded Chirayu scheme if there is a change in government.

"Who will ensure our payments if the new government takes over?" asks one doctor, noting that similar issues have occurred in the past.

There are now promises from political parties to increase insurance coverage from Rs 5 lakh to Rs 25 lakh to attract voters.

However, concerns about payment delays remain unaddressed.

According to doctors in Haryana, a 15-day payment schedule set in the policy is manageable, but when payments are stuck for months, it becomes a challenge to sustain operations, especially since most patients now come under these schemes.

In contrast, states like Uttar Pradesh have smoother payment processes, and the entire scheme functions efficiently there.

In Haryana, the problem lies in overstating the number of beneficiaries without a corresponding increase in budgetary allocations.

One doctor points out: "Earlier, fewer patients were covered under the scheme, but now with 90 per cent of our patients coming through it, and payments being delayed, how can we continue running a 100 per cent operation with just 10 per cent of our revenue?"

The focus should be on treatment quality, free from political motivations. If the current challenges continue, hospitals may have no choice but to collectively cut back or halt services.

Already, the suggestion emerging in medical groups is to take patients based on their risk capacity due to the current unreliability in reimbursement of claims.