Ayushman Bharat is a genuine achievement. It has brought health coverage to millions of Indians who had none before. But let me be direct: the healthcare coverage gap in India remains a serious challenge. For a family dealing with advanced cancer, an organ transplant, or a rare disease, the available coverage is often not enough. This blog is about the gap, and about what we can do about it right now.
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The Achievement and the Limitation
Ayushman Bharat — Pradhan Mantri Jan Arogya Yojana (PM-JAY) is one of the most ambitious government health insurance programmes in the world. It covers over 50 crore Indians for hospitalisation expenses up to Rs. 5 lakh per family per year. For routine hospitalisations, minor surgeries, and many common medical conditions, it provides genuine and meaningful protection.
I want to be clear: this is important and good. Every Indian covered by PM-JAY who gets treatment they could not otherwise afford represents a real victory. The programme has already helped millions of families.
But here is the reality that I see every day at ImpactGuru, from thousands of families who come to our medical crowdfunding platform in desperation: Rs. 5 lakh does not go very far when you are dealing with the most serious medical conditions.
The Numbers Behind the Gap
Let me give you some numbers, because vague references to ‘high costs’ often obscure the real picture of the healthcare coverage gap in India:
• A bone marrow transplant for leukaemia or lymphoma costs between Rs. 15 lakh and Rs. 40 lakh in India’s better hospitals — 3x to 8x the PM-JAY coverage limit.
• A liver transplant costs between Rs. 20 lakh and Rs. 35 lakh. A kidney transplant costs between Rs. 5 lakh and Rs. 15 lakh. Neither is fully covered in practice by most insurance schemes.
• CAR-T cell therapy — a revolutionary cancer treatment now available in India — costs approximately Rs. 30–40 lakh per treatment. Insurance coverage is minimal.
• Long-term cancer treatment — chemotherapy, targeted therapy, immunotherapy — can cost Rs. 2–5 lakh per month for advanced cancers, with treatment lasting 12–18 months or longer.
• Rare disease treatments, including enzyme replacement therapies and gene therapies, can cost Rs. 50 lakh to several crore rupees per year.
For these conditions — which are not rare edge cases but rather the leading causes of catastrophic health expenditure in India — the coverage gap is enormous. A family with PM-JAY coverage and a child with leukaemia is still facing a potential shortfall of Rs. 30 lakh or more.
Private Insurance: Better But Not a Complete Solution
Many middle-class Indians rely on private health insurance rather than government schemes, and rightly feel better protected. But private insurance has its own significant limitations when it comes to catastrophic illness:
• Sum insured limits — even policies with Rs. 10–25 lakh coverage — are frequently exhausted by complex, multi-year treatments.
• Pre-existing condition exclusions mean that patients who needed insurance most — those with a history of heart disease, diabetes complications, or prior cancer — often find their claims reduced or rejected.
• Sub-limits on specific treatments, room rent, and ICU charges mean that the actual payout is frequently far less than the headline coverage amount.
• Insurance claim processing during a medical emergency is stressful, time-consuming, and frequently disputed — causing delays that have direct health consequences.
I am not arguing against health insurance. Everyone should have the maximum insurance coverage they can afford. I am arguing that insurance, whether government or private, is a necessary but not sufficient solution to India’s healthcare financing challenge.
The Three-Layer Approach to Healthcare Financing
In conversations with patients, families, hospital administrators, and policy experts, I have come to believe that sustainable healthcare financing in India requires three complementary layers:
Layer 1 — Government Coverage: PM-JAY and state government schemes provide the foundation — basic hospitalisation coverage for the most vulnerable populations. Expanding this coverage in terms of both beneficiary reach and sum insured is a legitimate and important policy priority.
Layer 2 — Private Insurance: For the middle class, comprehensive private health insurance with adequate sum insured (ideally Rs. 25 lakh or more per family) provides the second layer of protection. The insurance industry needs to continue improving product design, claim settlement ratios, and coverage terms.
Layer 3 — Community-Funded Support: For the gap that government schemes and insurance cannot cover — the Rs. 20 lakh shortfall, the experimental treatment, the post-insurance top-up — community-based medical crowdfunding on platforms like ImpactGuru provides the third and often decisive layer.
This three-layer model is not theoretical. It is what we see working in practice, every day, on ImpactGuru. Families who have government coverage or private insurance routinely use crowdfunding to cover the amount their insurance did not.
Medical crowdfunding is not an alternative to insurance or government schemes — it is the layer that makes the other two actually work for the most serious conditions.
What Needs to Change: A Policy Wish List
While I believe that medical crowdfunding fills a critical gap right now, I also believe that we should be working to make that gap smaller. Here is what I believe needs to change at a policy level:
1. Increase PM-JAY coverage limits for high-cost conditions, particularly cancer, organ transplants, and rare diseases, to Rs. 20 lakh or more.
2. Mandate comprehensive rare disease treatment coverage in private insurance products — with government reinsurance backstops if necessary.
3. Create a National High-Cost Treatment Fund for conditions whose costs exceed any reasonable insurance threshold, funded by a combination of government budget and corporate CSR.
4. Streamline insurance claim processing with mandatory 24-hour cashless approval timelines for life-threatening emergencies.
5. Invest in public awareness campaigns so that every Indian understands what their government coverage includes and does not include.
These are not radical proposals. Variations of all of them exist in various high-income countries. India has the administrative capacity to implement them. What is needed is the political will and the healthcare finance expertise to design them well.
What You Can Do Today
While policy reform takes time, the coverage gap exists now. Patients are facing it today. Here is what you can do:
• If you or a family member is facing a medical expense that exceeds your insurance coverage, start a fundraiser on ImpactGuru immediately. Do not wait until you have exhausted all other options.
• If you work in HR or employee benefits, advocate for your employer to increase the company health insurance sum insured and to provide ImpactGuru awareness as part of employee wellness programmes.
• If you are a doctor or hospital administrator, consider how you can proactively connect patients who cannot afford treatment with crowdfunding options. ImpactGuru has partnership programmes specifically for hospitals.
• If you are a policymaker or have access to policymakers, advocate for the coverage expansions and structural reforms outlined above.
The healthcare coverage gap in India is not inevitable. It is the result of underinvestment, policy lag, and lack of awareness. Every one of us, as patients, families, professionals, and citizens, can contribute to closing it.
