Is publicly funded health insurance associated with healthcare utilisation and financial protection in India? Evidence from a cross-sectional household survey (CAMS 2022–2023)

Objectives To examine the association of India’s publicly funded health insurance (PFHI), mainly Ayushman Bharat–Pradhan Mantri Jan Arogya Yojana, with healthcare utilisation, out-of-pocket expenditure (OOPE) and catastrophic health expenditure (CHE). Design Cross-sectional study using nationally representative data from the Comprehensive Annual Modular Survey 2022–2023. Multivariable logistic regression and Heckman two-stage models were applied, adjusting for socioeconomic and demographic covariates and survey design. Setting All states and union territories of India. Participants 302 086 households (173 096 rural; 128 990 urban) surveyed between July 2022 and June 2023. Results PFHI coverage was associated with higher outpatient (adjusted OR 1.404, 95% CI 1.328 to 1.484, p<0.01) and inpatient care use (adjusted OR 1.168, 95% CI 1.128 to 1.210, p<0.01). At the 20% threshold, PFHI coverage significantly reduced the likelihood of CHE for both outpatient (adjusted OR 0.869, 95% CI 0.810 to 0.932, p<0.01) and inpatient care (adjusted OR 0.790, 95% CI 0.737 to 0.846, p<0.01). Heckman model estimates showed a significant reduction in inpatient OOPE (coefficient –0.205, 95% CI −0.258 to −0.153, p<0.01), while outpatient OOPE reductions were modest (–0.047, 95% CI −0.087 to −0.006, p<0.05). However, outpatient care remained inadequately covered, with high OOPE and CHE persisting even among insured households. Financial vulnerability was higher among the uninsured, socioeconomically disadvantaged groups and rural residents. Conclusions PFHI was associated with improved access to inpatient services and partial financial protection, but association with outpatient care indicates a major source of financial burden. Policy reforms should expand PFHI benefits to outpatient services, strengthen primary care through Ayushman Arogya Mandirs and tailor implementation to state contexts and vulnerable populations to achieve equitable and comprehensive financial protection.