Bridging the gap between health insurance eligibility and uptake: A multistate quantitative analysis of...

Publicly-funded health insurance schemes, wherein governments subsidize insurance contributions for disadvantaged groups, are a key strategy under universal health coverage. India's Pradhan Mantri Jan Arogya Yojana (PM-JAY) uses an entitlement-based approach whereby approximately 700 million beneficiaries are automatically eligible for scheme benefits, subject to a simplified identity verification procedure instead of enrolment. This study investigates the determinants of undergoing verification among PM-JAY's target population to identify underserved groups and inform strategies to expand coverage. We used cross-sectional survey data from 2019-2020, covering 50,002 individuals across five states. We examined individual and household characteristics associated with verification using logistic regression models with district-level random effects, and beneficiary experiences with the verification process. About one-fifth of eligible individuals had verified their status within a year of launch. Verification was more likely among older adults, with those ≥60years having higher odds than those 0-15 years of age (adjusted Odd Ratio [AOR] 2.339; 95% CI 2.071-2.641). Those with higher education had higher odds than those with no formal education (AOR 2.303; 95% CI 2.048-2.590), those with prior PFHI enrolment had higher odds compared to those not enrolled (AOR 1.947; 95% CI 1.827-2.075), and those with chronic illness had higher odds than those without (AOR 1.175; 95% CI 1.071-1.289). Women and household members other than spouses were less likely to verify. Disadvantaged castes and minority religions demonstrated relatively higher verification rates. District-level factors explained nearly one-third of variability, indicating that infrastructure and implementation capacity differences influence uptake. Many beneficiaries reported long wait times, varying documentation demands, and informal payments during verification. Addressing these barriers requires gender-sensitive outreach, streamlined household-wide verification, and strengthened local health system capacity. Policy reforms that simplify verification, ensure equitable access, and strengthen health infrastructure are vital to advancing effective universal health coverage for India's most vulnerable populations.