Why do Indians still pay so much for healthcare from their own pockets?

India has expanded health insurance coverage, but millions of families still fall between government schemes and private insurance. In our sunday special edition of 'YOUR INDIA', Santosh Nair looks at the “missing middle”, medicine costs and the public-private gap that keeps household medical spending high.

A shopkeeper earning a modest but steady income falls seriously ill. He is too well-off, on paper, to qualify for India’s largest government health insurance scheme, meant for the poorest households. He is nowhere close to being able to afford a private health insurance policy either. When the hospital bill arrives, it is entirely his own to pay.

This gap has a name now, coined by government policymakers themselves: the missing middle.

According to a NITI Aayog report, roughly thirty per cent of India’s population, about forty crore people, fall into this category, with no meaningful financial protection for health at all. They earn too much to be automatically covered under Ayushman Bharat, the government scheme built primarily around the poorest households identified through census data. They earn too little, or work too informally, to reliably afford private insurance premiums on their own. When illness arrives, this group pays almost entirely out of pocket, the same as someone with no scheme at all, despite not being counted among........

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