Beyond coverage: why Ayushman Bharat-Pradhan Mantri Jan Arogya Yojana struggles to deliver healthcare in Jammu and Kashmir

Ayushman Bharat-Pradhan Mantri Jan Arogya Yojana (PM-JAY), the biggest publicly financed health insurance program in the world, has substantial use issues, especially in places like Jammu and Kashmir that are affected by conflict. Despite the program's goal of ensuring equal and cashless access to healthcare, the existing literature does not offer region-specific insights into the actual obstacles preventing its adoption. This study intends to identify and measure the physical, administrative, financial, and informational hurdles experiences by the beneficiaries in the urban and semi-rural areas of Jammu and Kashmir face when utilizing PM-JAY. Primary data was gathered through structured interviews with 320 randomly chosen PM-JAY recipients using a cross-sectional approach. To evaluate the relative effects of various obstacles on scheme use, the study used binary logistic regression, chi-square tests, Pearson correlation, and descriptive statistics. Despite being enrolled, only 48.4% of enrollees reported accessing PM-JAY services. The most significant positive predictors of usage were health literacy and awareness gaps, notably knowledge of empanelled hospital lists (OR = 1.245, <i>p</i> < 0.05) and awareness of scheme entitlement (OR = 1.253, <i>p</i> < 0.05). A statistically significant negative factor was inadequate road infrastructure (OR = 0.761, <i>p</i> < 0.05). Despite being often mentioned, administrative and financial obstacles were surprisingly not significant in the regression model. There were no discernible variations in use between the two districts, indicating problems with systemic access. Increasing PM-JAY use in disadvantaged areas requires more than just financial incentives; it also requires better physical infrastructure and informational availability. To convert coverage into useful access, policymakers should concentrate on region-specific IEC initiatives, transportation connectivity, and health system navigation support mechanisms. These interventions are essential for translating PM-JAY's theoretical coverage into meaningful, equitable healthcare access, particularly in underserved and fragile regions like Jammu and Kashmir.