Abstract
Background Out-of-pocket expenditure (OOPE) finances 43.4% of total health expenditure in India, and emergency trauma—unforeseeable, unpostponable and costly—is among the sharpest tests of whether a health-financing mechanism protects households from catastrophic spending. Insured and uninsured patients are normally treated in different facilities at different tariffs, confounding the effect of the payment mechanism with the setting in which care is given. Methods We compared OOPE across three financing arrangements—Ayushman Bharat–Pradhan Mantri Jan Arogya Yojana (AB-PMJAY), private health insurance and self-payment—using billing and admission records for 1,599 of 1,711 consecutive road traffic accident admissions through the emergency department of a 2,000-bed tertiary teaching hospital and regional trauma centre in coastal Karnataka, India, between July 2023 and July 2024. All groups were treated at the same institution under the same price schedule, so total charges are directly comparable, isolating the effect of the payment mechanism. Results Of 1,599 patients, 63 (3.9%) were AB-PMJAY beneficiaries, 262 (16.4%) were privately insured and 1,274 (79.7%) were uninsured. Median total charges were statistically indistinguishable across groups (₹90,979, ₹86,170 and ₹85,091; Kruskal–Wallis p = 0.70). Every AB-PMJAY beneficiary incurred zero OOPE. Privately insured patients paid a median of ₹11,598, averaging 25.6% of charges (median 16.7%) and ranging from full reimbursement to none. Uninsured patients bore the entire charge. At a 10%-of-income threshold, catastrophic expenditure affected 0%, 22.5% and 78.7% of the three groups. Conclusions Complete protection was achievable and was achieved for every identified beneficiary: the binding failure for the uninsured four-fifths was the absence of cover, not its design. India’s 2025 cashless trauma entitlement addresses that absence, but 23.7% of the uninsured patients here were billed above its ₹1.5 lakh ceiling.