One of the most controversial and least understood aspects of coverage under the Affordable Care Act is the network concept. More precisely, the narrow-network concept, since the whole goal of health insurers that steer patients to networks of preferred doctors and hospitals is to keep the provider roster limited and therefore (so they expect) cheaper.
As the ACA has rolled out, the question of whether these narrow networks serve patients well has devolved into really two questions. (1) Are there enough doctors and hospitals of all types so that patients can get the care they need without unnecessary delay? (2) Are customers getting sufficient, and accurate, information about the networks to make a fair choice about which health plan to choose?
These are important questions, in part because they've become the leading attack point of anti-Obamacare Republicans in Congress. The GOP no longer can claim that the ACA has failed to bring insurance to millions of Americans who lacked access to it before, or that the ACA would drive up healthcare costs. Both claims have been destroyed by real numbers.
So the new issue is access. "There is a difference between coverage and care," said GOP anti-Obamacare front man Sen. John Barrasso, R-Wyo., last week, as quoted by The Hill. "It’s a fact that there are people who now have coverage and can’t have access to care."
Let's take a look at how this has played out, and what can be done about it.
First, narrow networks aren't new, and aren't exclusive features of ACA plans. Many workers who get their coverage through their employers have been offered choices of preferred provider organizations, or PPOs, from standard health insurers, and it's not uncommon for them to discover that some of their doctors are dropped from the network from year to year. It's common for enrollees to be steered to a specific hospital for surgery, too, and not always the biggest or most celebrated hospital in town. Go outside the preferred network, and be prepared to pay more for a doctor visit, sometimes even the full price.
The launch of individual insurance under the ACA in 2014 introduced many more people to this trend. Low-income enrollees who were assigned to Medicaid (in states that expanded the program) may have faced stricter constraints, because Medicaid's low doctor reimbursement rates often keep its networks especially narrow.
The program has become a particular target of the GOP. "Giving people Medicaid insurance is almost like giving them nothing," House Speaker John Boehner said recently on "Meet the Press," "because you can’t find a doctor that will see Medicaid patients."
Leaving aside that Congress could address that issue by raising Medicaid reimbursement rates, the evidence for his claim is equivocal. A study published last year by the Journal of the American Medical Assn. found that Medicaid patients had more trouble getting doctor's appointments than insured patients or uninsured patients willing to pay cash, though they do much better than uninsured patients who said they could pay only a limited amount.
Other studies have found the issue to be more nuanced: A Kaiser Family Foundation survey last March found access to care by Medicaid patients to be comparable to that of employer-insured clients, and far better than the uninsured. Kaiser found important gaps in coverage, however, especially in access to psychiatrists, substance abuse specialists, and dentists.
What about narrow networks for conventional insurance customers? The ACA leaves the task of ensuring that all enrollees have reasonable access to primary care doctors, specialists, and hospitals to the states.
As the Commonwealth Fund determined in a new study, the rules are wildly varied. Some require "adequate" access, often without defining the term. Others set specific limits on wait times or distance traveled to get care. California, for example, mandates minimum hours health services must be open, maximum wait times for primary and maximum travel distances for appointments with primary care and specialty doctors, minimum ratios of doctors per enrollees, and other standards. The state Department of Insurance tightened up these rules for health plans under its jurisdiction this year, after complaints soared about overly sparse networks.
But enforcement is still too sketchy. As my colleague Chad Terhune has reported, California insurers have been accused of issuing inaccurate doctor lists, which can result in members getting treatment from a non-network provider they thought were covered, and incurring huge bills as a result. In November, state regulators accused California's two biggest private insurers, Blue Shield and Anthem Blue Cross, of illegally overstating the number of doctors available to patients. A follow-up report is imminent. (The insurers disputed the state's findings or blamed doctors for giving patients wrong information.)
Another issue, aired recently by Richard Mayhew, the health insurance expert at the website Balloon-Juice: how many of the doctors listed in networks are accepting new patients? This is known as "panel status." It's almost entirely unregulated by states, but it's plainly a key issue for new enrollees. Some doctor directories specify if they're accepting new patients, but the practice is inconsistent at best.
For all this, however, narrow networks are accepted within healthcare as a key to holding costs down. Most patients appear to be content with the tradeoff -- lower prices, less doctor choice. Surveys have shown that most new enrollees are happy with their healthcare -- more than 70% rating their coverage and quality of care "excellent" or "good" in a Gallup poll. A Commonwealth Fund survey in mid-2014 found more than 60% of the previously uninsured said they were "better off" than before with their coverage.
For all the hue and cry in recent years about whether Obamacare enrollees could "keep their doctor" or "keep their hospital," relatively few people actually have "a doctor" they see consistently over years, and fewer have "a hospital" they go to for their care. That's because most people don't have chronic conditions requiring long-term consultation. (An exception may be the elderly, but they're typically covered by Medicare, which seems to have more consistent coverage.)
As ACA coverage continues to take hold, Americans' familiarity with narrow networks will increase, along with awareness of the tradeoffs. They're likely to become more accepting of the trend, unless network shrinkage begins really to bite into doctor availability or insurers become less flexible. The intrusion of rules and restrictions into coverage helped wreck the managed care trend in the 1980s, and that could happen again.
What may be most important is holding insurance companies to their promises and obligations to keep their networks adequate--and to keep them from lying about the availability of doctors. That's the looming challenge for state regulators. Let's hope they're up to it.