Americans who get their health insurance through the exchanges set up by the Affordable Care Act may have more difficulty finding a doctor next year, but it won’t necessarily have anything to do with insurers leaving the system. It could be because the Trump administration earlier this year quietly announced that it is dropping federal review of something called “network adequacy” in deference to state regulators.
When implementation of the ACA began in 2014, health care researchers immediately noticed that the insurers offering plans on the exchanges were pursuing what they called a “narrow network” strategy. That meant that they were keeping the web of care and service providers considered “in-network” as small as possible to lower costs.
The law requires insurers who want to sell their policies through the exchanges to “maintain a network that is sufficient in number and types of providers, including providers that specialize in mental health and substance use disorder services, to assure that all services will be accessible to enrollees without unreasonable delay.”
The Obama administration, over the next few years, found that insurers were not always complying with those requirements — at least not in a way that the administration believed the law intended — and began placing new requirements on them. Among other things, the Obama Department of Health and Human Services worked up a requirement under which medical professionals in particular fields had to be within specific geographic range of 90 percent of the people covered by a qualifying plan.
In a Federal Register filing in February, the Department of Health and Human Services announced that determinations of network adequacy would be left to the states going forward. States that don’t have the capacity to set network adequacy on their own would be expected to revert to the standard used in 2014, before the Obama administration added additional requirements.
Health care experts have expressed concern that the reduced level of federal scrutiny will create an atmosphere in which insurers can continue to narrow their networks.
“While the future of the ACA’s marketplaces remains uncertain, insurers are likely to continue to push the envelope towards narrower provider networks in order to deliver more competitive premiums for consumers,” wrote Sabrina Corlette, a research professor at the Center on Health Insurance Reforms at Georgetown University's Health Policy Institute. “And while many consumers have shown willingness to trade a broad choice of providers for a lower price, overly narrow networks could impinge on their ability to access care in a timely way.”
While some states have the capacity to police insurance companies to assure that coverage is accessible to consumers, Corlette warned, not all of them do.
“Some states do not conduct network adequacy reviews; in these states, [the federal Center for Consumer Information and Insurance Oversight] has done them. It remains to be seen, in the absence of federal oversight, whether these states will have the capacity or willingness to take on a more expanded role. Accreditation alone will not assure that consumers have access to plans with adequate provider networks.”