Although the main thrust of the Affordable Care Act was to get more people health insurance, access is about more than just being uninsured. You still need to be able to see the doctors you need. One of the concerns expressed most often by consumers and experts alike involves the adequacy of networks in the plans offered in the exchanges.
Insurance companies can often reduce the cost of premiums by making deals with limited networks of physicians for reduced rates. By steering more patients into those networks, physicians can make up in volume what they might give up in per-patient reimbursement. Regulations mandate that all plans include "reasonable access" to "a sufficient number and type of providers", but the devil is in the details. Research can inform us as to the adequacy of networks in exchange plans.
In a recent study in JAMA (Adequacy of Outpatient Specialty Care Access in Marketplace Plans Under the Affordable Care Act), researchers looked at physician networks in 34 states that used the federal exchange during open enrollment in 2015. In each state, they focused on the most populous county, and the silver plans with the lowest premium, the second lowest premium, the median premium, and the most expensive premium. In all, they examined 135 plans.
For each, they used online directories to look for specialists in-network in Ob/Gyn, dermatology, cardiology, psychiatry, oncology, neurology, endocrinology, rheumatology, and pulmonology. They looked for in-network specialists within two radii: up to 100 miles and about half of that. The main outcome of interest was whether a specialist could be found in that radius. They repeated their analysis at two points one month apart, and called plans that seemed deficient to confirm that status. The costs of needing to go out-of-network for specialists was also assessed.
Using the narrow radius, about 14% of plans were deemed specialist-deficient. Even using the broad radius, 13% of plans were deficient. The specialties most likely to be lacking were endocrinology, rheumatology, and psychiatry. Almost a quarter of states had at least one plan that was specialist deficient, and 12 insurers had at least one plan that was specialist-deficient. However, when they reassessed, a third of 19 originally deficient plans had added specialists. But still, that left 13 plans without any physicians in some specialties in-network.
Going out of netw0rk would cost patients, too. One-quarter of the deficient plans offered no coverage for out-of-network services. More than half of plans set cost-sharing for out-of-network care at 50% or more. Almost half of these plans would not cover any drugs that were prescribed by out-of-network physicians, even if patients used in-network pharmacies to fill their prescriptions.
In multiple states, and in multiple plans, patients would not be able to find in-network physicians for at least one specialty. If they were forced to go out-of-network, they'd face significant costs. Further, plans had high turnover, meaning that people thought they were adequately covered when they weren't.
It is entirely reasonable for the administration and those who support the ACA to celebrate the reduction of uninsurance in the United States. The percent of people who lack insurance in the U.S. right now is the lowest that it has been, ever. But we have to acknowledge that the point of health care reform was to get more people health care. If insurance doesn't actually offer access to needed health care, then it's not really "insurance".