Access to Care–Exchange Enrollees

 VII. Key Issues: Regulation & Reform >> C. Health Reform >> Affordable Care Act (ACA) >> ACA Impact Analysis >> ACA Impact on Access >> Impact on Access to Care >> Access to Care–Exchange Enrollees (last updated 9.28.17)

Limited Choice of Plans on ACA Exchanges


  • States Will Have Limited Choice of Plans on the Exchange.  In Illinois, only six insurers signed up to sell plans even though state officials originally expected 16. “Does the relative lack of competition, the absence of a big player like UnitedHealthcare and the Obamacare demands for certain coverages mean that Illinois rates will be higher than they are now? Sounds like a real possibility. But Illinois officials won’t say if bad news is coming. Maybe they’re waiting for the PR firm that was awarded a $35 million contract last month to promote the Illinois exchange to get up to spin speed.” Editorial: What Will Illinois Pay For Health Care?” (The Chicago Tribune, 8.14.13)
  • Little Competition in Some State Exchanges.  Kaiser Family Foundation reports that the number of plans offered in the non-group Exchanges ranges from 1 (West Virginia) to 17 (New York). “Some states have so few carriers offering plans in the marketplaces that the lack of competition has kept rates high. West Virginia and New Hampshire, for example, currently have only one carrier for their entire states, respectively. Wyoming only has two, after most of the state’s insurers skipped the exchange, and has the highest rates in the country. Analysts, however, say that there is likely to be more competition in future years: Insurers will wait and see how 2014 plays out and re-evaluate their strategies. Aetna, for one, says it is ‘taking a measured, multiyear approach to exchanges.’” (MarketWatch, 11.12.13)
    • “Consumers in 515 counties, spread across 15 states, have only one insurer selling coverage through the online marketplaces, the Journal found. In more than 80% of those counties, the sole insurer is a local Blue Cross & Blue Shield plan.” There are 3,007 U.S. counties, of which 520 are located in states with state-based Exchanges (calculated by author using data from here); the 515 counties therefore represent 20.7% of counties in the remaining states.
    • Lower Incomes in One-Plan Counties. “In the 515 counties with only one insurer participating in the federally run marketplace, average household earnings were $56,766 in 2012, more than 20% below the national level, census data show.”
    • Higher Prices in One-Plan Counties. “Residents of wealthier, more populated counties in the U.S. receive lower-priced choices than those living in counties with a single insurer… The price differences reflect the strategy of insurers to pick markets where they believe they can turn a profit—and avoid areas of high unemployment and a concentration of unhealthy residents they deem more risky.”
    • Long before the health-care law, the costs of coverage were generally higher in rural areas. Many of the counties with few competing insurers are located in such Southern states as Georgia, Mississippi and West Virginia, where rates of obesity and smoking are high.
    • Jon Urbanek, a senior vice president at Florida Blue, said premiums in poor or rural areas can be pricier because of a shortage of hospitals and doctors, compared with higher-income markets.
  • One-Plan Counties. “Hundreds of thousands of Americans in poorer counties have few choices of health insurers and face high premiums through the online exchanges created by the health-care law, according to a February 12, 2014, analysis by The Wall Street Journal of offerings in 36 states using federally-facilitated exchanges.”
  • New Hampshire’s Obamacare Nightmare. Wall Street Journal editorial board member Joe Rago on the skyrocketing health care premiums and limited doctor network under the new health-care law. New Hampshire has only one insurance provider in its exchange. (Wall Street Journal Video, 4.9.14)


  • How Obamacare Exchanges Have Decreased Competition Among InsurersDaily Signal (1.16.15)
    • 2015 State-Level Competition. A comparison of the number of insurers selling coverage in the 2015 exchanges with the number of insurers that sold individual policies in the states before Obamacare took effect shows that the Obamacare exchanges are nationally 21.5 percent less competitive at the state level.In 2015, consumers in one-third of the 3,134 counties in the United States face an exchange market that is either an insurer monopoly or duopoly.
    • 2015 County-Level Competition.
      • Though state-level insurer participation is a good measure of competition, it isn’t necessarily a reflection of the choice consumers have. For instance, there are 14 different insurers selling policies on the Texas exchange, but no Texas county has more than nine carriers offering coverage and 62 percent of the state’s counties have only one or two insurers offering coverage in the exchange in 2015. Thus, a more accurate measure of choice is at the county level since health insurance is offered and priced on a local basis.
      • In 2015, consumers in one-third of the 3,134 counties in the United States face an exchange market that is either an insurer monopoly or duopoly. This means that residents in these counties have only one or two insurers from which to choose. In 58 percent of total U.S. counties there are three or fewer insurers participating on the exchanges. When compared with 2014 insurer participation, county-level competition has improved in some instances for 2015, but choice is still very limited for a significant share of the country. A lack of insurer competition combined with Obamacare’s standardization of benefits means consumers in Obamacare’s exchanges will have very little choice. To see how competition and choice fare in your state and county, read the full analysis.”


  • Beilenson, Peter. (2.10.16) Risk Adjustment’ Threatens Obamacare. [Opinion] “While well-intended, the implementation of this safeguard has had the unintended consequence of a ‘reverse Robin Hood effect’— taking money from predominantly new, small, innovative plans (the new competitors that the ACA hoped would add both choice and innovation to health insurance markets around the country) and giving it to the big, established insurance carriers. The enormous risk adjustment windfall that went to the big multi-state insurance corporations is partly responsible for the current merger frenzy that will certainly result in less choice for Americans in insurance markets nationwide.”


  • Insurance Options Dwindle in Some Rural Areas. “Health-insurance customers in a growing number of mostly rural regions will have just one insurer’s plans to choose from on the Affordable Care Act’s exchanges next year, as some companies pull out of unprofitable markets. The entire states of Alaska and Alabama are expected to have only one insurer on the health law’s signature online marketplaces next year, according to state regulators. The same is expected to be true in parts of several other states, including Kentucky, Tennessee, Mississippi, Arizona and Oklahoma, state regulators said. So far, more than 650 counties appear on track to have just one insurer on the exchanges in 2017, according to the Kaiser Family Foundation, which is tracking withdrawals as they become public. That would be up from 225 in 2016.” (Wall Street Journal, 5.15.16)
  • Is It Time To Acknowledge That Obamacare Is Collapsing? “People joked for a while about how insurers were pulling out of Obamacare markets so fast we might end up with areas in which there were no insurers at all.  It’s no joke anymore: with Aetna’s massive withdrawal yesterday from the Affordable Care Act marketplace, Pinal County, Arizona, the third most populated county in that state, currently has no insurers selling policies on the Exchange. The issue isn’t so much whether people will be subject to the individual mandate tax of up to 2.5% of their income when there are no policies available… The issue is that Pinal County, although a bit of an outlier for now, is a harbinger for fundamental problems with the ACA now manifesting themselves with greater clarity across the country. When an insurer covering over 7% of those in the Exchanges and previously hoping to expand instead drops out, we better look at what is going on.” Chandler, Seth. (Forbes, 8.16.16)
  • Obamacare Options? In Many Parts of Country, Only One Insurer Will Remain. “A central tenet of the federal health law was to offer a range of affordable health plans through competition among private insurers. But a wave of insurer failures and the recent decision by several of the largest companies, including Aetna, to exit markets are leaving large portions of the country with functional monopolies for next year. According to an analysis done for The Upshot by the McKinsey Center for U.S. Health System Reform, 17 percent of Americans eligible for an Affordable Care Act plan may have only one insurer to choose next year. The analysis shows that there are five entire states currently set to have one insurer, although our map also includes two more states because the plans for more carriers are not final. By comparison, only 2 percent of eligible customers last year had only one choice. A similar analysis by Avalere Health, another consulting firm, also highlighted the increase in areas with only one insurance carrier.” (New York Times, 8.19.16)
  • In North Carolina, ACA Insurer Defections Leave Little Choice for Many Consumers. More than 250,000 people in North Carolina are losing the health plans they bought under the Affordable Care Act because two of the three insurers are dropping out — a stark example of the disruption roiling marketplaces in many parts of the country. The defections mean that almost all of the state, from the Blue Ridge to the Outer Banks, will have just one insurer selling ACA policies when the exchanges open again for business in November. The remaining company, Blue Cross Blue Shield of North Carolina, agonized over whether to leave, too. Instead, it is raising its rates by nearly 25 percent. In no other state will as many people find such limited choice. But what is happening to nearly a half-million North Carolinians epitomizes a national checkerboard of ACA haves and have-nots.” (Washington Post, 10.14.16)
  • What Her Patients Say About Healthcare Reform. “Ohio’s ACA marketplace was spared until now. We enjoyed a robust number of carriers — in 2016, each of our counties hosted at least four insurers. In less than a year, however, six carriers — Aetna Inc., All Savers Health Plans, Healthspan Inc., Healthspan Integrated Care, InHealth Mutual, and United Healthcare of Ohio Inc. — have announced they will exit our ACA exchange. And large insurer Medical Mutual of Ohio is eliminating all preferred provider (PPO) plans for those who purchase their own coverage— on and off our ACA exchange. The company, which offered plans in all 88 counties, will discontinue those in 57. An estimated 25 percent of these customers will have to find new coverage for next year, and an unknown number will be transitioned to limited single-hospital system plans. In 2017, 19 Ohio counties will offer only one marketplace provider — Anthem Blue Cross and Blue Shield— and 28 counties will offer only two.” (Dayton Daily News, 10.14.16)

Data Sources

  • Kaiser Family Foundation. KFF has produced an annual snapshot (2016) of competition on the ACA Exchanges at the state and county level showing how many plans are competing (all based on official DHHS enrollment figures for states using the marketplace). These reports provide a very rough picture of competition within ACA Exchanges across states and how it has changed over time, but excludes states running their own ACA Exchange.
  • Mark Farrah and Associates. County Health Coverage. This proprietary report synthesizes data from a variey of sources, showing county-level market shares within several health insurance segments, including Private Risk, Private ASO, Managed Medicaid, Medicare Advantage, and PDP. Thus, unlike the KFF and DHHS reports, this report provides a complete picture of the non-group market, including both ACA Exchanges and off-Exchange coverage. There are further breakdowns by product type for HMO, PPO, and POS. There also are insured population demographics and Medicare eligible by county.

Limited Choice of Providers on ACA Exchanges

Pre-ACA Exchange Predictions

  • Narrow Networks May Result in High Out-Of-Network Expenses. “Often unbeknownst to patients, some of the doctors and other providers at their in-network hospital may themselves be out of network and not under contract to a particular insurer… The new law continues to allow out-of-network providers to ‘balance bill’ patients for amounts the insurer doesn’t pay.” (Kaiser Health News, 7.20.10)
  • Health Reform Will Only Exacerbate the Shortage of Medical Caregivers. “Americans who have enrolled in health insurance for the first time under the ACA are likely to discover that having coverage doesn’t guarantee them easy access to a primary care doctor, dentist or mental health professional.” (The Pew Charitable Trust, 12.30.13).
  • Yes, Obamacare’s Exchanges Will Narrow Your Choice Of Doctors — And That’s A Good Thing. “Under Obamacare’s exchanges, people who really want to keep their doctor, at any price, will often have to pay higher premiums for the privilege. And people who prefer lower premiums, above all, might need to choose a different doctor. But the overall effect of this dynamic will be that hospitals and doctors will have to compete on price, just like people do in every other sector of the economy.” Roy, Avik. (Forbes, 9.24.13
  • ACA Enrollees May Find Their Doctors Won’t Participate. “Many doctors are disturbed that they’ll be paid less – often a lot less – to care for the millions of patients who are projected to buy coverage through the health law’s new insurance marketplaces. ‘As it is, there is a shortage of primary care physicians in the country, and they don’t have enough time to see all the patients who are calling them,’ said Peter Cunningham, a senior fellow at the nonpartisan Center for Studying Health System Change in Washington. If providers are paid less, he said, ‘Are (enrollees) going to have difficulty getting physicians to accept them as patients?’ Insurance officials acknowledge that they have reduced rates in some plans, saying they are under enormous pressure to keep premiums affordable. They say physicians will make up for the lower pay by seeing more patients, since the plans tend to have smaller networks of doctors. But many primary care doctors say they barely have time to take care of the patients they have now.” (McClatchy DC, 11.20.13)


  • Plans Use Narrow Networks in Exchanges; Public, Politicians Predictably Perturbed. “With managed care organizations rolling out plans around the country amid a controversial IT problem and widespread confusion over what plans are available and what they have to offer, legislators in states from coast to coast have been grumbling over their discovery of something they consider a nasty surprise: narrow networks, which offer a limited number of providers access to a wider group of members in exchange for more favorable rates.”  (Managed Care Magazine, January, 2014)
  • Obamacare’s Narrow Networks are Going to Make People Furious — But They Might Control Costs. “Narrow networks are health insurance plans that place limits on the doctors and hospitals available to their subscribers. They tend to do this in two ways, the first — and most obvious — by simply not paying for trips to doctors that aren’t in their restricted network. The second version, a bit more nuanced, typically has health insurance plans charging higher co-payments to go see a doctor who isn’t in the ‘top tier.’ In this case, you can go out-of-network — but will have to pay a higher price in order to do so. …A narrow network isn’t inherently a bad health insurance policy. It all depends on the quality of providers that end up in the narrow network, and how well they work together to deliver health care.” (Washington Post, 1.13.14)
  • Narrow Provider Networks Need More Work, ACP Says. “Overly narrow provider networks assembled by insurers limit patient access to clinicians, the American College of Physicians (ACP) said today in its annual report on the state of the nation’s healthcare. The society representing internal medicine practitioners proposed an extensive list of provider-network reforms that would affect not only federally qualified health plans (QHPs) offered through state marketplaces, or exchanges, under the ACA, but also those in the Medicare Advantage program. Some Medicare Advantage plans across the country have been dropping physicians from their networks without telling them the reason.” (Medscape Medical News, 2.11.14)
  • Confusion Mounts Over Which Hospitals, Doctors Accept New ACA Health Insurance Plans. “There’s been plenty of confusion about which hospitals and doctors are participating in the new Obamacare health plans offered through the state’s health insurance exchange. Figuring out who takes each plan is puzzling not only consumers, but also doctors and hospitals. …Consumers who sign up for a plan through the exchange only to discover their doctor or hospital is not in the plan’s network can switch to another plan during the open enrollment period which ends March 31. After March 31, consumers cannot change plans until the next open enrollment period which starts Nov. 15.” ( 3.11.14)
  • White House Looks to Tightens Health Plans’ Standards After Consumers Complain. “Many health plans held down premiums this year by limiting the choices of doctors and hospitals available in the exchanges, and consumers expressed concern about such narrow networks. The administration said it would examine health plans to make sure consumers have ‘reasonable access’ to care in 2015. Federal officials will look, in particular, at whether health plans have enough hospitals, primary care doctors, cancer specialists and mental health experts in their networks.” (New York Times, 3.14.14)
  • Expanded 2015 Provider Network Requirements Finalized. “Insurance plans sold in the next open enrollment season of federal-run marketplaces will have expanded provider network requirements under recently issued guidance. The Obama administration included the expanded provider network requirements in a final 2015 letter to insurers in the 34 insurance marketplaces created by the Affordable Care Act (ACA) and operated by the federal government. The 16 state-run marketplaces, or exchanges, will conduct their own reviews of insurance plan compliance. The new federal requirements, which were first proposed in February, added an assessment by the Centers for Medicare & Medicaid Services (CMS) of whether health plans’ provider networks allow policyholders ‘reasonable access’ to a range of healthcare services, including those provided by hospital systems, mental health providers, oncology providers, and primary care providers. ‘If CMS determines that an issuer’s network is inadequate under the reasonable access review standard, CMS will notify the issuer of the identified problem area(s) and will consider the issuer’s response in assessing whether the issuer has met the regulatory requirement and prior to making the certification or recertification determination,’ according to CMS’s letter to insurers…Other changes included in the new rules for 2015 marketplace insurance plans included an increase in the minimum share of ‘essential community providers’ (ECPs) that exchange plans were required to include, from 20 percent to 30 percent. Such providers include those that serve predominantly low-income and ‘medically underserved’ individuals.” (Healthcare Financial Management Association, 3.20.14)
  • Primary Care Access for New Patients on the Eve of Health Care Reform. “Between November 13, 2012, and April 4, 2013, we made 907 calls to 7788 primary care practices requesting new patient appointments. Across the 10 states, 84.7% (95% CI, 82.6%-86.8%) of privately insured and 57.9% (95% CI, 54.8%-61.0%) of Medicaid callers received an appointment. Appointment rates were 78.8% (95% CI, 75.6%-82.0%) for uninsured patients with full cash payment but only 15.4% (95% CI, 13.2%-17.6%) if payment required at the time of the visit was restricted to $75 or less. Conditional on getting an appointment, median wait times were typically less than 1 week (2 weeks in Massachusetts), with no differences by insurance status or urgency of health concern… It is not known whether the primary care system can accommodate the increased demand, nor is it clear whether the system meets current demand… A strained primary care system may place many of the goals of the ACA at risk.” (JAMA Internal Medicine, 4.7.14)
  • How Obamacare Leaves Some People Without Doctors. “The Affordable Care Act increased insurers’ costs by forbidding denial of coverage to consumers with pre-existing conditions and by imposing taxes and fees to fund aspects of the new law. To make up for ACA costs and keep premiums low, Blue Shield asked its doctors and hospitals to accept payments from the insurer at rates reduced up to 30 percent. Not surprisingly, some doctors and hospitals rejected Blue Shield’s reduced payment rates and decided not to re-sign contracts with the insurer. …Blue Shield of California now has about 40 percent fewer physicians and 25 percent fewer hospitals in its network than last year. By comparison, Blue Shield gained over 255,000 new enrollees on the exchange alone from October through February, according to Covered California figures.” (Huffington Post, 4.10.14
  • Are Narrow Networks a Good Way to Control Out-of-Control Health Spending? “Narrow networks have low premiums for a reason: They limit choice. Having limited options can be frustrating, especially if a doctor or hospital you like doesn’t end up in your network. However, evidence suggests that individuals who are currently uninsured and low-income individuals — the people most careful about pricing of insurance – say they’d rather have fewer choices and lower rates than pay more for a broader network… Narrow networks limit choice, but don’t necessarily compromise access to care.”  (National Review, 7.10.14)
  • Specialty Care Is A Challenge In Some ACA Plans. “Complaints about narrow networks with too few doctors have attracted the attention of federal regulators and have even prompted lawsuits. But they’re also causing headaches in the day-to-day work of doctors and clinics… ‘I could not find a surgeon,’ (Dr.) Zhang said. When he finally found a surgeon who actually took the insurance, it wasn’t someone he had ever worked with before. He said he would have preferred a surgeon who specialized primarily in cancer, because the patient’s cancer was complicated and had spread to 30 lymph nodes. ‘You have limited options,’ he said of the patients in the HMO. ‘So you’re like a second-class citizen, you know? That’s my feeling, you have this insurance and you cannot see certain doctors.’” (Kaiser Health News, 7.16.14)
  • She Has Insurance Under the Affordable Care Act, But Can’t Find a Doctor. “Charlene Lake thought she got a decent deal through the Affordable Care Act marketplace: a Humana HMO that included a family doctor a few miles from her home. Five months later, Lake wonders if she can even use the insurance she bought…. She’s got company. Humana is scrambling to add 100 new doctors to its Tampa Bay network after it enrolled three times more people in marketplace plans than it anticipated. But aside from first-year fumbles, the case also shows the downside of limiting consumer choice of physicians through what is known as narrow networks… ‘This is a complete mess,’ she said. ‘They took away my doctor… and replaced him with an office that doesn’t even answer their phone.'” (Tampa Bay Times, 7.20.14)
  • New Health Law Rules Could Widen Insurer Networks. “In a recent memorandum to insurers, the Obama administration said it would focus on ‘those areas which have historically raised network adequacy concerns, including hospital systems, mental health providers, oncology providers and primary care providers.’ Under the new standards, insurers will generally be required to have contracts with at least 30 percent of ‘essential community providers’ that treat ‘low-income, medically underserved individuals’ in their area. These providers include community health centers, clinics for people with H.I.V./AIDS and family planning clinics.” (New York Times, 7.20.14)
  • New Health Plans’ Limitations Anger Enrollees. “Nancy Pippenger and Marcia Perez live thousands of miles apart but have the same complaint: Doctors who treated them last year won’t take their insurance now, even though they haven’t changed insurers. ‘They said, “We take the old plan, but not the new one,”‘ says Perez, an attorney in Palo Alto, Calif. In Plymouth, Ind., Pippenger got similar news from her longtime orthopedic surgeon, so she shelled out $300 from her own pocket to see him. Both women unwittingly enrolled in policies with limited networks of doctors and hospitals that provide little or no payment for care outside those networks… ‘Obamacare products have lower prices than they would have if they had had (larger) commercial networks,’ said Robert Laszewski, an industry consultant and former insurance executive. ‘They’re one-size-fits-all networks designed for low-income people accessing insurance for the first time.'” (Kaiser Health News, 7.26.14)
  • Some Florida Doctors Decline to Accept Obamacare. “Nearly 1 million Floridians enrolled in a private health plan through the ACA exchange, but some, like Childe, are finding that some physicians refuse to honor their coverage – even when the doctors are included in the plan’s provider network. Some physicians say they’re concerned they won’t be paid for their services by either the insurer or the patient, and that insurers are not adequately informing doctors of their inclusion in exchange plan networks. ‘You don’t want to be in a situation where you provide service, and turn around and there’s no contract in place to reimburse you,’ said Jay Millson, executive vice president of the Florida Academy of Family Physicians.” (Miami Herald, 7.28.14)
  • Doctors Wary of  Insurance Exchange Patients. “‘The exchanges have become very much like Medicaid,’ says Andrew Kleinman, a plastic surgeon and president of the Medical Society of the State of New York. ‘Physicians who are in solo practices have to be careful to not take too many patients reimbursed at lower rates or they’re not going to be in business very long.'” (USA Today, 10.27.14)
  • Health Law Impacts Primary Care Doc Shortage for Exchange Plans. “The Papas were among the 6.7 million people who gained insurance through the Affordable Care Act last year, flooding a primary care system that is struggling to keep up with demand. A survey this year by The Physicians Foundation found that 81 percent of doctors describe themselves as either over-extended or at full capacity, and 44 percent said they planned to cut back on the number of patients they see, retire, work part-time or close their practice to new patients. At the same time, insurance companies have routinely limited the number of doctors and providers on their plans as a way to cut costs. The result has further restricted some patients’ ability to get appointments quickly… ‘Coverage does not equal access,’ said Halby, who instead recommends his clients choose a plan outside the exchange that has a much broader provider network but also will not come with the government premium subsidies.” (Associated Press, 12.7.14)
  • Relation Between Narrow Networks and Providers of Cancer Care. “We examined provider networks offered on the 2014 individual health insurance exchanges, assessing oncologist supply and network participation in areas that do and do not contain one of 69 National Cancer Institute (NCI)–Designated Cancer Centers… We find that narrower provider networks have a higher likelihood of systematically excluding oncologists affiliated with NCI-Designated or NCCN Cancer Centers. These hospitals are recognized for their high-quality clinical cancer care, education, and research programs. This finding suggests that narrow provider networks may not just have fewer providers from which to choose; in addition, the more limited list of available providers may not offer the same quality care as those providers who have been excluded from the network. This highlights a critical tradeoff consumers face when purchasing a narrow network plan: consumers may benefit from the fact that narrow networks generally have lower premiums, but they may face reduced access to the higher-quality providers in their market… Specifically, we also call for provider directories to reflect indicators of care quality and clinical expertise, such as—for providers of cancer care—NCI or NCCN affiliation and other care quality designations.” (Journal of Clinical Oncology, 7.5.17)


  • Exchange Plans Include 34 Percent Fewer Providers than the Average for Commercial Plans. “Specifically, the analysis finds that exchange plan networks include 42 percent fewer oncology and cardiology specialists; 32 percent fewer mental health and primary care providers; and 24 percent fewer hospitals. Importantly, care provided by out-of-network providers does not count toward the out-of-pocket limits put in place by the ACA.” (Avalere, 7.15.15)
  • Access to Specialty Care Lacking in Many ACA Plans. “Data from a new study show that nearly 15% of federal marketplace insurance plans lack in-network physicians for at least one specialty, highlighting concerns about patients’ access to healthcare specialists… Data from the broad and narrow searches of the 135 plans showed specialist deficiencies in 18 (13.3%; 95% confidence interval [CI], 8.5% – 20.3%) and 19 (14.1%; 95% CI, 9.1% – 21.1%) plans, respectively. Endocrinology, rheumatology, and psychiatry, which were the three most commonly excluded specialties, were lacking in 8 (5.9%; 95% CI, 3.0% – 11.5%), 9 (6.7%; 95% CI, 3.4% – 12.4%), and 6 (4.4%; 95% CI, 2.0% – 9.6%) plans, respectively; an additional 7 to 14 plans also included fewer than five in-network physicians in these specialties. At least one specialist-deficient plan was also identified in each of nine of the 34 states (23.5%; 95% CI, 11.8% – 41.5%) examined, as well as among plans offered by 12 different insurers. However, ‘there was no significant difference in the proportion of specialist¬-deficient plans across insurance plan premium levels,’ the authors note. Specialist-deficient plans also carried high out of-network costs. Among 19 plans, 5 (26.3%; 95% CI, 10.4% – 52.4%) did not cover out-of-network services, and 11 of the remaining 14 plans (78.6%; 95% CI, 46.0% – 94.0%) involved cost-sharing of 50% or more. Nine of 19 plans (47.4%; 95% CI, 25.0% – 70.8%) did not cover medications prescribed by out-of-network providers.” (Medscape Medical News, 10.30.15)


  • As Obamacare Plans Limit Choices, Doctors Want Provider Network Scrutiny. “The move by insurance companies to sell more HMOs and health plans with narrow lists of medical care providers – particularly on public exchanges under the Affordable Care Act – has doctors calling for state legislation and closer scrutiny of insurer networks by insurance commissioners and the Obama administration. The American Medical Association, the American Academy of Family Physicians and other lobbies are sounding the alarm about what they say is a need for more regulatory oversight of health plan preferred lists of doctors known as networks. Doctor groups are advocating state legislatures and the Centers for Medicare & Medicaid Services update their so-called ‘network adequacy’ statutes to ensure patients have an ample supply of physicians in their communities.” (Forbes, 2.21.16)
  • Obamacare Disaster Will Be Obama’s Enduring Domestic Legacy. “In fact, commercial insurers across the country are hemorrhaging money on Obamacare at alarming rates. Health Care Service Corp. (which owns Blue Cross and Blue Shield affiliates in Illinois, Montana, New Mexico, Oklahoma and Texas) has lost ‘well north of $2 billion’ in its first two years — twice as much as UnitedHealth. Highmark, the nation’s fourth-largest Blue Cross plan, lost nearly $600 million in 2015. Blue Cross and Blue Shield of North Carolina has projected it will lose more than $400 million in the first two years, and the company has said it may leave the exchanges entirely next year… commercial insurers who stay in Obamacare are responding to massive losses by narrowing provider networks, with fewer doctors and hospitals to choose from. And those that quit are being replaced by Medicaid HMOs with even less doctor choice.” Thiessen, Mark. (Washington Post, 4.25.16
  • Think Your Obamacare Plan Will Be Like Employer Coverage? Think Again. “A typical Obamacare plan looks more like Medicaid, only with a high deductible. The typical marketplace plan covers a small number of low-cost doctors and hospitals, and offers fewer frills than employer plans. The recent high-profile exits of many of the national insurers from markets around the country will only heighten the shift… According to analyses by two consulting firms — Avalere Health and McKinsey — the number of plans that offer a wide choice of doctors and hospitals is on a steady decline. Two-thirds of plans were health maintenance organization plans that offer care from only a limited choice of doctors and hospitals this year, according to an analysis from McKinsey’s Center for U.S. Health System Reform. And even plans that offer out-of-network benefits were limiting the doctors who would be covered as in-network. ‘With recent carrier exits, this trend is only growing,’ said Erica Coe, a McKinsey partner.” (New York Times, 8.19.16)
  • Insurers Move to Limit Options in Health-Care Exchange Plans. “Under intense pressure to curb costs that have led to losses on the Affordable Care Act exchanges, insurers are accelerating their move toward plans that offer limited choices of doctors and hospitals. A new McKinsey & Co. analysis of regulatory filings for 18 states and the District of Columbia found that 75% of the offerings on their exchanges in 2017 will likely be health-maintenance organizations or a similar plan design known as an exclusive provider organization, or EPO. Both typically require consumers to use an often-narrow network of health-care providers—in some cases, just one large hospital system and its affiliated facilities and doctors. Only a quarter of the exchange plans next year would still be broader designs such as preferred-provider organizations, or PPOs, which generally offer larger selections of doctors and hospitals and include out-of-network coverage, the McKinsey analysis found.” (Wall Street Journal, 8.31.16)
  • To Keep Obamacare Viable, Insurers Are Restricting Access To Doctors. “’Because the use of narrow networks is one of the last remaining strategies available to insurance companies to offer lower-cost plans on health insurance marketplaces, the success of coverage expansions could be tied to the successful implementation of narrow networks,’ Daniel Polsky, executive director of the Leonard Davis Institute of Health Economics at University of Pennsylvania, wrote with colleagues in the October issue of the journal Health Affairs.” (Forbes, 10.9.16)
  • Savings? Yes. But Narrow Health Networks Also Show Troubling Signs. “One way plans might save money could make it harder for patients to get care — so that they get less of it. Narrow network plans may do this if they don’t cover enough nearby providers, with the ones they do cover too busy to take new patients in a timely fashion. Clearly this would be especially problematic if appointments with one’s preferred primary care doctor are hard to obtain. Are today’s narrow network plans actually doing this? Until recently, we had no data to answer this question. But two studies published earlier this year — one focused on Massachusetts, the other on California — provide some insight… ‘If patients struggle to obtain primary care appointments, narrow network plans may have a rocky future,’ Mr. Haeder said. Consumers revolted against managed care in the 1990s, he notes, and they could very well revolt against poorly managed and loosely regulated narrow networks.” Frakt, Austin. (New York Times, 10.17.16)


  • Doctor Participation Drops As Obamacare Enrollment Begins. “Even as some of the nation’s largest health insurers scale back participation on public exchanges under the Affordable Care Act, doctors and hospitals expect a slight decrease in engagement on the Obamacare marketplace for 2017. The number of doctors participating in health plans on public exchanges dipped 4% to 57% of physicians  in ‘health insurance plans offered in the federal or state exchanges under the ACA,’ SERMO, a doctor social media network said. That compares to 61% who said they were going to participate a year ago before 2016 open enrollment, according to SERMO’s poll of 1,682 doctor exchange participants.” (Forbes, 10.31.16)
  • Obamacare Customers Lose Coverage for Top Chicago Children’s Hospital. “Lurie Children’s Hospital is the latest in a growing list of top Illinois hospitals that will now cost Obamacare customers much more to access, now that all four marketplace insurers covering the hospital in-network for 2016 are dropping it from their provider networks next year. Lurie was in-network this year for four marketplace plans, including Coventry, Harken, United Compass and Land of Lincoln. But Land of Lincoln folded a few months ago, the other three have narrowed their networks for next year and other Obamacare insurers never covered the hospital to begin with. Lurie has posted a notice on its website, warning patients that they will need to get prior authorization from their marketplace plan before getting care — or they’ll likely have to pay the full bill.” (Washington Examiner, 12.1.16)

Evidence from Insurers

  • Less Choice, Lower Premiums. “Insurers including Aetna and Health Net say narrower networks, made up of hospitals and physicians selected using cost and patient-outcomes criteria, are necessary to keep their exchange plan premiums affordable while still meeting the requirements of the PPACA. They increasingly have offered such plans to employer groups over the past few years, touting annual cost savings of 10% to 25%… Insurers say they are able to charge lower premiums for narrow-network plans because they can select more cost-effective providers, and in some cases they are able to pay them lower reimbursement rates in exchange for funneling more patients to them. But some physician groups, hospitals and patient advocates say they are concerned … that patients, particularly those who need specialized providers, may not have adequate access to care… Dr. Reid Blackwelder, president-elect of the American Academy of Family Physicians, said that family physicians need to work in tandem with specialist physicians whose work they know and trust and that health plans whose provider networks are too small could make it more difficult to do that.” (Modern Healthcare, 8.17.13
  • Keeping Your Doctor No Easy Feat Under Obamacare. “When Blue Shield of California was designing the new health plans it would offer individuals under the Affordable Care Act (ACA), the insurer made a simple request to doctors and hospital in its network — lower your prices or get left behind. The insurer asked providers to accept reimbursement rates as much as 30 percent lower than what Blue Shield previously paid through plans sold on the individual market. Some providers got on board, but not all. According to the company, just 60 percent of the doctors and 75 of the hospitals that participate in the Blue Shield of California’s group plans will be included in individual plans purchased through Covered California, the state’s new insurance exchange. …A Dec. 13 McKinsey study of 20 U.S. metropolitan areas found that two-thirds of ACA plans analyzed had ‘narrow’ or ‘ultra narrow’ networks, with at least 30 percent of top 20 hospitals excluded for coverage.” (TIME Magazine, 1.1.14)
  • The Skinny on Narrow Networks in Health Insurance Marketplace Plans. “The Leonard Davis Institute of Health Economics has assembled the first integrated dataset of physician networks for the plans offered on the ACA marketplace. This data brief uses this new resource to describe the breadth of the physician networks in plans sold on the state and federal marketplaces. The percent of physician networks that were classified as small or x-small came to 41% overall, 55% for HMO networks, and 25% for PPO networks.” (Robert Wood Johnson Foundation, June, 2015)
  • State Variation in Narrow Networks on the ACA Marketplaces. “In this Data Brief, we present network sizes summarized up to the level of the state and the rating area. This analysis should help regulators and consumers assess and understand the trade-off between premiums and network size as we enter the next open enrollment period.” (Robert Wood Johnson Foundation, August, 2015)

Evidence from States

  • CA:
    • Obamacare’s Next Problem: Doc Shock. “Blue Shield is restricting access to close to half of its doctors and a quarter of its hospitals in the individual market — and Blue Shield spokesman Steve Shivinsky told The Orange County Register these providers “had to agree to cut their rates” to get into the network. In Southern California, the Los Angeles Times reported, Health Net individual policyholders will have access to less than a third of the doctors on employer plans. Peter Lee, executive director of Covered California, told the San Francisco Chronicle that all but three of the 12 state exchange providers limit doctors and hospitals.” (San Francisco Chronicle, 12.5.13)
    • Doctors Surprised To Be On Covered California Provider List. “Some doctors who did not want to accept patients on the Covered California exchange said they were surprised to discover they were on the exchange’s provider networks. …Independent physicians across California say they can’t afford to participate in Covered California’s insurance plans because the reimbursement rates are too low, and they say they don’t have the clout doctors with larger medical groups have to negotiate higher rates. They also warn that could mean a shortage of doctors in areas largely served by independent physicians.” (, 2.10.14)
    • California Doctors Opting Out of New Plans. “Local insurance agents this week are warning that doctor networks in new insurance plans purchased this year may be a lot smaller than you think. One Exeter pediatrician estimates that 80 percent of Tulare County’s private doctors have opted against accepting Covered California plans.” (Visalia Times Delta, 3.14.14)
    • Californians Upset Over Doctor Shortage in New ACA Plans. ”Many new enrollees are questioning Covered California’s definition of affordable, quality care, complaining they can’t find any doctor, let alone a quality one, to accept their new insurance.” (KPIX-CA TV via Washington Free Beacon, 4.4.14)
    • In The United States, ACA Marketplaces Lack Network Adequacy. “In the price-competitive ACA Marketplaces, plans with relatively narrow provider networks have proliferated. To find out how this affected access to care, Simon Haeder of the West Virginia University and coauthors used a ‘secret shopper’ survey of 743 primary care providers from five of California’s 19 insurance Marketplace pricing regions in 2015. They found that inaccurate and outdated provider information and a resistance to new patients were commonplace, both inside and outside California’s Marketplace, with only about 30 percent of efforts to make an appointment with a specific primary care physician ending in success. The authors conclude that more frequent updating (California currently requires quarterly updates), potentially coupled with incentives and penalties for both providers and insurers, might be the only path to improved access for patients.” (Health Affairs, 7.6.16)
  • IL: Major Chicago Hospitals Not In 2017 Obamacare Marketplace Plans. “Some of Chicago’s largest hospitals said they will not be part of any Cook County Affordable Care Act marketplace plans in 2017. University of Chicago Medical Center and Rush University Medical Center both said they don’t plan to be in network for any Obamacare marketplace plans next year. The change means patients with doctors at those hospitals will either need to find a plan off the marketplace, and lose Obamacare subsides, or find a new doctor. Northwestern Memorial Hospital said it will also be out of the marketplace, but will have exceptions for some of its partner hospitals. Suburban hospitals in the Northwestern system, like Delnor-Community Hospital in Geneva and Northwestern Medicine Central DuPage Hospital, will be in network for some plans. Patients with a primary care doctor at one of those locations will be able to access specialist throughout the entire Northwestern system, according to a Northwestern spokesman.” (WBEZ, 10.19.16)
  • IN: Many Plans Offer Very Limited Choices of Providers. “This fall, Indiana’s new online health-insurance marketplace will present some tough choices for consumers like John Nowak, who will be able to pick a plan from his current insurer—or go for one that includes his primary-care doctor… Similar situations are likely to occur around the country, as details emerge about the coverage available through the new consumer marketplaces created by the federal health law. Many of the plans will include relatively few choices of doctors and hospitals. In some cases, plans will layer on other limits, such as requirements that patients get referrals to see specialists, or obtain insurer authorization before pricey procedures.” Wilde Mathews, Anna. Many Health Insurers To Limit Choices Of Doctors, Hospitals. (The Wall Street Journal, 8.14.13)
  • NY:
    • Hard Choices on New York State Health Exchange. “New York State, almost from the start, has provided a textbook lesson in how to make the Affordable Care Act work. But it has done so by making some tough decisions.” The state “took some aggressive and unpopular steps that few other states have taken, by creating a highly centralized system limiting consumer choice, essentially giving insurance seekers little incentive to shop off the exchange. As a result, most New Yorkers who are not insured through an employer are effectively barred from choosing any doctors or hospitals they want… Donna Frescatore, executive director of New York State of Health, as the exchange is called, said the state’s decisions had been vindicated by the fact that premium rates had dropped more than 50 percent from previous years.” (New York Times, 4.13.14)
    • New York Doctors are Treating ObamaCare Like the Plague, a New Survey Reveals. “A poll conducted by the New York State Medical Society finds that 44 percent of MDs said they are not participating in the nation’s new health-care plan. Another 33 percent say they’re still not sure whether to become ObamaCare providers. Only 23 percent of the 409 physicians queried said they’re taking patients who signed up through health exchanges. ‘This is so poorly designed that a lot of doctors are afraid to participate,’ said Dr. Sam Unterricht, president of the 29,000-member organization. ‘There’s a lot of resistance. Doctors don’t know what they’re going to get paid.’ Three out of four doctors who are participating in the program said they ‘had to participate’ because of existing contractual obligations with an insurer or medical provider, not because they wanted to. Only one in four ‘affirmatively’ chose to sign up for the exchanges. ‘Obama Care wants to start right away, but who see all these new patients???? Not me,’ e-mailed one doc. Another said, ‘I plan to retire if this disaster is implemented. This is a train wreck.’ ‘I refuse to participate in the exchange plans! I am completely opposed to this new law,’ said a third respondent.” (New York Post, 10.29.13)
  • OH: Obamacare’s Low-Cost Premiums Offer Fewer Ohio Providers. “The restrictions in some cases will be significant. Consider hospitals that care for adults. CareSource, which is offering the lowest-cost public marketplace plan in Ohio, includes only Ohio State University’s Wexner Medical Center on its marketplace provider network in Franklin County. Anthem Blue Cross and Blue Shield in Ohio, meanwhile, limits its Franklin County adult hospitals to Mount Carmel’s. Wexner Medical Center and OhioHealth are out of network…’The use of narrow networks may also lead to higher out-of-pocket expenses, especially if a patient has a complex medical problem that’s being treated at a hospital that has been excluded from their health plan,’ according to the report.” (Columbus Dispatch, 10.7.13)
  • WA: New Washington State Rules Could Limit Cheaper Health Plans With Narrow Networks. “The practice of offering relatively inexpensive health plans with bare-bones provider networks has created tension between making health care affordable and keeping it accessible. It’s set to come to a head this week in Olympia. The growth of ‘narrow networks’ in Washington comes as the Affordable Care Act limits the ability of insurance companies to control their costs. That’s made it harder to offer plans at a range of prices — something the companies want to do as they compete for comparison shoppers on the health exchanges.” (KPLU, 4.21.14)
  • Washington D.C.: District Residents Find Long Delays Getting Insurance From Exchange Plans. “Consumers who signed up for private health insurance through the District’s new insurance marketplace are experiencing lengthy delays in getting coverage, in some cases two to three months long, because of problems processing their applications, according to residents and enrollment personnel. In some cases, delays are forcing people without insurance to postpone doctor and dental visits. The delays seem to be affecting coverage through CareFirst, the dominant carrier in the region, and Kaiser Permanente, according to consumers and enrollment personnel. Insurance and exchange officials have declined to say how many people are affected.” (Washington Post, 6.18.14)

Access to Prescription Drugs in ACA Exchange Plans

  • Drug Formularies in Health Exchange Plans. “Plans can and are using tiered formularies. As a result, expect to see plans utilize traditional multi-tier formularies with a generic tier, and preferred and non-preferred brand tiers, with widely varying cost-sharing differentials between tiers (and the implementation of traditional formulary controls like prior authorization and step edit programs).” (Lexology, 9.26.13)
  • Insurers, PBMs Are Expected to Ratchet Up Drug Formulary Management on Exchanges (with Chart: Commercial Versus Exchange Formularies). “Health plans and pharmacy benefit managers (PBMs) are likely to take an extra tough line on managing their pharmaceutical formularies in the insurance exchanges, industry sources tell HRW. Drug benefits on the exchange also will generally feature more coinsurance and cost-sharing requirements than similar benefits in commercial plans, new analysis shows… ‘In general, we are seeing public-exchange formularies that are more tightly managed than the commercial plans by leveraging utilization management programs, closed plan designs and generically driven drug lists,’ Julie Huppert, vice president of health care reform at PBM giant Express Scripts Holding Co., tells HRW.” (AIS Health, 10.7.13)
  • Medical Society Prescribes Reforms for Drug Formularies Established by QHPs. “‘Many plans are imposing highly restrictive pharmacy formularies that make it difficult for patients to get the medicines that work best for them,’ said ACP President Molly Cooke in a news briefing today. Federal and state regulators must monitor QHP formularies and other plan benefits to ensure that they do not discriminate against patients with complex medical problems such as cancer, HIV/AIDS, and hepatitis C, according to the ACP. And when a QHP declares a drug off-formulary for a patient who requests it, the plan should allow the patient to receive it while the decision is under appeal.” (Medscape Medical News, 2.11.14)
  • ObamaCare Patients with Serious Pre-existing Diseases Could Face Expensive Drug Costs. “People with serious pre-existing diseases, precisely those the president aimed to help with ObamaCare, could find themselves paying for expensive drug treatments with no help from the health care exchanges. Those with expensive diseases such as lupus or multiple sclerosis face something called a ‘closed drug formulary.’ Dr. Scott Gottlieb of the American Enterprise Institute explains, ‘if the medicine that you need isn’t on that list, it’s not covered at all. You have to pay completely out of pocket to get that medicine, and the money you spend doesn’t count against your deductible, and it doesn’t count against your out of pocket limits, so you’re basically on your own.’ The plan had claimed it would rescue those with serious pre-existing conditions. ‘So it could be that a MS patient could be expected to pay $62,000 just for one medication,’ says Dr. Daniel Kantor.” (Fox News, 2.16.14)
  • Prescription Drugs Harder to Get. “ObamaCare participants are twice as likely to face administrative barriers to using certain prescription drugs as people who receive health coverage through an employer, according to a new analysis. The research from consulting firm Avalere Health points to a little-known facet of policies on the ObamaCare exchanges known as ‘utilization management controls.’ The controls allow insurance companies to limit access to certain medications to try and control costs and prevent abuse. People who enroll in ObamaCare plans are likely to encounter the hurdles if they’re prescribed brand-name cancer or mental health drugs, Avalere found. At least 51 percent of brand-name mental health meds come with special controls on the exchanges, compared with only 11 percent on the employer-based market, the analysis found.” (The Hill, 3.24.14)
  • Drug, Network Comparisons Needed for Exchanges. “Left as-is, current exchange formulary and network search technology has the potential for a lot of consumer dissatisfaction and backlash. In just under half of the public exchanges, it is ‘difficult or impossible’ for shoppers to figure out which drugs are covered by health plans, researchers at Avalere Health found in a study of 12 state-based and five federally-run exchanges.” (Health Care Payer News, 4.28.14)
  • ObamaCare Insurers Accused of Overcharging for HIV/AIDS Drugs. “Analysis of prescription drug formularies and cost structure for all silver-level Qualified Health Plans in Florida — one of the options under ObamaCare — found the four insurance providers charged inordinately high copayments and co-insurance for drugs used to treat HIV and AIDS. They say the way drug pricing is structured, people with HIV and AIDS would have to pay more than $1,000 a month for their treatments. Some plans are also requiring prior authorization or approval by the plan for HIV drugs, the groups allege. ‘When you put up roadblocks to assessing life saving medications through these high out of pocket costs and prior authorizations people with HIV are more likely to miss doses, experience gaps in treatment and go off treatment altogether,’ said Carl Schmid, deputy executive director at The AIDS Institute.” (The Hill, 5.29.14)
  • Under Obamacare’s “Closed Formularies,” Patients With Serious Chronic Diseases like MS Don’t Get Access to Vital Medicines. “The challenge for consumers is that most of the plans have ‘closed’ formularies where non-formulary drugs aren’t covered. Moreover, the cap on out of pocket spending only applies to costs incurred on drugs included on a plan’s formulary. That means that patients could be saddled with the full cost of many of these drugs, with no limits on that spending.” Gottlieb, Scott, M.D. (Forbes, 6.14.14)
  • Obamacare Insurers Hit High-Cost Patients with High Drug Costs. “An analysis released in June by Avalere Health (and commissioned by PhRMA) found that the majority of plans sold on the health exchanges placed a significant out of pocket burden on patients with serious illnesses like cancer by requiring high cost-sharing for all medicines used to treat certain conditions. The report found that in seven of 19 classes of medicines for serious illnesses, such as cancer and HIV/AIDS, more than 20 percent of Silver plans—the standard plan on the exchanges– require patients to pay 40 percent or more out of pocket costs. Similarly, in 10 of the 19 selected classes, at least 20 percent of Silver plans require coinsurance of 30 percent or greater for drugs in the classes. The study also finds that more than 60 percent of Silver plans place all covered medications for multiple sclerosis, rheumatoid arthritis, Crohn’s disease and certain cancers in the plan’s highest formulary tier. ‘The Exchanges were meant to provide patients access to the medicines they need, especially for the sickest among us. Yet this report paints a very different picture, one in which many Americans still find themselves unable to access the care they desperately need due to high out of pocket costs.’” (Fiscal Times, 7.10.14)
  • Preventing HIX Drug Benefits Horror Stories. “Medications that individuals have long been taking, whether for life-threatening diseases like leukemia, chronic diseases like diabetes or more minor conditions like acid reflux, can suddenly be unavailable or available at higher out-of-pocket costs or through generic versions.” (Health Care Payer News, 10.3.14)
  • From HIV to Cancer to Crohn’s, ObamaCare Exchange Plans Fail the Sick. “It turns out ObamaCare didn’t solve the problem of ‘pre-existing conditions’ after all. It made premiums more affordable for people with chronic health conditions that are expensive to treat — but at the price of sticking them with unaffordable co-payments for their medications…Pre-ObamaCare, about half the states had a system in place for helping people with pre-existing conditions: state high-risk pool plans, which for years offered government-subsidized coverage to patients with pre-existing conditions. But the Affordable Care Act banned those pools. So now, with exchange plans failing them, the chronically ill have nowhere left to go.” (New York Post, 8.10.14)
  • Out-Of-Pocket Prescription Costs Under A Typical Silver Plan Are Twice As High As They Are In The Average Employer Plan. “Using national data, we compared cost sharing and prescription and medical spending for patients covered by employer-sponsored plans to the spending for those in a typical silver plan in the Marketplaces. Our results show that out-of-pocket expenses for medications in a typical silver plan are twice as high as they are in the average employer-sponsored plan, resulting in fewer prescriptions filled and refilled and in higher spending on other medical services. Maintaining the use of cost-effective prescription medications might require lower cost sharing for patients with chronic conditions than is currently found in the Marketplaces.” (Health Affairs, October, 2015)
  • Using Drugs to Discriminate — Adverse Selection in the Insurance Marketplace. “We found evidence of adverse tiering in 12 of the 48 plans — 7 of the 24 plans in the states with insurers listed in the HHS complaint and 5 of the 24 plans in the other six states (see the Supplementary Appendix for sample formularies). The differences in out-of-pocket HIV drug costs between adverse-tiering plans (ATPs) and other plans were stark (see graph). ATP enrollees had an average annual cost per drug of more than triple that of enrollees in non-ATPs ($4,892 vs. $1,615), with a nearly $2,000 difference even for generic drugs. Fifty percent of ATPs had a drug-specific deductible, as compared with only 19% of other plans. Even after factoring in the lower premiums in ATPs and the ACA’s cap on out-of-pocket spending, we estimate that a person with HIV would pay more than $3,000 for treatment annually in an ATP than in another plan. Our findings suggest that many insurers may be using benefit design to dissuade sicker people from choosing their plans. A recent analysis of insurance coverage for several other high-cost chronic conditions such as mental illness, cancer, diabetes, and rheumatoid arthritis showed similar evidence of adverse tiering, with 52% of marketplace plans requiring at least 30% coinsurance for all covered drugs in at least one class. Thus, this phenomenon is apparently not limited to just a few plans or conditions.” (New England Journal of Medicine, 1.29.15)
  • Avalere Analysis: Exchange Benefit Designs Increasingly Place All Medications for Some Conditions on Specialty Drug Tier. “New analysis from Avalere Health finds that some exchange plans place all drugs used to treat complex diseases – such as HIV, cancer, and multiple sclerosis – on the highest drug formulary cost-sharing tier. ‘Plans continue to innovate on benefit design in the exchange markets,’ said Dan Mendelson, CEO of Avalere. ‘These designs are calibrated to optimize enrollment by delivering low and stable premiums – the primary metric that consumers use to select a plan.’” (Avalere, 2.11.15)
  • Out-Of-Pocket Prescription Costs Under A Typical Silver Plan Are Twice As High As They Are In The Average Employer Plan. “The health insurance Marketplaces created under the Affordable Care Act have attracted nearly ten million enrollees, including many people who were previously insured by an employer-sponsored plan. The most popular Marketplace plan—the silver plan—has significantly higher cost sharing than does a typical employer-sponsored plan, which may cause patients to reduce the use of cost-saving services that are essential for managing chronic conditions. We estimated the impact of higher cost sharing on drug and medical spending among patients with chronic conditions. Using national data, we compared cost sharing and prescription and medical spending for patients covered by employer-sponsored plans to the spending for those in a typical silver plan in the Marketplaces. Our results show that out-of-pocket expenses for medications in a typical silver plan are twice as high as they are in the average employer-sponsored plan, resulting in fewer prescriptions filled and refilled and in higher spending on other medical services. Maintaining the use of cost-effective prescription medications might require lower cost sharing for patients with chronic conditions than is currently found in the Marketplaces.” (Health Affairs, October, 2015)
  • Access to Specialty Care Lacking in Many ACA Plans. “Data from a new study show that… nine of 19 plans (47.4%; 95% CI, 25.0% – 70.8%) did not cover medications prescribed by out-of-network providers.” (Medscape Medical News, 10.30.15)
  • Cancer Meds Often Bring Big Out-Of-Pocket Costs For Patients, Report Finds. “[M]ost insurance plans in the six states that were examined placed all or nearly all of the 22 medications studied into payment ‘tiers’ that require the biggest out-of-pocket costs by patients, the American Cancer Society Cancer Action Network said. Those drugs include some well-known treatments, such as Gleevec for certain types of leukemia and Herceptin for breast cancer, and even some generics…With many cancer drugs costing more than $5,000 a month, paying a percentage, also known as “co-insurance,” means patients must pay hundreds or even thousands of dollars at the pharmacy counter until they reach their annual insurance deductible. This appears ‘not to be designed to encourage use of cheaper or more effective alternatives, but to extract the maximum patient cost-sharing for cancer drugs,’ the report said. The study out Wednesday by ACS/CAN reviewed the drug formularies for 66 silver-level plans available to consumers in California, Florida, Illinois, North Carolina, Texas and Washington. These plans cover about half of marketplace enrollees nationwide.” (Kaiser Health News, 11.19.15)
  • Health Insurers Find Back Door to Limit Choice. As cutting edge drugs come to market, insurance companies are scrambling to find ways to justify not paying for them… The flawed justification was normalized by President Obama in 2009, when he oversimplified pharmacoeconomics, saying, ‘If there’s a blue pill and a red pill, and the blue pill is half the price of the red pill and works just as well, why not pay half price for the thing that’s going to make you well?’ Insurance companies are using this concept to cut costs by excluding the red pills. To do so,  they’ve cooked up a clever way to justify exclusions from formularies by founding and funding a group called the Institute for Clinical and Economic Review.” (USA Today, 5.26.16)
  • Nearly All ACA Benchmark Plans Violate Rules on Addiction Treatment Coverage. “Despite federal rules that require plans to cover addiction treatment without restrictions, the ACA does not specify which substance use disorder benefits should be covered, leaving that decision up to the discretion of states. The law requires plans cover at least one addiction treatment medication in each of four classes: anti-craving, opioid reversal, opioid dependence treatments and tobacco cessation. The report found that 45% of 2017 benchmark plans were in violation by not providing coverage for an addiction treatment medication that was in each of the four classes… EHB-benchmark plans for Alabama, Michigan, Mississippi, South Carolina and South Dakota violated parity rules that prohibit limits on treatment that applied to addiction treatment only by restricting the number of visits allowed for such services.” (Modern Healthcare, 6.7.16)
  • Obamacare’s Out-of-Pocket Costs for Specialty Drugs Increases 16% in One Year. “Out-of-pocket costs for specialty drugs under the Affordable Care Act increased 16 percent from 2016 to 2017, according to a report from HealthPocket. While prescription drug coverage comes standard with Obamacare plans, not all medications prescribed to individuals will be paid for. ‘For a plan to help pay for a drug, the drug must first be included on the health plan’s formulary,” the report states. ‘Drugs that are off-formulary are not only paid for completely out-of-pocket by the enrollee but those expenses do not count towards the annual cap on out-of-pocket spending.’… ‘As out-of-pocket costs for specialty drugs continue to be a problem without resolution, consumers taking these medications need to be vigilant in their insurance shopping,’ says Kev Coleman, head of research and data at the company. ‘For these consumers, cost-sharing for specialty drugs and annual caps on out-of-pocket expenses can be even more important factors than premiums when financially comparing health plans.’” (Washington Free Beacon, 12.12.17)

Other Access Issues

  • Some Still Lack Coverage Under Health Law: Backlogs, Technical Glitches Stall Insurance Policies. “Months after the sign-up deadline, thousands of Americans who purchased health insurance through the Affordable Care Act still don’t have coverage due to problems in enrollment systems. In states including California, Nevada and Massachusetts, which are running their own online insurance exchanges, some consumers picked a private health plan and paid their premiums only to learn recently that they aren’t insured. Others received a policy but then got married, had a baby or another ‘life event’ that required their coverage to be updated, yet have been waiting months for the change to take effect. As a result, some of these people say they have put off medical treatments or paid out of pocket for health expenses. Some insurers say they will be reimbursed.” (Wall Street Journal, 7.7.14)
  • The ACA’s Pediatric Essential Health Benefit Has Resulted In A State-By-State Patchwork Of Coverage With Exclusions. The approach used to establish the Affordable Care Act’s pediatric essential health benefit has resulted in a state-by-state patchwork of coverage with inconsistent exclusions, particularly with regard to services for children with mental or developmental disabilities. (Health Affairs, December, 2014)

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