Narrow networks threaten care access

Patients that receive their health coverage through Affordable Care Act marketplaces and Medicaid plans face a wide variety of access to care based primarily on where they live. State and federal standards enacted to make sure they have access to in-network primary and specialty care providers don’t always provide the access needed, and the proliferation of “narrow” insurance networks, where insurers limit the number of providers patients can see, further restricts their care access.

Researchers from Georgetown’s Center for Health Insurance Reforms and the Center for Children and Families found that access to health care services depends largely on where people live. There is wide variation in standards for physician networks among states and even among Medicaid marketplace plans in the same state. As a result, individuals face different levels of access depending on which state they reside in.

For those in marketplace health plans, there are few federal protections. Federal regulations require states to oversee insurer networks for Medicaid managed care organizations, but there are no requirements for marketplace qualified health plans.

Even at the state level, protection for access to primary care providers and rural health clinics are limited. Federal regulations requiring health plans to contract with essential community providers, like community health centers and rural health clinics, offer states flexibility, but most states do not enforce standards stronger than basic requirements.

For patients with different language or cultural requirements, there are no federal requirements that individuals be able to access health care that meet their needs.

“Having health insurance should give people the peace of mind that they can get the care they need,” said Andrea Ducas, senior program officer at the Robert Wood Johnson Foundation, which funded the research in part, in a statement. “One important dimension of that is having enough providers that accept your insurance. Policymakers can bring greater peace of mind to more people by ensuring that provider networks are adequate in size and scope of coverage.”