Access to Care Is Significant Threat for ACA Marketplaces, Medicaid Enrollees

A Georgetown University study finds that policies limit already narrow networks.

Between government regulations, missing mandates, and health plan policies, narrow networks can get even slimmer for some consumers.

A recent Georgetown University study found that adequate access to care is a significant threat for many marketplace and Medicaid enrollees. Why? Because the standards designed to protect these consumers vary significantly and often lack the protections to enforce provider network adequacy and choice.

Study highlights

Details from the study findings include:

• Diverse state network standards make geography a differentiator. The study notes that there is "dramatic variation in standards for health insurers' physician networks across states and among Medicaid and marketplace plans in the same state." This can limit in-network access based solely on where someone lives.
   
• Marketplace plans lack key protections. Qualified marketplace plans are not subject to the same payer network oversight as managed Medicaid plans.
   
• States could protect access, but often don't or can't. The study found that while states have "considerable flexibility" to help protect access to essential providers, most "do not enforce standards stronger than baseline requirements." 
   
• Cultural and linguistic access compounds geographic issues. The Georgetown research further noted: "There are no federal requirements that individuals be able to access healthcare that meets their language or cultural needs."

The Georgetown study was published by the university's McCourt School of Public Policy, Center on Health Insurance Reforms, and its Health Policy Institute Center for Children and Families.

Funding was provided by the Robert Wood Johnson Foundation, whose senior program officer, Andrea Ducas, commented: "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."

Coverage without care

The Georgetown findings pair with other access limitations. These include longstanding and widespread provider shortages and the baked-in inequalities of markets that are more rural with more dispersed populations, and longer distances to travel for any kind of care—in-network or otherwise.

The sum total is that geography is often destiny when it comes to healthcare, and that coverage without care remains a reality. While narrow networks are a design innovation that theoretically lower costs for members and health plans alike, they can have unintended adverse effects in markets that are already disadvantaged.