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More Insured, but the Choices Are Narrowing



In the midst of all the turmoil in health care these days, one thing is becoming clear: No matter what kind of health plan consumers choose, they will find fewer doctors and hospitals in their network — or pay much more for the privilege of going to any provider they want.

These so-called narrow networks, featuring limited groups of providers, have made a big entrance on the newly created state insurance exchanges, where they are a common feature in many of the plans. While the sizes of the networks vary considerably, many plans now exclude at least some large hospitals or doctors’ groups. Smaller networks are also becoming more common in health care coverage offered by employers and in private Medicare Advantage plans.

Insurers, ranging from national behemoths like WellPoint, UnitedHealth and Aetna to much smaller local carriers, are fully embracing the idea, saying narrower networks are essential to controlling costs and managing care. Major players contend they can avoid the uproar that crippled a similar push in the 1990s.

The Times would like to hear from Americans who have signed up for health care under the Affordable Care Act.

“We have to break people away from the choice habit that everyone has,” said Marcus Merz, the chief executive of PreferredOne, an insurer in Golden Valley, Minn., that is owned by two health systems and a physician group. “We’re all trying to break away from this fixation on open access and broad networks.”

But while there is evidence that consumers are willing to sacrifice some choice in favor of lower prices, many critics, including political opponents of the new health care law, remain wary about narrowing networks. A concern is that insurers will limit access to specialists or certain hospitals. “Too often, Obamacare cancels the policy you wanted to keep and tells you what policy to buy,” Senator Lamar Alexander, a Tennessee Republican, said in a speech in April.

Dr. Monica Wehby, a pediatric neurosurgeon, is using the potential reaction to narrower networks as momentum for her campaign for Senate in Oregon. A Republican promising to repeal the Affordable Care Act, her slogan is “Keep your doctor. Change your senator.”

Other complaints involve confusion over which providers are participating in which plans.

“The thing you’re buying is access to the provider network,” said Lynn Quincy, a policy expert at Consumers Union. “Right now it feels like you’re forced to guess.”

In response, state and federal regulators say they are more closely monitoring the plans being offered in the coming year to be sure they are clear and that consumers have sufficient access to hospitals and doctors. In some cases, they are already insisting on changes.

Nonetheless, for people who are directly picking plans in the open markets, insurers say price is turning out to be critical. People “are weighing affordability and breadth of network,” said Karen Ignagni, the chief executive of America’s Health Insurance Plans, an industry trade group. “What we’re finding is individuals are experiencing a preference for affordability,” she said.

Minnesota would seem to be a case in point.

On the state exchange, PreferredOne offered an inexpensive plan with a network of 13 hospitals, but those low premiums helped the insurer grab 60 percent of the individual insurance market.

While many insurers are including only those hospitals and doctors willing to charge lower prices, experts say the makeup of the networks is likely to evolve over time, focusing less directly on price and more on the ability of providers to deliver coordinated and high-quality care.

Although a similar attempt to restrict choice failed in the early ‘90s, after opposition to H.M.O.s and managed care, insurers insist these efforts will not run into the same resistance because they are now working more closely with providers, and customers are more concerned about costs. “It’s a new era,” said Dr. Sam Ho, the chief medical officer for United Healthcare.

Others agree. “You’re going to see this as a dominant strategy,” said Jeff Hoffman, who works closely with hospitals for Kurt Salmon, a consulting firm.