The Good, the Bad, and the Ugly: Physician Coverage under the ACA

By Elizabeth Guo

A recent study in JAMA by Dorner, Jacobs, and Sommers released some good and bad news about provider coverage under the Affordable Care Act (ACA). The study examined whether health plans offered on the federal marketplace in 34 states offered a sufficient number of physicians in nine specialties. For each plan, the authors searched for the number of providers covered under each specialty in each state’s most populous county. Plans without specialist physicians were labeled specialist-deficient plans. The good: roughly 90% of the plans covered more than five providers in each specialty. The bad: 19 plans were specialist-deficient and 9 of 34 states had at least one specialty deficient plan. Endocrinology, psychiatry, and rheumatology were the most commonly excluded specialties.

Here’s where it gets ugly.

Excluding certain specialists from coverage can be a way for insurers to discriminate against individuals with certain conditions by excluding them from their plans. By excluding rheumatologists, insurers may prevent enrolling individuals with rheumatoid arthritis; by excluding endocrinologists, insurers may prevent enrolling individuals with diabetes. Individuals with chronic conditions need to see specialists more frequently than healthier adults, and how easily a patient with chronic conditions can see a specialist can affect his health care outcomes.

The study adds to the growing body of empirical research showing that even after the ACA, insurers may be structuring their plans to potentially discriminate against individuals with significant chronic conditions. In January, Jacobs and Sommers published a study showing that some plans were discriminating against patients with HIV/AIDS through adverse tiering by placing all branded and generic HIV/AIDS drugs on the highest formulary tier. Another study found that 86% of plans place all medicines in at least one class on the highest cost-sharing tier. These studies show that despite being on a health plan, individuals with certain chronic conditions may still have trouble accessing essential treatments and services.

The recent study may also signal a larger problem in insurance benefit design. Dorner, Jacobs and Sommers examined coverage for “silver plans” offered on federally funded marketplaces. Plans on these marketplaces need to meet the ACA’s stringent requirements that detail what types of benefits the plans must offer. For example, plans sold through the exchange “must not employ marketing practices or benefit designs” that discourage enrollment by individuals “with significant health needs.” These standards are not explicitly enumerated for plans sold off the public exchange. The ACA’s explicit provisions suggest that theoretically, patients purchasing health plans through the marketplace should be protected against discrimination by health plans. If researchers are finding potentially discriminatory benefit designs on plans sold through the public exchange, what does that mean for plans sold off the exchange?

While the ACA has already allowed millions of people with chronic conditions to be able to obtain insurance, ensuring that these individuals can obtain appropriate care will require ongoing oversight. Dorner’s recent study suggests that the government should more carefully monitor whether plans on the public marketplace adhere to ACA’s requirements, but reducing discrimination on the basis of health status will require greater scrutiny of benefit designs for plans both on and off the mark


2015-2016 Peter Barton Hutt Student Fellow During her fellowship year, Elizabeth Guo was a third year student in the JD/MPH Program at Harvard Law School and the Harvard School of Public Health. Her interests lie at the intersection of law, health care reimbursement, and biopharmaceutical regulation. Elizabeth graduated from Harvard University with a BA in social studies, focusing on the bioethics of assisted reproduction in China. Prior to law school, she was a senior associate at Avalere Health working with life science clients on a range of health policy topics, including Medicare coverage and reimbursement, biosimilar regulation, and healthcare quality programs. Elizabeth served as a student editor of the Journal of Law and Technology and a member of the Mississippi Delta Project’s Delta Project’s Food Policy Initiative. Elizabeth's fellowship paper was entitled: "Reputation and Judicial Deference: An Examination of FDA’s Reputation and Judicial Deference to Agency Action."

2 thoughts to “The Good, the Bad, and the Ugly: Physician Coverage under the ACA”

  1. Was there any consideration of whether the lack of specialists might be due to no one in that area being willing to accept a plans contracted rate? Did the plans set out to exclude particular specialists, or did the specialists exclude themselves by demanding higher fees than the company was willing to pay?

  2. Elaine – thank you for your comment. Your questions raise interesting points about market power and insurance design. I’m assuming that Dorner’s article didn’t look into insurance contracting because information about contracting negotiations are usually not publicly available. However, your comment raises two issues worth pointing out.

    First, the ACA requires that plans sold through the public market maintain “sufficient choice of providers.” Thus, a plan sold on the market with an inadequate number of specialists might violate the ACA’s requirements despite an insurer’s good faith effort to retain an appropriate number of specialists.

    Second, even if the specialists refused insurers’ low rates in specialist-deficient plans, could we still find discrimination if an insurer intentionally sets specialist rates at a level that few specialists would willingly accept? Given that the large majority of plans in Dorner’s study provided five choices within each specialty, I’m skeptical that the insurers could not have designed their specialist-deficient plans in a way that would have allowed beneficiaries more choice between providers.

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