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'Narrow' markets change U.S. health care

Jul 1, 2014 - By Misty Williams, MCT News Service

ATLANTA -- The cancer had already spread to her abdomen by the time Beth Brock managed to escape from her health insurance nightmare.

The Woodstock business owner learned last fall her insurance didn't meet the Affordable Care Act's new standards, so she reluctantly chose a different health plan that her doctors assured her they accepted. But they didn't.

Brock, 48, was waiting at her OB/GYN for a pre-surgical visit -- the last step before an operation to remove an ovarian cyst -- when the billing office called to say it didn't accept her new plan after all. It would be two months before she untangled the mess and switched to a health plan that covered a broader array of doctors. By then, the cyst had grown from slightly larger than a walnut to bigger than a softball.

"I had lost all that time," said Brock, who is undergoing chemotherapy. "If (the surgeon) could have operated on me in January ... it wouldn't have had the opportunity to grow huge and spread."

Her chance of living for another five years is 40 percent.

Nearly nine months after the scrambled launch of the federal Health Insurance Marketplace, some Americans have been shocked and dismayed to find their new insurance plans can offer far fewer doctors, specialists and hospitals to choose from than they've come to expect.

The so-called narrow networks, experts say, enable insurers to curb costs and, in turn, offer lower premiums to consumers. Nationwide, nearly half of all federal marketplace networks are considered narrow.

The trend is not limited to Obamacare plans. The Affordable Care Act may have hastened the trend, but employers and insurers in recent years have increasingly turned to narrow networks to rein in health care spending. That means millions of Americans -- not just those with marketplace plans -- may be choosing from smaller lists of doctors and hospitals in years to come. Brock, for example, did not buy a marketplace plan but still wound up with a limited network.

As part of the health care overhaul, insurance companies may no longer deny coverage to Americans with high-blood pressure, heart disease, diabetes or other pre-existing conditions. They also can't charge exponentially higher premiums to people because they are women or sick or getting older.

The changes have made affordable health coverage a reality for millions of previously uninsured Americans. But the greater regulation has also left narrow networks as one of the last major tools insurers can use to lower costs and keep their premiums competitive.

"In the past, they didn't compete on networks, but they didn't take anyone who was sick," said Gary Claxton, vice president with the nonprofit Kaiser Family Foundation. Now, "networks are what they got."

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Fewer options isn't necessarily a bad thing, consumer advocates say, as long as patients have access to the doctors and specialists they need.

An insurer that limits access too severely may compromise quality of care and potentially expose patients to crippling bills if they're forced to seek care "out of network." Many insurers will pay for an outside specialist if its network doesn't have one.

Advocates argue insurance companies need to do a better job of providing reliable, easy-to-find information to consumers about which doctors and hospitals are included.

Directories on insurance company websites aren't always up to date or fail to disclose whether the doctor accepts new patients, said Cindy Zeldin, head of consumer advocacy group Georgians for a Healthy Future.

Still, narrow networks are likely better than nothing for many previously uninsured people, said Claxton, the executive with the Kaiser Family Foundation.

A Kaiser survey earlier this year shows that about 55 percent of individuals who are uninsured or buy their own insurance would rather have a plan that costs less and has a limited range of providers, versus 34 percent of people who get their insurance through work.

Graylen Graham is just happy to have insurance.

Graham, 51, went without health insurance for five years but didn't think he could afford insurance until a friend urged him to check out Obamacare.

Graham, who suffers from asthma, high blood pressure and Crohn's disease, ended up qualifying for a Humana plan with a broader network and premium fully covered. But Graham didn't care what provider he went to just as long as he finally had insurance.

"My blood pressure is back under control," he said. "I'm doing pretty good."

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Affordable Care Act