KFF: A look at narrow networks in ACA marketplace plans

By Paige Minemeyer / August 28, 2024

People enrolled in Affordable Care Act (ACA) marketplace plans had access to 40% of their local physicians in-network on average, according to a new analysis from KFF.

Just 4% of people with marketplace coverage were enrolled in plans that included more than three-quarters of local doctors in-network, according to the study. By comparison, 23% of people were in a plan that provided access to less than a quarter of local physicians in-network.

The study found that some of the plans with the narrowest networks were in large metropolitan counties. On average, enrollees in these regions had access to 34% of local doctors in-network.

For example, marketplace plans in Cook County, Illinois—or Chicago—saw 14% in-network physician participation. Lee County, Florida, or Fort Myers, had 23% participation. Both were among the lowest in the study, the researchers said.

The researchers note that evaluating network adequacy in ACA plans is a key topic of concern.

"A central challenge in analyzing network breadth is the quality of available data," they wrote in the article. "The inclusion of so-called 'phantom providers'—physicians listed in the network but who are not actually available to plan enrollees at the location or in the specialty they are listed—may increase the apparent breadth of plan networks without actually increasing access to care."

The report found that people with marketplace coverage were more likely than people with employer plans to need to visit a provider who is out-of-network. Twenty percent of all enrollees in marketplace plans needed an out-of-network provider, compared to 13% of people in employer plans.

Thirty-four percent of marketplace members in poor health said they needed to secure services from an out-of-network provider, the study said.

Some experts have argued that insurers deploy narrow networks on the marketplaces to help premiums stay low.

The researchers said a forthcoming KFF analysis found that patients who struggle to find a doctor are more likely to delay care. People with non-group coverage, including marketplace plans, were more than twice as likely as those in employer plans to say they delayed care for this reason (7% versus 3%).

"Among those who visited a hospital or emergency room during the past year, 11% of non-group enrollees reported skipping or delaying care, compared to 5% of those with employer coverage," the researchers wrote.