I remember having coffee in New York’s historic Algonquin Hotel with health insurance whistle-blower Wendell Potter as he lamented that President Obama had campaigned for the Affordable Care Act by promising that people would be able to keep their insurance with the doctors and hospital they liked.
“People around him should have known better,” Potter told me. “I thought that was nonsense and that those words would haunt him.”
As the former Cigna public relations executive and the author of Deadly Spin: An Insurance Company Insider Speaks Out on How Corporate PR Is Killing Health Care and Deceiving Americans, explained it, insurers constantly alter their plans by adding and dropping doctors and hospitals from the plan networks as they hunt for the best providers who’ll accept the lowest payments.
Critics blame Obamacare for provider churn. But the fact is, provider churn is a routine industry practice. President Obama should have known that the ACA would not reverse that basic business strategy.
Furthermore, under pressure from rising medical costs, many insurers are reducing the number of doctors and hospitals in their networks drastically.
As a result, there is a good chance that a doctor or hospital you like might disappear from your plan’s network, no matter what health insurance you’re buying—including Obamacare plans.
For example, United HealthCare, the nation’s largest health insurer, dropped the Yale University Medical Group from all of its networks in Connecticut in 2014—as part of a 10 percent reduction in providers nationwide. Many of United’s plan members lost their favorite doctors virtually overnight.
In addition, insurance companies are shedding providers from their Obamacare plans. For instance, Anthem Blue Cross lowered its ACA plan premiums by 25 percent for its largely working-class and middle-class customers on the New Hampshire exchange in 2014 by sharply restricting the network serving them. Anthem’s move touched off a furor because the insurer excluded ten of the state’s twenty-six hospitals. To make matters worse, Anthem was the only company selling insurance on that state’s exchange.
Insurance companies insist that tighter networks help them keep a lid on premiums by driving plan members to less expensive doctors and hospitals that nonetheless provide quality care.
But as networks tighten, the costs of going to a doctor or hospital that’s not in your plan’s network often rise, sometimes by as much as 40 percent to 100 percent. New York State is a case in point. None of the more than fifty health plans sold on New York’s online exchange in 2016 offered any out-of-network coverage, including the top-tier platinum plans that charge around $600 a month in premiums. That means if you are in a network hospital and under the care of a network doctor but get treated by an out-of-network physician or specialist or surgeon (perhaps while you are unconscious), you might be liable for 100 percent of that out-of-network care.
Furthermore, if you get hit with out-of-network charges in an ACA plan, not a penny of that money counts against your out-of-pocket maximum of up to $12,800 for a family. A bill to protect patients in that jam in the California legislation stalled on the last day of the 2015 session in the face of heavy health industry lobbying. What a surprise!
Even when your hospital is in your network, your health plan might cover only certain procedures, such as trauma care. So shop carefully.