The first thing Michelle Pool did before picking a plan under President Barack Obama’s health insurance law was check whether her longtime primary care doctor was covered. Pool, a 60-year-old diabetic who has had back surgery and a hip replacement, purchased the plan only to find that the insurer was mistaken.
The $352 a month Pool paid for the gold plan through Covered California’s exchange was cheaper than the cost of coverage under her husband’s insurance and seemed like a good deal because of her numerous pre-existing conditions. But after her insurance card came in the mail, the Vista, Calif., resident learned her doctor wasn’t taking her new insurance.
“It’s not fun when you’ve had a doctor for years and years that you can confide in and he knows you,” Pool said. “I’m extremely discouraged. I’m stuck.”
Stories like Pool’s are emerging as more consumers realize they bought plans with limited doctor and hospital networks, in some cases after websites mistakenly indicated that their doctors were included.
Before the law took effect, experts warned that narrow networks could limit patient’s access to care, especially in cheaper plans. But with insurance cards now in hand, consumers are finding their access limited across all price ranges.
The dilemma undercuts President Obama’s 2009 pledge that “If you like your doctor, you will be able to keep your doctor, period.”
Narrow networks are part of the economic trade-off for keeping premiums under control and preventing insurers from turning away those with pre-existing conditions. Even before the Affordable Care Act, doctors and hospitals would choose to leave a network — or be pushed out — over reimbursement issues as insurers tried to contain costs.
Insurance trade group America’s Health Insurance Plans says studies show the biggest factor influencing consumer choice is price. Insurers say that if consumers want low premiums, their choices may be limited.
Insurance companies also argue there’s wide variation in what doctors and hospitals charge, with some increasing prices every year. Insurers say there’s little evidence that higher-priced hospitals or doctors are actually delivering better care.
Further complicating matters, the trade group says doctors and health plans often renegotiate throughout the year, meaning a doctor listed in a network at the time of enrollment may not be there a few months later.
Insurance agents Craig Gussin in San Diego and Kelly Fristoe in Texas helped dozens of clients switch plans just before the enrollment deadline when clients realized their doctors weren’t covered. Now, they’re struggling to help clients who realized they were in that position after the March 31 enrollment deadline, when consumers are locked into plans for one year.
Gussin says that even after his mad-dash to make switches before the deadline, he still has a half-dozen clients who are stuck — and he expects the number to grow as more try to schedule appointments with doctors. He and other agents fear it will be one of their most serious issues in 2014.
“Everybody I talk to is having the same issue. It’s probably the number one item that we’re seeing right now,” said Gussin, who is petitioning Covered California for special enrollment status to help clients change plans.
Health counselor Nathalie Milias, who helped enroll nearly 300 Miami-area residents in ACA plans, says most of them chose a plan with $0 monthly premiums and deductibles — but with much more limited choices. She says tax credits could have allowed them more robust plans if they were willing to spend more, but many are working poor who didn’t want to pay another bill.
Marie Bien-Aime, a 59-year-old cook at a Miami restaurant, enrolled in that plan to avoid a monthly payment, but she realized her longtime health clinic didn’t take the plan. Shortly before the enrollment deadline, Bien-Aime upgraded to a plan that costs $37 per month.
“Paying $37 isn’t good for me, but I had to do it because I wanted to keep my doctor because he’s so good,” said Bien-Aime, who was previously uninsured.
Many consumers are still learning. They hear “Obamacare” and think it’s free, like Medicaid or Medicare, said John Foley, an attorney and navigator.
“They don’t expect to pay anything,” said Foley. “For a couple more dollars a month you can get a really good plan and they’re like, ‘This is free. I don’t want to pay for this.’ “
Even with pricier plans, some consumers have access problems.
James Potts’ $647-per-month silver plan was issued by the same company that had insured him with a different plan cancelled under the Affordable Care Act. The 64-year-old property insurance agent assumed his doctors would remain the same under the insurer’s new plan, and didn’t double check.
When Potts got a nasty cold, he called three facilities near his home in Wichita Falls, Texas, and was shocked to find none took the insurance, including his primary care doctor.
“It was a waste of money for me,” he said. “I couldn’t find doctors that would talk to me.”
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