Under the Affordable Care Act, the federal government was the backstop for making sure that health plans sold in every state had enough in-network hospitals and physicians, including specialists, in their service area so that those buying their coverage could receive in-network care and not have to pay for more expensive out-of-network treatments.

But the Trump administration has changed all that.

A report from the Pew Trusts says that, as of last month, it’s now up to the states to make sure that insurers have “network provider adequacy”—enough doctors and facilities to treat the patients who sign up for their care.

Even before the administration’s intervention to weaken yet another facet of the ACA, that was an issue, as evidenced by a class action lawsuit filed against the Centene Corporation for failing to have enough staff and facilities to treat those who signed up for its plans. But now a number of states that relied on the government for monitoring and enforcing network adequacy will have to take on that job themselves.

The change, according to the report, affects 28 states that rely on the federal health insurance exchange and 11 states that operate exchanges in some sort of partnership with the federal government. Twelve states, however, were already responsible for keeping track of network sufficiency, since they operate their own exchanges.

While some states are fine with it, regarding the federal government’s role as duplicative, others aren’t necessarily prepared for it—either with sufficient staff or know-how to do the job or enough regulations to ensure it’s done effectively.

And critics say that it’s yet one more cut to protections for consumers, with Betsy Imholz, a health policy expert at Consumers Union, the research and advocacy arm of Consumer Reports, quoted saying, “Our concern is that the Trump administration is rolling back a lot of the assurances consumers should be able to rely upon without keeping a minimum of standards that would protect them.”

Mike Kreidler, the Washington state insurance commissioner, says in the report that he doubts many states on the federal exchange are ready to tackle the job of regulating network adequacy right now and be effective at it.

“Many of those states are not geared up for this,” he’s quoted saying, adding, “It’s labor intensive and requires a lot of in-house expertise. Even we are a work in progress. The federal government stepping away like this, that is just not good.”

Instant Insights /

States, not feds, now responsible for ensuring sufficient doctors in health plans

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