4 months ago

A KFF analysis of physician networks in the Affordable Care Act’s Marketplace plans finds wide variations in the share of local practicing physicians who participate, with the least costly plans generally having a smaller share of physicians than more expensive plans.

The analysis examines the breadth of physician networks listed in Marketplace plan directories in 2021 in nearly every county nationally in relation to the number of actively practicing physicians locally. 

On average, Marketplace enrollees had access to 40% of practicing physicians in their area in 2021, with wide variations across plans. For instance, 23% of enrollees were in plans with no more than a quarter of local doctors, while only 4% were in plans with at least three-quarters of local doctors.

Plans with networks that include a larger share of local physicians typically have higher premiums. For example, Marketplace silver plans with at least half of local participating doctors in their networks on average cost 8% more than plans with less than a quarter of participating doctors on average.

This can lead to savings for consumers comfortable with a narrower doctor network, but higher costs for enrollees who want access to plans with a broader network. For example, in counties where the two lowest cost plans have narrower networks (up to a quarter of doctors) but one with a broader network is offered (at least half of doctors), it would cost $95 extra per month to enroll in the broader network plan.

The breadth of a plan’s network can be a factor in enrollees’ ability to access care.  A 2023 KFF survey found that one in five consumers enrolled in Marketplace plans said that a provider they needed was not covered by their insurance, more than the share with employer coverage who say so.

Other findings include:

• Marketplace consumers living in large metropolitan areas on average are in networks that include only about a third of local physicians, while those living in rural counties on average are in networks with about half of local physicians. Those differences reflect the smaller pool of providers in many rural areas.
• Even with higher average participation rates, enrollees in rural counties often have relatively few in-network doctors, particularly specialists. For instance, at least 2.5 million enrollees in rural counties have fewer than 10 dermatologists and fewer than 10 gynecologists in their local area.
• Marketplace enrollees on average have in-network access to about half of active OB-GYN physicians (55%) and surgical specialists (53%) in their markets, but a smaller share of primary care doctors (43%) and psychiatrists (37%).
• On average, 27% of active practicing physicians were not in any Marketplace plan networks, with much higher shares in some counties such as Cook County/Chicago in Illinois (60%), Dallas County in Texas (36%), and Lee County/Fort Myers in Florida (41%). Marketplace enrollees who want to see those doctors would not be able to find any plan that includes them in its network.

For consumers, assessing the breadth of Marketplace plans’ networks when choosing a plan can be extremely difficult. In 2021, for example, enrollees on average had a choice of 58 different plans in their county, including variations offered by the same insurer with different provider networks, with no overall way to measure the breadth of each option’s network. In addition, not all providers listed in a plan’s network will be open to taking new patients, further narrowing options for some consumers.

The analysis also examines how much choice consumers have in the breadth of the networks in their county where they live, variations within and across geographic areas, and differences across plan insurers.