Health & Spirit

Trump administration: Let states decide if health plans have enough doctors

Michael Ollove, on

Published in Health & Fitness

Several states, some that operate their own insurance exchanges and some that use the federal exchange, have adopted similar rules.

But, according to a Commonwealth Fund study, as of 2014, 23 states and the District of Columbia had not. Instead, they relied on HHS to determine network adequacy.

In shifting responsibilities, the Trump administration is getting rid of the requirement that states use quantitative measures to evaluate network sufficiency.

And that is what concerns many health policy experts. "Because not all states regulate network adequacy in a clear-cut way, we think the federal floor was necessary and is still needed," said Sarah Lueck, a senior health policy analyst at the Center on Budget and Policy Priorities, a liberal think tank.

Some state officials noted that applying the same federal rules to every state created some problems. The Wisconsin Office of the Insurance Commissioner complained to the Obama administration that in one case, it had required an insurance plan to increase its number of providers in an area that turned out to be in the middle of 8,600-acre Lake Butte des Morts.

In another case, it said, HHS failed to appreciate that the Wisconsin River bisected a certain area, which essentially made it impossible for patients on one side of the river to see providers on the other.

"The point is the problem you run into with federal government is that they don't know the state like we do," Wieske said. "When you have a federal system, it's one size fits all ... but often, one size doesn't fit all."

A few states already regulate their own network adequacy -- some quite aggressively, such as California and Washington, which have their own exchanges.

In December, Washington state fined Coordinated Care $1.5 million and ordered it to stop issuing individual health insurance policies in the state because of inadequate networks. The company agreed to a consent order detailing how it would address its network deficiencies. The lawsuit, involving plaintiffs in multiple states, was filed the next month.

Mike Kreidler, the Washington state insurance commissioner, doubts that many states on the federal exchange are ready to effectively regulate network adequacy now.

"Many of those states are not geared up for this," he said. "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."


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