Children Insured under Affordable Care Act May Lack Access to Pediatric Specialists

The Patient Protection and Affordable Care Act (ACA) was created to provide access to comprehensive and affordable healthcare, but concerns have been raised about patient access to in-network providers, particularly specialists.  

In a paper published online today in Pediatrics, Charlene A. Wong, MD, MSHP, Kristin Kan, MD, MPH, MSc, and colleagues collected and analyzed data from the ACA silver-level health insurance plans and found that pediatric specialists are not well-represented in “narrow” networks – those with no or limited numbers of physicians from a given geographic area. In addition, the proportion of insurance networks including no specialists was significantly higher for all pediatric specialties than for adult specialties (excluding nephrology). Specialties where they found more narrow networks for pediatric providers included pediatric cardiologists. hematologists/oncologists, infectious disease, endocrinologists, nephrologists, neurologists and psychiatrists. 

Wong, an assistant professor of pediatrics and member of the Duke-Margolis Center for Health Policy, said, “Even before the ACA was adopted, narrow networks were being used as a way to control healthcare costs. We didn’t know to what extent the increase in narrow networks might affect pediatric healthcare access compared to adult healthcare access until we analyzed the data. Our hope is that these results catalyze a policy discussion around network adequacy standards.”

Children, particularly those with chronic medical conditions or developmental concerns, need to have access to pediatric specialists through the health insurance marketplace.  While they may be able to see a specialist close to home, families may face considerable out-of-pocket costs if that provider is not included in their plan’s network.

The authors believe that children's access to healthcare should be included in broader health policy discussions moving forward. “The availability of pediatric providers in any network, whether it be employer-sponsored insurance, a public insurance program, or the next generation of individual marketplaces under the Trump administration, is critical to ensuring high quality healthcare for our country's children and youth,” said Wong.   

Wong conducted this research as an Adolescent Medicine fellow at the Children’s Hospital of Philadelphia and a Senior Fellow at the Leonard Davis Institute of Health Economics at the University of Pennsylvania.

The study was supported by a grant from the Robert Wood Johnson Foundation.

Wong CA, Kan K, Cidav Z, et al. Pediatric and Adult Physician Networks in Affordable Care Act Marketplace Plans. Pediatrics. 2017;139(4):e20163117.