In the new health insurance marketplaces created by the Affordable Care Act, 95 percent of Americans will have at least two insurance companies from which to compare and select plans, according to a Health and Human Services Department analysis.
But that also means 5 percent of Americans — including all residents of New Hampshire and West Virginia — will not have a choice.
Anthem Blue Cross and Blue Shield is the only insurance company participating in New Hampshire's exchange. "The legacy of our company has been to participate aggressively in the state," said Anthem spokesman Chris Dugan.
Anthem covers approximately 80 percent of residents purchasing plans on the state's existing individual market, said Tyler Brannen, a health policy analyst at the New Hampshire Insurance Department. Because of New Hampshire's small population, the financial returns of another insurance company offering competing policies in the state would not be as great as in an urban market.
"Any other carrier would have to weigh the risk," Brannen said.
Anthem is offering 11 plans on the exchange, with monthly premium contributions ranging from $177 to $1,784 before tax subsidies. One big change Anthem is making to its coverage is the number of doctors and hospitals included in its insurance network.
"By partnering with certain providers, we are providing a product that is 25 percent lower than it would be by using a broader network," Dugan said.
There is a downside, though. The shift eliminates 10 of the 26 major hospitals in New Hampshire from the Anthem network for people who currently purchase Anthem insurance on the individual market and will shift to Anthem's ACA exchange market next year, Brannen said.
Dugan was not sure if Anthem would continue to offer plans in the individual market, in addition to its exchange market options. Regardless of what Anthem does, Brannen said, he expects the individual market will phase out.
"To the extent that people may qualify for a subsidy," Brannen said, "I can't think of any reason to purchase products from Anthem outside of the exchange."
Consumers are frustrated and see the changes as a loss, Brannen said, especially because they don't have an alternative to Anthem.
But the use of narrow networks to drive down the cost of health insurance isn't just a function of the Anthem monopoly — it's a nationwide trend. A recent study from the Health Research Institute at PricewaterhouseCoopers found that 69 percent of insurers reported narrow-network contracts.
Next year, some people could have to drive as far as 45 minutes to see an in-network doctor, Brannen said. But that doesn't violate the state's adequacy standards that regulate provider distance in insurance plans, he added.
Raising those standards could be the next task for policymakers, he suggested, as voters enter the exchange and come to terms with the realities of their new coverage.