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Summary

At a time when more Americans—particularly people of color—are enrolled in Medicaid, new Avalere analysis finds that provider networks for primary care and certain specialties in Medicaid are narrower on average than those of commercial plans in certain metropolitan areas, ranging from 63% smaller in Miami to 18% in New York.

Previous Avalere analysis found that, before the COVID-19 pandemic, Black and Hispanic people were more often covered by Medicaid compared to White people (27% and 29%, compared to 11%, respectively). In addition, Black and Hispanic people have been disproportionately impacted by pandemic-related job losses, driving larger reductions in coverage in employer-sponsored insurance for these individuals (a 13% decrease in the number of both Black and Hispanic people with employer coverage compared to a 6% decrease for White people).

Access to care in Medicaid may differ from access in employer coverage. For example, there are typically differences in formularies, cost sharing, and provider networks. With more people shifting into Medicaid due to job losses during the pandemic, their provider choices could become more limited than they were in their commercial insurance.

Comparison of Medicaid Networks in Metropolitan Areas

Avalere compared Medicaid networks to commercial insurance plan networks for key provider types—primary care, behavioral health, cardiology, and oncology—in select large metropolitan areas to understand potential differences in access. Specifically, Avalere analyzed the average number of each type of provider included in commercial and Medicaid networks in each area. Avalere then calculated the size of the average Medicaid network in each area as a percentage of the average commercial network.

As shown in Figure 1, the analysis finds that Medicaid networks in these urban areas included fewer providers than the average off-exchange commercial plan network—ranging from 63% fewer in Miami to 18% fewer in New York.

Across nearly all provider types and cities included in the analysis, Medicaid networks were significantly narrower:

  • Primary Care: Medicaid networks had 72% fewer primary care providers in Miami and 40% fewer in New York.
  • Oncology: Medicaid networks had 72% fewer oncologists in Miami and 40% fewer in New York.
  • Cardiology: Medicaid networks had 65% fewer cardiologists in Houston and 17% fewer in New York.
  • Behavioral Health: Medicaid networks had 77% fewer behavioral health providers in Chicago and 12% more in New York.
Figure 1. Average Number of Providers in Network by Metropolitan Area, Medicaid as a Percentage of Commercial, 2018
Figure 1. Average Number of Providers in Network by Metropolitan Area, Medicaid as a Percentage of Commercial, 2018

*Reflects average across provider types (i.e., primary care, oncology, cardiology, and behavioral health). Medicaid network average as percentage of commercial network average weighted equally for each provider type.

“Prior to the pandemic, Medicaid beneficiaries had access to fewer providers than people in commercial plans,” said Natascha Dixon Edelin, Associate Principal at Avalere. “While Medicaid coverage encompasses a relatively small portion of the overall population compared to commercial coverage, shifts in pandemic-related unemployment will likely result in increased Medicaid enrollment, compounding the number of individuals trying to access providers who take Medicaid.”

Before the pandemic, people of color were disproportionately represented in Medicaid enrollment in the states where the metropolitan areas included in this network analysis are located (Figure 2). While the distribution of Medicaid enrollment at the city level may differ from the distribution at the state level, these data suggest that the Medicaid beneficiaries in the cities analyzed above are likely disproportionately people of color. As a result, people of color may more frequently face challenges related to limited provider choice due to Medicaid network breadth than White people in these areas.

Figure 2. Distribution of Medicaid Enrollment by Race and Ethnicity by State, 2019
Figure 2. Distribution of Medicaid Enrollment by Race and Ethnicity by State, 2019

Potential Implications for Patient Access

Having fewer providers in network does not necessarily mean that people with Medicaid ultimately cannot access necessary care. In addition, the composition of provider networks is also 1 way health plans keep costs low for states, helping them afford Medicaid coverage for people in their state. However, fewer choices could mean that enrollees may have to travel farther (despite state-set time and distance standards) or wait longer to see a provider, which can have implications for receiving timely care, particularly for non-urgent services like preventive care.

Further, as the pandemic continues, many states are experiencing budget challenges that could have implications for their ability to provide support as more people transition into the program. “As more Americans, especially people of color, move into Medicaid, they are likely to face differences in the providers that are in network,” said Kelly Brantley, Practice Director at Avalere. “As a result, patients may experience disruptions in their care as they identify new providers.”

The Biden administration has signaled its interest in reviewing current Medicaid policies to identify those that may be limiting access. In addition, President Biden has convened a COVID-19 Health Equity Task Force that will address health inequities through recommendations on COVID-19 response and recovery, including equitable resource allocation, outreach to minority populations, data collection, and long-term planning. As the administration seeks to identify policy changes that could mitigate racial disparities in healthcare, policymakers may revisit the impact of Medicaid networks on access to care.

These disparities in networks are likely to occur for other specialists and in other cities, potentially shifting patterns of care in a broader manner than what these data show. As federal and state governments consider the policies that influence these networks, stakeholders should understand both the guiding policies as well as the levers involved in shaping the future landscape.

Methodology

Avalere used 2018 network data from Strenuus to identify providers within the counties in each metropolitan statistical area (MSA), restricted to those in the state of the MSA’s principal city, and identified those with a specialty within 1 of the 4 specialty groups analyzed. Avalere then averaged the number of providers across all networks operating in the state by line of business (i.e., Medicaid and other commercial), excluding those with fewer than 10 providers in a specialty group. Avalere then compared the average number of providers in Medicaid networks to those in other commercial coverage (which includes both group and off-exchange individual coverage).

To estimate the share of non-dual individuals of each racial and ethnic group enrolled in Medicaid in each state, Avalere used the 2019 American Community Survey. Avalere excluded individuals enrolled in Medicare during the year and categorized individuals into the following groups: White, non-Hispanic; Black, non-Hispanic; Asian-Pacific Islander, non-Hispanic; American Indian-Alaska Native, non-Hispanic; multiple races, non-Hispanic; and Hispanic of any race.

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