By Margot Sanger-Katz

New York Times

When Obamacare was developed, one goal was to allow middle-class Americans to use the new marketplaces to buy the same kind of health insurance they had at their jobs. People could retire early, or quit a corporate job and become a freelancer, and still have the great care and financial protection that come with high-end plans.

But six years into the health law, the reality is that a typical Obamacare plan looks more like Medicaid, only with a high deductible. The typical marketplace plan covers a small number of low-cost doctors and hospitals, and offers fewer frills than employer plans. The recent high-profile exits of many of the national insurers from markets around the country will only heighten the shift.

That change in norms may not be all bad. It largely reflects the preferences of Obamacare’s consumers, who are shopping aggressively for the most affordable health insurance they can find. But it is different from how the law’s marketplaces were imagined and described when the legislation was written.

The bill said that benefits should be similar to those from employer plans. The law was supposed to help people like middle-class professionals hoping for a change. President Barack Obama infamously promised: “If you like your doctor, you will be able to keep your doctor. Period.” As networks of doctors narrow, that is getting tough for some shoppers.

When the first Obamacare plans were released for 2014, many experts and customers were surprised at how many featured very limited numbers of doctors and hospitals.

Three years later, and the trend has only intensified. Many of the companies providing employer-based coverage, like UnitedHealth Group, Aetna and Humana, which tended to offer broad networks, have been exiting the markets.

Although the local Blue Cross plans largely remain, many are sharply narrowing the networks offered by their exchange plans. The other insurers are either local plans that are often tied to a particular health system or a company that specializes in Medicaid patients. Unlike many employer plans, these policies often do not allow people to go out of network for care if they want the visit to be covered.

According to analyses by two consulting firms — Avalere Health and McKinsey — the number of plans that offer a wide choice of doctors and hospitals is on a steady decline. Two-thirds of plans were health maintenance organization plans that offer care from only a limited choice of doctors and hospitals this year, according to an analysis from McKinsey’s Center for U.S. Health System Reform.

And even plans that offer out-of-network benefits were limiting the doctors who would be covered as in-network. “With recent carrier exits, this trend is only growing,” said Erica Coe, a McKinsey partner.

Those changes have been a shock to many middle-class professionals who thought the Obamacare marketplace would match their previous experience from the corporate world.

When Chris Foley, 42, left his career in finance to begin one in stand-up comedy and acting, he assumed his health insurance would look like the coverage he’d received while working for big banks.

The transition was a challenge. First, he bought a plan through a New York state program before Obamacare that had skimpier coverage and bigger deductibles than his corporate plan. Then, when he signed up for his first Obamacare plan in 2014, he found that his doctor of 15 years wasn’t covered by any of the options. He needed a colonoscopy last year, and had a hard time finding a doctor who was covered. He was surprised when he was asked to pay $450 out of pocket for a prescription drug at the pharmacy.

“I was frustrated; I was pretty angry about not having good coverage,” said Foley, who said he briefly considered a return to the corporate world. But over time, he said, he made peace with his skimpier insurance. His premiums were affordable. “I was covered for any kind of disaster or hospital visit or anything like that, and that’s very important,” he said.

Insurers say they are shrinking the benefits in response to market pressures.

“What’s driving it is the demand from consumers who are paying directly for these plans,” said Jon Kingsdale, who teaches at the Boston University School of Public Health and is a managing director at the Wakely Consulting Group. “When they compete on the exchange head to head with broader-network, higher-premium plans, the narrow-network, lower-premium plans are winning.”

Whether the narrower plans that are dominating the Obamacare exchanges are ultimately good or bad for patients’ health is not clear. Many of these plans are new, and there’s not much evidence about whether they do a good job of caring for patients while avoiding high-cost providers, or simply cover so few doctors, particularly specialists, that patients struggle to get necessary care.

One recent study, of a narrow network plan in Massachusetts, found that patients who chose it over a more traditional employer plan spent less on health care and were no worse off. There are also longstanding narrow HMO plans, like Kaiser Permanente and the Group Health Cooperative, that have good reputations and happy customers. But those results may not apply broadly.

Recent surveys from the Kaiser Family Foundation and the Commonwealth Fund, two health research groups, found that large majorities of customers liked the cheaper plans they bought.

Many of those customers are not like Foley. They didn’t have insurance before. Or their previous coverage, and expectations, were based on their experience with Medicaid.

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