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Opinion: Health care system needs reform in regard to in- and out-of-network coverage
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Northeast Georgia Medical Center staff members travel through the hospital hallways largely absent of everyone but staff on May 15, 2020. - photo by Scott Rogers

The COVID-19 pandemic illustrates the need for health care reform, specifically around health insurance plans’ discretion on network coverage. The current problem with costs of health care deviate from the specific plan type offered or chosen by the patient consumer. Whether it is Medicare, Medicaid, employer-provided or from the Patient Protection and Affordable Care marketplace, it gives too much power to the carrier or agency to decide where the patient consumer uses that coverage.

Imagine a world where there are no in-network/out-of-network stipulations to health care coverage. 

If there is unlimited patient choice behind the provider of use, then we’d most likely see an increase of preventive care usage as well as a massive decline, if not complete abolition, of out-of-network surprise medical care costs. This in hand would transfer the purchasing power of medications and prescriptions to the carriers, increasing prior authorizations to offset the increase in costs of consumer usage at the contracted copayment and premium rates. 

On the surface, it immediately appears the consumer would be sacrificing medications and services needed for lower overall costs. However, even if there is an increase in prior authorizations, medical providers are not contractually obligated to carriers, and the prior authorizations would diminish as patient consumers seek better coverage options in a free marketplace. For example, patients and providers have the ability to explore lower cost generic medications in turn giving the power of choice back to the patient and the provider. 

How is COVID-19 relevant? It’s simple actually: there is no COVID-19 vaccine. Therefore, under the provision of the Affordable Care Act, insurance carriers dictate whether or not it is accessible and from whom the patient accesses that vaccine at an in-network cost. If there is federal legislation reform to amend the ACA provisions for universal access to the COVID-19 vaccine when it is developed, then why haven’t federal legislators explored eliminating network types (such as Exclusive Provider Organization, EPOs; Health Maintenance Organization, HMOs; Point of Service, POS; Preferred Provider Organization, PPO)? The process to make the COVID-19 vaccine universally free for all Americans has been discussed in the news, as well as by both chambers of Congress, but no elected official has discussed eliminating network types to replace it with protected patient choice of medical provider via Employer, ACA Marketplace, Medicaid/Medicare insurance coverage while eliminating the in-network and out-of-network system in place today. 

If we as a country can transition to telehealth efficiently for in-network providers during the COVID-19 pandemic, then we must transition to universal medical access via patient protected choice of provider without eliminating a single source of coverage. 

The 5th, 9th, and 14th Amendments of the U.S. Constitution illustrate citizens are guaranteed to not be deprived of life, liberty or property while enumerating rights that were absent specific to the creation of our country. Health care coverage is a right. We need congressional leaders and a president who recognize that right.

Brandon Lawson


Regional events