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ARUN RATH, HOST:

November will be a busy month with the midterm elections as well as open enrollment for health care in 2015. Some states are starting to release information about how much health plans on the Affordable Care Act exchanges may cost next year. This week, California announced that on average, its premiums will increase by about 4 percent. And in Florida, the state's largest insurer says its average increase will be almost 18 percent. Lots of variables go into figuring out how much insurance plans will actually cost. One of them is how much doctors are paid. And as Jeff Cohen of member station to WNPR reports, those physician reimbursement rates could have an impact on the quality of care that patients get.

DR. DOUG GERARD: How are you today?

JEFF COHEN, BYLINE: Doug Gerard has a patient in one of his exam rooms complaining of joint pain...

UNIDENTIFIED PATIENT: My ankles, my knees...

COHEN: He checks her out, asks her a few questions about her symptoms...

GERARD: Any one joint more than the others?

COHEN: And then does a few tests...

GERARD: Let's do the labs and see what we have.

UNIDENTIFIED PATIENT: OK.

COHEN: Before sending her on her way. For typical, quick visit like this, Gerard could get reimbursed $100 or more from a private insurer. For the same visit, Medicare pays less - about $80. And now with the new private plans under the Affordable Care Act, Gerard says he would get something in between but closer to the lower Medicare rates. And that's not something he's willing to put up with. So he decided not to accept patients with two of the three insurance plans offered in Connecticut's exchange.

GERARD: I cannot accept a plan that was - the potentially commercial-type reimbursement rates, we're now going to be reimbursed at Medicare rates. You have to maintain a certain mix in private practice between the low reimbursers and the high reimbursers to be able to keep the lights on.

COHEN: Three insurers offered plans in Connecticut in 2014. Gerard is only accepting one. He won't say which, but he will say it pays the highest rate.

GERARD: I don't think most physicians know what they're being reimbursed. Only when they start seeing some of the rates come through or if they have an accountant, somebody who looks at their billing, will they realize how low a rate they agreed to.

COHEN: Gerard's decision to reject two plans is something officials in Connecticut are concerned about. If reimbursement rates to doctors stay low in Obamacare plans, more doctors could reject those plans. And that could mean that people will get access to insurance, but they may not get access to a lot of doctors. That worries Kevin Counihan, who runs Connecticut's health insurance marketplace.

KEVIN COUNIHAN: I think it could lead, potentially, to this kind of distinction that there is these different tiers of quality of care.

COHEN: His agency recently approved rules geared at getting more providers into plans on the exchange. The goal is to make sure that everyone gets good care regardless of their income.

COUNIHAN: And the different tiers of quality of care means, somehow, that people think that, well, just because my income is below 400 percent of the federal poverty level, I'm going to get inadequate care or lesser care than someone making above 400 percent. That's been something, at least in our state, that we're trying to work against. And the carriers are as well.

COHEN: NPR asked all three of the insurers on Connecticut's exchange to comment - two declined, one agreed. Ken Lalime is the CEO of Healthy CT, an insurance co-op. He says insurers face a real challenge figuring out how to pay doctors enough but also keep consumer premiums low.

KEN LALIME: Every time you increase payments to providers you have to offset that with increased reimbursement from the consumer. So there's this balance between what - how much do you want to cost to provide that service? - cost being, OK, and how much you can pass along in your premium rates. So it's a balancing act.

COHEN: Healthy CT may have missed the balance. Barely any consumers bought their insurance in 2014. Lalime says he thinks low reimbursement rates are forcing some doctors to decide against accepting insurance under the Affordable Care Act. Bob Russo is sure of it. He's a radiologist, and he's also the president-elect of the Connecticut State Medical Society. He says that the low rates and administrative burdens that come along with the Affordable Care Act could make it a financial loser.

BOB RUSSO: You know, you get what you pay for. If you can't convince people that they're not losing money doing their job, it's a problem. And they haven't been able to convince people of that.

COHEN: He, like Counihan, worries about creating a tiered health care system. He says, think about Medicaid. Before a recent rise in rates, it paid doctors even less than Medicare, so many stopped accepting Medicaid patients altogether.

RUSSO: There's no question that Medicaid, under its old rates, wasn't working. So have we just invented a new Medicaid that kind of slid the scale up a little bit more to make access a little bit more?

COHEN: The experience of these doctors is a good reminder that the Affordable Care Act is more than a thought exercise in health care. It's happening. And here's another reminder - open enrollment for 2015 begins in just over three months. For NPR News, I'm Jeff Cohen in Hartford.

RATH: This story is part of a reporting partnership between NPR, WNPR and Kaiser Health News.

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