This issue began to emerge back in May when Covered California announced its low premiums to some fanfare -- a "home run" for the state, officials said at the time.
But some critics seized on news that participating insurers had achieved those lower costs, in part, by relying on narrow networks that excluded UCLA Medical Center and Cedars-Sinai Medical Center -- two of the state's most prominent, if expensive, hospitals.
Similar stories followed in other states, as exchanges released their rates and participating health care providers.
"We knew it was going to be narrow," one Missouri insurance broker told Kaiser Health News after one local briefing. But the actual list of participating hospitals "was kind of eye-opening."
The issue plays directly to one of the biggest fears sparked by the Affordable Care Act: The law will limit patient choice. But supporters say that's not the case.
"Narrow networks may seem like a bad idea," David Dranove and Craig Garthwaite blogged last month. The two Northwestern University professors acknowledged that excluding some providers from health plans offered through the exchanges runs the risk of disrupting care patterns.
But the model is "not some cruel attempt to limit patient choice foisted upon us by the insurance industry," the professors added. "Instead, these plans may provide our best opportunity for harnessing market forces to lower prices."
The simple equation: Insurers say that limiting the size of the network allows them to steer patients to high-quality facilities and doctors; participating providers, meanwhile, may agree to price cuts in exchange for new volumes.
And narrow networks aren't necessarily a new idea, Darius Tahir points out at National Journal. In some ways, it's the same concept behind payers' attempts in the 1980s and 1990s to limit their network size, which met with criticism and helped create "Any Willing Provider" laws.
Could narrow networks be better perceived -- and received -- with better phrasing? Industry consultant Vince Kuraitis thinks so.
"The very term 'narrow network' creates a negative connotation and doesn't speak to potential benefits," Kuraitis comments at The Health Care Blog. But choosing to describe "the same networks as 'high-performance networks' or 'intelligent networks'... [t]he connotations here are much more positive."
Do Providers Want In? It's Complicated.
Some hospitals -- initially left out of exchange plans -- are fighting to be included.
- Seattle Children's Hospital sued the state insurance commissioner, which helped begin a battlewith a local insurer over whether the facility's rates are too high.
- Eleven Kentucky hospitals have filed complaints; so far, the department has ordered Anthem to accept applications from three of those hospitals.
Yet many top facilities are choosing to opt out of exchange plans.
And some doctors are sitting out, too, citing low reimbursement.
Presented with contracts that paid up to 30 percent less than traditional rates, "we said, this doesn't make a whole lot of sense for us," Richard Thorp, president of the California Medical Association told the Wall Street Journal.
Why? In part, prominent providers' doubts echo the concerns of Aetna, Cigna and other insurers that pulled out of the exchanges: The startup uncertainty and potential patient population aren't worth the risk in year one.
But hospital executives also are fearful that agreeing to price concessions to play on the exchanges will hamper their efforts to bargain in the future.
"[O]nce you've agreed to low rates for one company, how do you ever negotiate for more with that company or any other company?" Michael Green, CEO of Concord Hospital, wrote in an op-ed explaining why his hospital wouldn't participate in New Hampshire's exchange.
"If the insurers decide to move small groups along with individual to the exchange, you could find that you've put your organization in financial peril," Green wrote.
Every indication is that the narrow network model will become the standard.
"I don't think there is anything about this trend that is limited to the exchange market," Sara Rosenbaum, a health policy professor at George Washington University, told Modern Healthcare.
But in the meantime, the provider fights -- and still-troubled websites -- mean that there's considerable confusion over which doctors and hospitals will be included in which plans next year.
On Covered California's website, the FAQ encourages consumers to check directories available on the site to see if their doctor is listed. But one practical challenge: That provider directory has been glitchy. Another: Providers may end up negotiating "right up to the Jan. 1, 2014 starting date," Phil Daigle of California Health Benefit Advisers writes.
Meanwhile, the dust-up over Covered California's hospitals is a sign of how quickly things can change -- and perhaps the lingering resistance to narrow networks, too.
After this summer's fuss, officials eventually ensured that Cedars-Sinai is now available through a few plans on the state's exchange. And so is UCLA, which announced the news with a banner ad: "Covered California now offers a choice U know."