Opinion Advocates for ideas and draws conclusions based on the author/producer’s interpretation of facts and data.
While the month of January now reminds the world of the fragile state of American democracy, this month also marks the first anniversary of the No Surprises Act, a 2020 law Congress passed that was intended to tackle some of the most egregious failings of American health care. It’s now illegal for emergency providers to bill patients for more than the in-network arrangement under a patient’s health plan in almost all scenarios. Health plans are required to treat out-of-network services as if they were in-network when calculating patient out-of-pocket expenses.
Patients will no longer be surprised to receive a bill as part of their treatment when they head to the emergency room, right? Wrong. Mistakes and harm will likely still happen as a consequence of the complexity of our health care system and the ongoing challenges patients must go through to sort through their medical expenses. Obtaining care remains hard. With groceries and gas costing us more, these bills are only more troubling, resulting in inescapable debt. One in 10 adults owe more than $5,000 for medical or dental care.
If America is serious about protecting its emergency room patients, particularly in the aftermath of the global pandemic, it must patch up this law to ensure patients have more protection against out-of-network expenses when they receive their bill. Outside the emergency room, patients, particularly uninsured patients, remain exposed to wallet-busting prices. America must move toward universal health care.
Despite its shortcomings, the No Surprises Act was the result of many years of advocacy. One in five emergency room visits resulted in a surprise charge. The law now covers all hospitals, doctors, and nearly all health care providers except for ground ambulances; notably, the law bans surprise bills for air ambulances. While rare, this protection is important, as air ambulances are exactly the type of large expenses patients need help to pay. In 2020, a Pennsylvania coronavirus patient received a surprise air ambulance bill of more than $52,000 for a flight between two hospitals that happened while she was unconscious.
Unfortunately, patients may still get hit with a surprise bill, but the chances of it being as egregious are less likely. When they do occur, they speak to a larger issue of our billing mess. One major loophole of the law is that the law may not cover all urgent care centers for emergency care. While many urgent care centers are considered emergency providers, others are not, and that could mean surprise bills, particularly for those living in rural America.
Kaiser Health News also reported a case where a surrogate for pregnancy received emergency care for a premature birth for twins. The babies spent more than a week in the neonatal intensive care unit, but their insurer, Cigna, paid for part of one child’s care but rejected much of the care for both infants. They cited that the care was not necessary because of how the babies received care via the obstetrics department, and not through the emergency department.
The coding of these services and billing caused a mess for Cigna to sort through. Cigna rejected justification paperwork sent by the hospital for the bill to be covered by them. Cigna and the hospital pointed fingers at each other in how to deal with the pending out-of-network and uncovered expense, even as the hospital sent the account to collections to shake down the couple. After more than a year of haggling and appeals, the couple worked with a separate firm dedicated to resolve billing disputes to reduce the $80,000 bill significantly as they dealt with collections, the hospital, and Cigna.
In most cases, people won’t be surprised by a large out-of-network bill in emergency settings. We must protect those who are as the law enters its second year.
Congress should require all physicians to join the same insurance networks as their hospitals, or force health plans to finance emergency care by paying hospitals for their services. This would allow hospitals to compensate physicians for their services on-site. Congress should also leverage average prices set by Medicaid, Medicare, or large private health plans for all non-network care. Medicare Advantage plans, privately managed care plans for many Medicare beneficiaries, already employ this practice for their patients for non-network care.
Congress could also set prices for care, a tall order in our current political environment. This would help nullify high unexpected out-of-network bills. Physician groups and the American Hospital Association object to this reform, however, and given their outsize role in Washington, they had a role in shaping the current law.
To address billing disputes, the law organizes arbitration panels to hold patients harmless while health plans and providers sort through claims issues. This is a roundabout way of protecting patients and skirting price setting while adding to America’s already bloated administrative health care expenditures. The law authorizes $500 million to finance its arbitration and regulatory system. The U.S. Department of Health and Human Services estimates that insurers will invest $5 billion to implement the act, and that operating costs might average $1 billion a year thereafter. Health plans will likely pass down these higher costs to beneficiaries and employers in the form of higher premiums and fewer benefits.
As it stands, this law does very little to protect against unchecked greedy actors exploiting loopholes of American health care. Until recently, a hospital staffing company employed a business model that coded services for patients at higher rates, thereby fleecing patients in which health plans and providers acted as intermediaries.
To be sure, patients willing to slog and wait out billing disputes often get their bills reduced. But with providers in and out of the emergency room still unleashing debt collectors on patients or making threats, they create unnecessary anxiety.
American health care is going to remain a pocketbook and electoral issue in every state. In November 2022, nearly 3 out of every 4 Arizona voters voted to place limits on debt collection, capping the limits of interest on medical debt at 3%. Joining those in Idaho, Missouri, Nebraska, and Utah, voters in South Dakota bypassed their Republican leadership and voted to expand Medicaid to more low-income citizens. Expanding Medicaid enables more low-wage workers to obtain treatment through public insurance, providing assurance that people won’t face high bills if they get sick.
Yes, we must close surprise billing loopholes and educate patients to scrutinize their bills, arming them with the tools to contest bogus bills. That’s vital as we emerge from the worst of the pandemic. However, it says something about a system that asks an unconscious patient to still verify that their ground ambulance ride is in-network prior to seeking treatment.
Until America gathers more steam and transitions toward universal health care, patients will continue to cough up large portions of their paychecks for medical bills. To escape this billing minefield for emergency care, members of Congress must look beyond wealthy donors writing checks and enact reforms to better protect patients from debt-inducing costs. The federal government should play a larger role, too: Medicare is the nation’s largest insurer, and alongside other federal programs, it can better set hospital treatment pricing, ensuring more consistencies and standards of care across regions.
Rather than hold on to remnants of our byzantine system, we must take steps toward enacting universal health care, reducing the eligibility age of Medicare, and expanding it to more kids so more people can take advantage of the government-sponsored health plan.
Yearly, we hear politicians extol the unique problems of high medical bills. They must make good on their promises of making health care an actual right, not an empty slogan for stump speeches at their campaign events.
Vijay Das is a writer, advocate, and senior adviser for Data for Progress. He previously was a health policy fellow in the United States Senate. He often writes on health and economic justice issues.