Pelosi enters fight over surprise medical bills

Speaker Nancy Pelosi (D-Calif.) is entering a contentious battle over protecting patients from getting “surprise” medical bills, trying to overcome a rift between two Democratic chairmen and allow a bipartisan priority to move forward. 

Pelosi met with House Energy and Commerce Committee Chairman Frank Pallone Jr. (D-N.J.) and House Ways and Means Committee Chairman Richard Neal (D-Mass.) on Wednesday and urged them to figure out a way to bridge the gap between their rival approaches, according to people familiar with the meeting. 

The effort would protect patients from getting bills for thousands of dollars when they go to the emergency room and one of their doctors happens to be outside their insurance network. It is seen as a rare area of possible bipartisan action in Congress and has support from President Trump. 

But the effort has been stalled by a rift between Pallone and Neal, who have put forward rival approaches to the issue, as well as intense lobbying from doctor and hospital groups opposed to the legislation from Pallone’s Energy and Commerce Committee and worried that it will lead to damaging cuts to their payments.

Now, Pelosi is stepping up her involvement to try to get legislation moving. All sides of the debate are closely watching the Speaker for clues as to which approach she favors. 

In the fall, Pelosi told industry representatives that “we are not going to give a handout to big insurance companies” in the surprise billing legislation, according to a person who heard the comment. That was taken as a negative comment about the Energy and Commerce bill, given that it echoes the argument from its critics that the measure favors insurers over doctors.

But more recently, in the meeting with the chairmen last week, Pelosi raised concerns about the role of private equity firms that own doctor-staffing companies in sending surprise bills to patients and said she wants to address that problem in the final legislation, according to a senior Democratic aide. 

That comment appears to be more positive toward the Energy and Commerce legislation, given that the committee has launched an investigation into the role of private equity in surprise billing. The doctor-staffing companies owned by private equity firms have run millions of dollars in ads against the Energy and Commerce bill. 

“The Leadership is meeting with the Chairmen as the committees work to reach consensus on surprise billing legislation that protects patients and holds bad actors accountable,” said Pelosi spokesman Henry Connelly.

All sides say they share the goal that patients should be protected from getting these massive bills, but the fierce dispute centers on how much the insurer should pay the doctor once the patient is taken out of the middle.

The bipartisan proposal from the Energy and Commerce Committee, which is also backed by the Senate Health Committee leaders, would set payments based on the median rate that insurers pay doctors in that geographic area, with the option of arbitration for some high-cost bills.

Doctors groups worry that would lead to cuts to their payments, and they are backing an alternative approach that would give the decision to an outside arbiter to determine the payment. The Ways and Means proposal is expected to more closely follow this approach, though the exact details remain to be seen and some doctor groups are starting to worry it will not go far enough in their direction.

Dr. Mary Dale Peterson, president of the American Society of Anesthesiologists, said in an interview that the approach from Pallone and Senate Health Committee Chairman Lamar Alexander (R-Tenn.) is “essentially pandering to the big insurance companies” by giving them too much leverage to lower doctors’ payment rates. 

She said doctors’ lobbying efforts have had an effect. 

“The authors of the Alexander-Pallone bill thought they were going get it passed this summer,” Peterson said. “Our legislators are listening and that’s why the process has slowed down.”

Doctors and local hospitals are powerful forces in lawmakers’ districts. 

Some doctors groups also argue insurers already got enough wins in the year-end spending deal, when they got billions in tax cuts from ObamaCare’s “Cadillac” tax and health insurance tax repeal. 

Senate Minority Leader Charles Schumer (D-N.Y.) has also raised concerns with Pallone and Alexander’s approach and is favoring the arbitration approach backed by doctors and hospitals.

Senate Majority Leader Mitch McConnell (R-Ky.) is a question mark. If there are still divisions on the issue, McConnell tends to try to avoid votes that would divide Senate Republicans.

Navigating the fight over surprise billing will not be easy for Pelosi, in light of the sharp divides among Democrats and their allies.

Some Democrats are also wary of giving Republicans a victory on health care, a key issue in the coming elections. Sen. Elizabeth Warren (D-Mass.), a leading presidential candidate, for example, voted against the surprise billing measure in committee last year because it did not address Trump’s “sabotage” of ObamaCare.   

But key Democratic allies like the consumer advocacy group Families USA and the AFL-CIO are favoring the Pallone-Alexander approach, which is also backed by the ranking members of their committees, Rep. Greg Walden (R-Ore.) and Sen. Patty Murray (D-Wash.).

The AFL-CIO warned in a “legislative alert” sent to lawmakers last week and obtained by The Hill that the arbitration proposals backed by doctors groups could “inflate physician and private equity profits at the expense of consumers.”

Some health policy experts also back the Pallone-Alexander approach, saying that it saves taxpayers money by removing the undue leverage doctors get to drive their payment rates up by threatening to surprise bill patients. 

“Any fundamental solution to the problem of surprise medical billing will necessarily reduce payments to some doctors,” said Ben Ippolito, a health policy expert at the American Enterprise Institute. “If you eliminate the outside option of surprise billing patients, some doctors will have less leverage.”

The Congressional Progressive Caucus is also becoming more involved in the issue. An aide to a progressive lawmaker said “many progressives are skeptical of private equity and arbitration-style approaches to surprise billing.”

Complicating matters further, the House Education and Labor Committee could also put forward yet another different proposal. A spokesperson for that committee declined to comment. 

“We have to end surprise medical billing,” said a spokesperson for Energy and Commerce Republicans. “It’s simply not fair for patients. If everyone engaging on this issue accepts that premise, then we can solve this problem. Let’s get this done.”