Fulfilling the promise of the No Surprises Act

Ringing in the New Year usually means champagne, confetti, and a ball drop. And, this year, families may have an extra reason to celebrate. At the stroke of midnight 2022, millions of America’s families got relief from surprise medical bills thanks to the No Surprises Act. This bill represents an historic step in the fight to protect people who have been victimized by surprise medical bills by plugging loopholes in our health system that have been exploited by private equity firms, hospitals, and corporate physician groups to collect excessive profits off the backs of Americans unlucky enough to get sick.

But some of those groups are working hard to preserve their profits by neutering the regulations needed to enforce the law’s new protections, which are designed to help patients like Nicki Pogue, from San Francisco, Calif.  

After running a high-altitude race, Nicki’s heart was pounding fast, she was dizzy and having trouble breathing. A friend rushed her to the closest hospital where she received an EKG, chest X-ray and blood tests. Her heart rate thankfully stabilized, and she was discharged from the hospital. But a month later, Nicki received a $13,000 bill. Nicki has health insurance through her employer, but the hospital was out-of-network, so she was on the hook to pay more than $10,000 for the emergency care she received. During her brief hospital stay, no one discussed with her whether the hospital was in or out of network, and Nicki didn’t think to ask — not that she had a choice to leave and go elsewhere. “That’s really not what you’re thinking about when you’re having life-threatening symptoms, like ‘hmm, I wonder which of these hospitals might be in my network.’” 

Think about how broken our health care system is when private equity firms, hospitals, corporate physician groups, laboratory companies, ambulance companies, and many others have made it a key business practice to refuse participation in health insurance networks so they can freely charge whatever they can when a family is experiencing a grave health care crisis. It’s unconscionable, hurts our access to health care, and can destroy families’ economic security.

Because of the bipartisan victory in Congress that made the No Surprises Act federal law, health care providers will now prohibited from charging more than 180 million Americans who are covered by employer plans like Nicki outrageous medical bills due to this exploitative business practice. The law also targets a major driver of overall insurance premiums and out-of-pocket costs for all consumers. Estimates from the Congressional Budget Office found that the No Surprises Act will reduce private health plan premiums and lower the federal deficit by $17 billion over ten years.

Now, those profiting off the backs of patients by using surprise billing as a business tactic have filed lawsuits to skew the rules that will enforce these new consumer protections in ways that preserve their ability continue charging out-of-control prices for medical services. Specifically, they are insisting that the impartial referees who will be called on to settle medical billing disputes between providers and insurers (which simply pass-through payments from large employers who actually pay the bills), consider factors other than the typical price paid to doctors covered by insurance, such as the severity of the patient’s illness or number of other doctors practicing in the area. 

They know what they are doing. The lessons from state-passed surprise billing laws in New Jersey, New York and Texas have made clear that considering prices above the norm will lead to significant increases in the cost of both in-network and out-of-network care as well as higher premiums for consumers and employers. And that’s an important point. If they win, these obscene prices hurt all of us because they are baked into the premiums we all pay.

Fulfilling the promise of the No Surprises Act hinges upon preventing abuse and misuse of the arbitration process to ensure reasonable prices are paid. Period. This protects our economic security and our access to life-saving care. The Biden administration must hold firm against this continued assault by private equity firms and other special interests and keep its promise to protect America’s families from unfair and financially crippling medical bills.

As President and CEO, Elizabeth Mitchell advances PBGH’s strategic focus areas of advanced primary care, functional markets and purchasing value. Mitchell leads PBGH in mobilizing health care purchasers, elevating the role and impact of primary care, and creating functional health care markets to support high-quality affordable care, achieving measurable impacts on outcomes and affordability. Frederick Isasi, J.D., M.P.H., is executive director of Families USA (FUSA), one of the nation’s leading nonpartisan, nonprofit health care advocacy organizations established to ensure that the best health and health care equally accessible and affordable to all.