clock menu more-arrow no yes mobile

Filed under:

Exclusive: the new bipartisan House bill to stop surprise medical bills, explained

The bipartisan push to end surprise medical bills is ramping up.

Dylan Scott covers health care for Vox. He has reported on health policy for more than 10 years, writing for Governing magazine, Talking Points Memo and STAT before joining Vox in 2017.

Congress is ramping up its push to stop surprise medical bills.

Reps. Frank Pallone (D-NJ) and Greg Walden (R-OR), the top Democrat and Republican on the House Energy and Commerce Committee, have jointly released a draft bill that would prevent patients from facing unexpected charges after they go to the emergency room or receive other non-emergency medical care.

The draft legislation, shared exclusively with Vox, is the most robust proposal yet as lawmakers from both parties and President Donald Trump say they want to end surprise billing. The plan would prohibit surprise charges not only for emergency care when a patient ends up at a hospital that is out of their insurance plan’s network, but also for non-emergency care when the facility might be in network but certain providers are not.

“The Energy and Commerce draft is the strongest proposal at the federal level to date,” Loren Adler, the associate director of the USC-Brookings Schaeffer Initiative for Health Policy, told me. “It clearly eliminates the problem of surprise billing in both emergency and non-emergency situations.”

Pallone has a powerful perch as the chair of his committee and, importantly, has the cooperation of Walden, the top Republican on the panel. The pair intend to move the bill through the committee and send it to the House floor.

“We must ensure that patients are not responsible for these outrageous bills, which is why our discussion draft removes patients from the middle,” Pallone and Walden said in a joint statement to Vox. “We look forward to receiving constructive feedback on ways to build upon our proposal, so we can advance a bipartisan solution that protects patients from costly surprise medical bills.”

The Senate has working on its own legislation for a while; Trump held an event last week urging Congress to pass a bill to stop surprise medical billing. This is a problem that, after the reporting of Sarah Kliff for Vox and other journalists on the egregious bills that Americans sometimes face when they end up in the emergency room, policymakers want to solve.

The House’s plan to end surprise medical bills, explained

The problem here is simple: Sometimes patients go to the emergency room and end up getting unexpected charges because the hospital itself or some of the doctors who treated them do not have contracts with the patient’s health insurer.

The Pallone and Walden bill takes a multi-pronged approach to ending surprise medical bills:

  • Health insurers would be required to treat out-of-network emergency care as in network for their enrollee’s cost-sharing and out-of-pocket obligations. So patients wouldn’t have to pay any more for receiving emergency treatment at an out-of-network hospital than they would at an in-network one.
  • Balance billing — when a health care provider sends a patient a bill charging them whatever the difference is between the price set for a service by the provider and the price the health insurer is willing to pay — would be prohibited.
  • Insurers would have to make a minimum payment to out-of-network providers for their enrollee’s care, based on the price the insurer pays to nearby in-network providers. (Some states have their own laws for setting those payments, however, and they would not be overridden by the federal law.)

One dividing line between the various bills has been on that latter point — what price does an insurer have to pay an out-of-network provider in lieu of surprise balance billing? Some plans have featured arbitration, which would require an insurer and provider to negotiate a price. That approach is favored by emergency room doctors but has been opposed by the White House, and the House bill opts instead to use a local market price.

We also typically think of surprise bills for emergency care — you get hit by a bus and get taken to a hospital you didn’t choose to go to and then face $30,000 bill for your troubles — but the House bill also tries to prevent surprise bills for scheduled care.

It stipulates that patients must receive both written and oral notice about whether their providers will be in or out of network and what charges they must face. If they do not sign a consent form after that notice, they can not be balance-billed. The legislation also prohibits balance billing from providers that a patient could not reasonably be expected to choose themselves, like anesthesiologists, radiologists, and pathologists.

The bill isn’t flawless in the eyes of experts who want to fix surprise billing. Like the other bills in Congress, it does not prohibit surprise billing for ground or air ambulances. (Here’s the story of one family that faced a $40,000 charge for their son’s air ambulance.) Pallone and Walden are aware of that gap and have asked stakeholders for input on how they could address surprise ambulance bills in future iterations of their legislation.

Even so, this is the most robust and foolproof plan introduced in Congress yet to stop surprise billing.

Lawmakers seem serious about fixing surprise medical bills

The safest bet is always against health care legislation passing Congress, especially in a time of divided government. But surprise medical bills might be the exception.

The Senate had already taken up the cause of surprise bills — Sens. Bill Cassidy (R-LA) and Maggie Hassan (D-NH) have been leading a group dedicated to the issue, while health committee chair Lamar Alexandar (R-TN) has also indicated his interest in tackling the issue — and it can only help that President Trump is on board.

Now we have another strong bipartisan plan for the pile, which should add to the momentum to fix the problem this year. Lawmakers still have issues to figure out; right now, it looks like the Senate is at odds with the House on the arbitration question. But their intent seems genuine.

Surprise bills are really only a symptom of the underlying disease plaguing American health care — exorbitantly high and irrationally set prices — but they are a particularly egregious example, as they can leave even patients who have insurance with medical bills that total tens of thousands of dollars. Vox’s Sarah Kliff summarized her findings after collecting ER bills for a year like this:

Patients find themselves in a vulnerable position during these encounters with the health care system. The result is often high — and unpredictable — bills. Hospitals are not transparent about the cost of their services, their prices vary wildly from one ER to another, and it’s hard to tell which doctors are covered by insurance (even if the hospital itself is covered). In many cases, patients can’t be certain what they owe until they receive a bill in the mail, sometimes weeks or months later.

States like California and New York have acted on their own to crack down on surprise bills, but Congress looks insistent on taking action nationwide. The Pallone/Walden bill yet is the most hopeful sign yet that the days of patients ending up in the emergency room with not only a broken arm but also a huge bill might be numbered.