All the ingredients were there to pass a much-needed federal package of reforms to protect patients from "surprise medical bills" — those unexpected and often shockingly high charges from seeing an out-of-network physician at an in-network hospital or clinic.
Earlier this year, President Donald Trump called for action to end this practice, which can leave even insured patients on the hook for thousands of dollars. Two of the Senate's most able dealmakers, the bipartisan duo of Patty Murray, D-Wash., and Lamar Alexander, R-Tenn., also put a priority on crafting legislation that could appeal to both political parties. A few weeks ago, it looked as if their solutions had serious momentum in Congress.
And then the health care industry's powerful lobbyists went to work. The result: Surprise-billing fixes didn't make it into end-of-year legislation. At best, Congress punted this important consumer protection measure to 2020. A more cynical take is that reforms are on ice indefinitely after the backlash from wealthy special interests spooked political leaders. Both political parties failed to stand up for patients, a reprehensible reality that requires rapid remedy and illustrates just how difficult it is to enact any kind of health care reform.
The Washington Post reported that Democratic Minority Leader Sen. Chuck Schumer worked "behind the scenes to raise objections to the package" and that he was "acting on behalf of powerful New York hospital groups, who have donated at least $1 million this year to the Senate Democratic fundraising arm." There was also little interest in bringing it to the Senate floor from Republican Senate Majority Leader Mitch McConnell, R-Ky.
Consumers ought to keep this cowardice in mind as the 2020 election looms. Congress had a chance to protect consumers from having to pay large sums unexpectedly out of pocket after a hospital stay or an emergency room visit. But lawmakers decided that keeping the cash flowing to those that profit most from surprise billing — namely, large physician and emergency room staffing companies owned by large private-equity firms — was more important. Out-of-network billing has proved to be a lucrative niche in the health care industry, which is why it attracted Wall Street's interest.
A look at the data makes legislative inaction even more galling. Surprise medical bills are common. A new Peterson-Kaiser Family Foundation (KFF) policy brief found that "18% of emergency visits and 16% of inpatient admissions at in-network hospitals resulted in at least one out-of-network bill." Insurers typically pay a smaller percentage for out-of-network care, often leaving patients on the hook to pay the remainder.
Those likeliest to wind up with higher-than-expected charges are those with serious medical conditions. Failing to put protections in place means many patients will have to pay substantial sums out of pocket at a time when they're grappling with the physical, emotional and financial strains that accompany illness. Roughly one in five of those who have surgery or seek care for mental illness will get a surprise out-of-network bill, according to the Peterson-KFF brief. One in 10 families with a newborn will as well.
Some states, such as New York, have taken action to limit patients' exposure to surprise bills. Congressional action to establish nationwide protection is preferable. One key reason: Many people get their health insurance through their jobs. Many large-employer plans are regulated at the federal level, not the state level.
Surprise-billing solutions generally involve limiting the amount that out-of-network providers can charge, and then finding a way to get the additional amount covered by insurance. This is a doable improvement that would help make health care more affordable for many Americans. Congressional leaders need to find their spines, put patients first and enact a fix.
