Health care reform must be next push
Congress agreed to ban the practice of out-of-network doctors and hospitals dropping huge bills on unsuspecting patients, finally protecting Americans from predatory medical billing.
With a lot of hard work, this could be the beginning of even more health care reform.
Lawmakers used the new pandemic relief bill to end balance billing, a devious practice where a doctor or hospital outside of a patient’s network sends a bill for what the insurance company will not pay. For example, patients visiting the emergency room, on average, get hit with $600 bill because so many ER doctors do not accept insurance, according to the Journal
of the American Medical Association.
Private equity firms that back private hospitals and doctors’ practices have made balance billing part their business plans. Firms that provide emergency physicians are notorious for intentionally staying out of insurance networks so they can charge outrageous rates. Anesthesiologists, radiologists and other doctors whom patients rarely get to choose also stay out of network to charge more.
In the most heinous instances, doctors wander into a surgery in progress, help for a few minutes, and then send a huge bill to a patient they had never met. The patient is powerless to reject the charge.
The problem is the gap between the rates insurance companies want to pay and what doctors want to charge. When an insurance company righ
teously limits how much it will pay an out-of-network provider, the patient gets a surprise bill for the unpaid balance.
Patient horror stories are legion and well documented by my colleague Jenny Deam, who has investigated this issue for years. While some states, including Texas, have tried to address balance billing, lobbyists for doctors, hospitals and insurance companies have blocked national legislation.
Until now.
Beginning in 2022, when health care providers and insurance companies cannot agree on a fee for a service, they will have to meet with an arbitrator, not harass the patient.
The independent arbitrator will consider the median innetwork provider rate for the region, consider any special circumstances and whether the provider has made a good-faith effort to join the insurer’s network. The arbitrator will determine a fair fee the insurer will have to pay.
Congress did leave one glaring loophole: ground ambulances. Most are not part of any insurance network and charge big bills, Deam found in a recent investigation. The Texas Legislature, though, could fix that problem when it meets in 2021.
Of course, ambulances are among the least of the health care issues that Americans need addressed. Progress on balance billing, though, could signal the time is ripe for compromise.
Neither side has won on the political battlefield. President Donald Trump failed to replace Obamacare during his tenure, and President-elect Joe Biden’s wants universal health care but faces stiff opposition. But there is plenty of middle ground for fiscal conservatives and social activists.
As a share of gross domestic product, the United States spends twice as much on health care as other rich countries, suggesting we are wasting a lot of money. Those other countries also manage to cover everyone,
while 43 percent of Americans have inadequate coverage, according to the Commonwealth Fund, a global health nonprofit.
For years, GOP leaders have failed to offer a detailed plan rooted in the private sector that controls costs and increases access through competition. But conservative recommendations from groups like the Heritage Foundation have merit.
For example, Democrats could allow everyone to set up health savings accounts, not just those with high deductible plans. They could also allow small businesses to form associations to negotiate better rates.
Liberals also have some good ideas. Republican leaders should embrace Obamacare’s expansion of Medicaid to help the working poor earn their way to a higher standard of living. Paying for primary care is cheaper than reimbursing hospital emergency departments for unpaid, bloated bills.
Both parties can give people greater control over their health
spending. Forcing doctors and hospitals to publicize their fees and pulling back the curtain on pharmaceutical pricing would give us the information needed to make wiser decisions.
The problem is the health care industry has more power in Washington than voters. The surprise billing legislation took years because insurance companies and providers fought over which arbitration system would give them a financial advantage.
The pandemic, though, created an opportunity for members of Congress to compromise on a deal that left both sides halfhappy.
Americans need to remind our politicians this is what we pay them to do, and we want to see more of the same in 2021. There are solutions to these problems, if we work together.