Doctor's Orders.

AuthorBlock, Daniel
PositionSurprise billing


On a warm spring day in 2019, Sonji Wilkes appeared before a House Energy and Commerce subcommittee to explain how an unexpected medical bill had upended her life. Soon after her son was born, doctors discovered that he had hemophilia. He was taken to the neonatal intensive care unit (NICU) after he wouldn't stop bleeding. The hospital was unfamiliar with his condition and lacked the drugs it needed to get his blood to clot. It called in an outside hematologist, who brought medication to staunch the flow. After pumping drugs through an IV line in the newborn's scalp, the bleeding stopped.

Wilkes spent the following few weeks processing the diagnosis. "It's quite a shock to find out that your almost-10-pound, healthy-looking baby boy has a lifelong disorder," she said. But a few weeks later, she received a second shock: a $50,000 bill for his treatment--not from the outside hematologist, but from the hospital NICU.

"My husband and I were dumbfounded," Wilkes told Congress. "We had been in an in-network facility. How could we possibly be responsible for that amount?" As it turned out, the hospital had contracted its NICU out to a physicians' group that didn't accept their insurance. Indeed, the group accepted no company's insurance. They were rogue.

The family refused to pay. They had been careful to pick a hospital that took their insurance. They had checked to make sure that their specific doctor took it as well. "We felt we had made a good-faith effort to stay in network," Wilkes, now 44, said.

It didn't matter. Their insurer refused to cover the cost, and the physicians refused to knock it down. The doctors' group went to collection. Wilkes's credit tumbled. Years later, after a class-action lawsuit, her bill was dismissed. But it was too late for her score to recover, and it has caused her financial headaches ever since. "My family incurred a devastating surprise bill," she told the subcommittee. "Failing to pass meaningful legislation means you are letting millions more families experience the fear and pain my family faced. Please get this done."

Surprise medical bills occur when insured individuals, like Wilkes and her son, are treated by out-of-network health care providers whom they cannot choose. This can happen in a wide range of situations, from emergency room procedures to biopsy reports. At least two Americans who returned recently from China, developed coughs, and were then required to get coronavirus tests received surprise bills topping $1,000. (The government has since passed legislation making coronavirus tests free.)

Considered obviously unfair, the practice is opposed by both parties in Congress. After Wilkes finished her opening remarks, every congressperson in attendance expressed sympathy. They told her that surprise billing was a problem they wanted to solve. Wilkes found testifying empowering. "I left feeling quite optimistic," she told me. "I remember sitting there and thinking, 'Wow, the system really works.'"

At the time, her positivity was well founded. When Wilkes spoke before Congress, Democratic and Republican members of the House Energy and Commerce Committee were working together to craft legislation that would stamp out surprise billing. On the Senate side, members of the Health, Education, Labor, and Pensions (HELP) Committee were drafting a similar bipartisan solution.

The two committees soon reconciled their legislation. The subsequent agreement would have fixed the amount doctors could charge for surprise bills, subject to appeal, and required that insurers cover the resulting costs. Within each commit tee, this approach commanded near-unanimous support. "I do not think it is possible to write a bill that has broader agreement than this," said Lamar Alexander, the Republican chairman of the Senate HELP Committee. Frank Pallone, his Democratic counterpart in the House, agreed. "I'm hopeful that this bipartisan, bicameral agreement can be voted on quickly."

The committees announced the deal on December 8. The insurance industry endorsed it. So did consumer advocates. The White House quickly signaled support and pushed for its inclusion in a must-pass December 20 spending package. Activists held their breaths. In an era of extreme polarization, where health care is a leading political issue, the government was on the verge of passing an important medical reform.

But over the next 48 hours, hospitals and doctors' groups came out against the proposal. The American Medical Association criticized the agreement. The American Hospital Association wrote that it would "jeopardize patient access to hospital care." In the Senate, Minority Leader Chuck Schumer reportedly signaled that he was uncomfortable pushing forward with the fix. Three days after the deal was released, Richard Neal and Kevin Brady, the top Democrat and Republican on the powerful House Ways and Means Committee, put out their own surprise billing proposal. It was a single page of bullet points that contradicted what Alexander and Pallone had set forth. It was a classic legislative maneuver designed to derail progress.

It succeeded. Congress did nothing. The December 20 deadline came and went.

The failure prompted broad outcry. "It's a plague on both our houses," said Zach Cooper, a professor of health policy and economics at Yale. He denounced Washington's inability to act despite "bipartisan agreement and support from the president." In an editorial, USA Today blasted a feckless Congress for leaving "the surprise medical bill plague untreated."

To keep hope alive, in the December 2019 legislative package congressional leadership deliberately extended spending on certain health care programs for just five months. This will force Congress to pass another health care bill in late May. Activists hope it will serve as a vehicle for fixing America's most openly grotesque health care flaw.

The stakes are high in this fight not only because surprise bills are so unjust, but also because it engages the most important long-term issue in health care: rising and unsustainable costs. Nearly 18 percent of U.S. GDP goes to health care today, up from less than 5 percent in i960. Since 2009, average premiums have increased more than twice as fast as wages. Deductibles have nearly doubled. Health care spending per person in the United States is now roughly twice that of other wealthy nations, with no appreciable differences in outcomes. The main reason for those higher costs is, quite simply, that Americans pay higher prices, for everything from knee...

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