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Surprise billing fight highlights hurdles for bolder health care changes

Disagreements over payments foreshadow difficulty of moving overhaul like ‘Medicare for All’

National Nurses United union members wave "Medicare for All" signs during a rally in front of the Pharmaceutical Research and Manufacturers of America in Washington on April 29. A September poll by the Kaiser Family Foundation found that 30 percent of people consider implementing a national Medicare for All plan a top priority. (Bill Clark/CQ Roll Call file photo) 
National Nurses United union members wave "Medicare for All" signs during a rally in front of the Pharmaceutical Research and Manufacturers of America in Washington on April 29. A September poll by the Kaiser Family Foundation found that 30 percent of people consider implementing a national Medicare for All plan a top priority. (Bill Clark/CQ Roll Call file photo) 

The challenge of passing legislation to stop surprise medical bills is underscoring just how hard it is in Washington to change the health care system, even in small ways, and raising questions about Democrats’ far more ambitious overhaul plans. 

Stopping surprise medical bills wasn’t supposed to be this difficult. Lawmakers in both parties want to protect patients from certain unanticipated out-of-pocket costs, and industry groups say they agree with the broad goal. But fights over payments to doctors and other medical providers that so far have stalled the legislation foreshadow the hurdles of moving a major overhaul, such as a “Medicare for All” government-run health care plan, after the 2020 elections.

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“Dealing with so-called surprise billing should be the low-hanging fruit that Congress should deal with relatively easy,” said Jim Manley, a Democratic strategist and former aide to then-Senate Majority Leader Harry Reid, D-Nev., and the late Sen. Edward M. Kennedy, D-Mass. “The fact that it’s been impossible to get done so far does not bode well for additional efforts to reform the health care system.”

Robert Blendon, a Harvard University professor of public health and health care, said polls suggest that public pressure should have persuaded lawmakers to address narrow health care issues like surprise billing.

A September poll by the Kaiser Family Foundation found that 56 percent of people said protecting people from surprise medical bills should be a top priority for Congress, while 30 percent called implementing a national Medicare for All plan a top priority.

[How ‘Medicare for All’ went from pipe dream to mainstream]

Blendon noted that no one on either side of the aisle opposes the concept of stopping surprise medical bills.

“And yet it’s not happening,” he said.

For Democrats to enact broader health care changes, particularly Medicare for All, a Democratic president would need to be elected alongside many lawmakers who also campaigned on the idea, Blendon said.

Industry’s opposition

The health care industry strongly opposes the potential payment cuts inherent in both the surprise billing legislation and Medicare for All proposals. Hospitals, which typically are in every congressional district and are often a top employer, are a powerful industry in Washington. Already, hospitals and other industry groups are lobbying against Medicare for All as the idea gains momentum in the Democratic presidential primary.

Addressing surprise bills and expanding health care coverage through Medicare for All involve very different goals. The first is a targeted fix to the health care system that has bipartisan support, while the latter would be a politically divisive effort with wide-ranging impacts for health care and the economy. But the biggest challenges to both come from their limits on medical providers’ payments.

Insurers and doctors are on opposite sides of the surprise billing fight. Both say they support protecting patients from high-cost bills for care inadvertently received outside of their insurance networks, but they are sharply divided on how to determine the payment. They are united in their opposition to a public option for consumers to buy into government-run health care or a single-payer system though.

[‘Medicare for All’ keeps defining 2020 political landscape]

Manley, a veteran of the passage of the 2010 health care law, said that securing industry support was crucial to passing that law and that fierce opposition would make it harder to pass a subsequent overhaul.

“We worked hard to try and bring as many stakeholders on board, to try to build the best system we can,” he said. “With Medicare for All, it’s just going to be a free-for-all.”

Loren Adler, associate director of the USC-Brookings Schaeffer Initiative for Health Policy who closely follows the surprise billing debate, said he agreed passing a major health care overhaul would be a challenge, given that lawmakers are struggling to advance the current legislation. Many of the same interest groups that have so far stifled surprise billing legislation would be out in even greater force against Medicare for All or even a public option.

“If Congress can’t get rid of the most obvious provider abuse there is, or one of the most, it seems hard-pressed that they’re going to do a much larger reform that includes a number of things that providers don’t like and that hospitals don’t like,” said Adler.

Taking on the industry

Lawmakers acknowledged that taking on the health care industry is never easy, and that interest groups weigh in whenever their interests are at stake.

Sen. Christopher S. Murphy, D-Conn., who sits on the Senate Health, Education, Labor and Pensions Committee, argues that the panel should instead focus on reversing steps the Trump administration has taken to weaken the health care law rather than the tougher task of taking on the health care industry.

“There are so many people making gobs of money off the status quo,” he said. “Any time you try to change it, there’s going to be huge resistance up here. And even if everybody identifies a common problem, you can’t move the needle on health care without taking money from some incredibly powerful interest group.”

Sen. Tim Kaine, D-Va., who has proposed legislation to add a public option and also sits on the HELP Committee that approved surprise billing legislation earlier this year, agreed that any health legislation is a challenge to move through Congress. But he anticipated that public pushback to the current health care system would fuel potential changes to the health care system under a Democratic Congress.

Consumers “don’t have enough options, so that’s coming,” he said. 

White House hopefuls Sens. Elizabeth Warren, D-Mass., and Bernie Sanders, I-Vt., both of whom support a single-payer plan and sit on the HELP Committee, voted against the surprise billing legislation by proxy, but for different reasons. Sanders is seeking additional funding for community health centers, while a Warren aide said she thought the legislation should strengthen the 2010 health care law.

[Senate Democrats skeptical of Warren’s ‘Medicare for All’ push]

Medicare for All proponents anticipate intense pushback from the industry in part because a single-payer plan would essentially make private health insurance companies obsolete and would mean significant changes for providers. To pass such a plan, a broad base of political support would be needed, said Eagan Kemp, a health care policy advocate for the liberal consumer rights group Public Citizen.

“It can be tough to sort of build a constituency around a more technical or amorphous idea, but Medicare for All has enough policy credentials that people can dig into it, but it also has enough messaging power that people can really engage around it,” Kemp told CQ Roll Call.

Public Citizen released a report earlier this year showing a surge in lobbying against Medicare for All, as congressional committees began holding hearings on the topic and the debate became a defining issue of the 2020 Democratic presidential campaign. The Partnership for America’s Health Care Future, a coalition of health industry trade groups, opposes both single-payer and public option proposals.

Kemp said Congress would likely only consider Medicare for All if there is more funding for advocacy campaigns because, he said, “We’ve just got to have the people on our side.” 

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