There’s a high-profile debate over health care playing out in the presidential race, and a lower-profile one taking place in Congress. Several Democratic presidential candidates are telling us that they are going to provide health care that is free at the point of service to all comers. In little-noticed congressional markups, members of both parties are demonstrating why these promises will not be met.
The legislation under consideration is aimed at so-called surprise medical bills — charges a patient assumes were covered by insurance but turn out not to have been. My family got one last year: The hospital where my wife delivered our son was in our insurer’s network, but an anesthesiologist outside the network assisted. The bill had four digits.
Surprise bills seem to be something of a business model for some companies. A 2017 study showed how bills rose when EmCare Inc. took over hospitals’ emergency rooms, with the percentage of visits incurring out-of-network charges jumping “like a light switch was being flipped on.”
Policy experts from across the political spectrum have devised ways to prevent this sticker shock. Benedic Ippolito and David Hyman have a short paper for the American Enterprise Institute (where I am a fellow) that suggests providers of emergency medicine should have to contract with hospitals, reaching agreement on prices and folding them into the total bill, rather than sending separate bills to patients and their insurers. In incidents where the surprise bill is the result of an emergency involving treatment by an out-of-network hospital (or transportation by an out-of-network ambulance), their solution would be to cap payments at 50% above the level that in-network providers get paid on average. In both cases, prices would be determined by a negotiation among parties that are informed and not in the middle of a medical emergency.
Sen. Lamar Alexander, a Tennessee Republican, has introduced a bill that includes a version of that cap. But provider trade groups favor a different measure introduced by Rep. Raul Ruiz, a Democrat from California, which would create a 60-day arbitration process to determine what insurers should pay out-of-network providers, and instructs arbiters to first consider the 80th percentile of list prices for a service in a given market. It is a generous approach that analysts with the USC-Brookings Schaeffer Initiative for Health Policy conclude “would likely result in large revenue increases for emergency and ancillary services, paid for by commercially-insured patients and taxpayers.” It would therefore mean higher premiums and federal deficits, while Alexander’s alternative has been estimated to reduce both. Ruiz has 52 cosponsors who range from liberal Democrats to conservative Republicans.
Turn from this dispute, for a moment, to the Medicare for All proposal (which has some of the same cosponsors as the Ruiz bill). It envisions sharp cuts in payments to providers — as high as 40%. Those cuts enable advocates to say they will cover the uninsured and provide added coverage to the insured while reducing national health spending.
Is this at all likely? The Alexander bill would try to rein in billing by one subset of providers in cases where the bills are especially unpopular. But the House Energy and Commerce Committee is watering down its surprise-billing legislation, accepting a provider-backed Ruiz amendment to add arbitration. It’s not as generous as Ruiz’s own bill, but its effect would be to keep payments at today’s rates.
The House is following a long line of precedents. For years, bipartisan majorities in Congress voted down planned cuts in provider-payment rates under Medicare; ultimately, they got rid of the planned cuts altogether. Now even modest measures like Alexander’s face determined and effective resistance.
There is, in short, very little appetite for cutting payments to providers. If medical-provider lobbies can force Congress to back off from addressing surprise bills — which are, in the grand scheme of our health care system, a small kink — what are the odds lawmakers will force a much larger group of providers, including the powerful hospitals lobby, to accept the much larger reductions that Medicare for All would have to entail? Maybe the Democratic presidential hopefuls should be asked that question at the next debate, so that we can judge whether Medicare for All is a fantasy or a fraud.
Ramesh Ponnuru is a Bloomberg Opinion columnist. He is a senior editor at National Review, visiting fellow at the American Enterprise Institute and contributor to CBS News.