Health care in the United States is expensive and, for many, unaffordable, conditions which drive unacceptable health outcomes and burden household and state budgets. This is true for patients across the spectrum, with even insured patients experiencing difficulty. In a recent KFF poll, about half of insured adults and 85 percent of uninsured adults reported difficulty affording health care costs.1 Patients of color are more likely to report difficulty affording care: 60 percent of Black patients and 65 percent of Hispanic patients reported difficulty affording care, compared to only 39 percent of white patients.2

These difficulties affording health care are driven by a variety of factors. Much of the country receives health coverage through an employer, and systemic racism results in unemployment rates that are consistently higher for Black and Hispanic workers than for white workers.3 As a result, Black and Hispanic people are far less likely than white people to have employer-sponsored insurance, or even any insurance at all.4 Similarly, the group of people who fall in the Medicaid coverage gap in states that have not expanded the program under the Affordable Care Act is disproportionately made up of people of color, depressing coverage rates among low-income households of color.5

Exacerbating these disparities, however, is the reality that hospitals often adopt policies that drive up the cost of care with no commensurate increase in quality. States have significant leeway to address these policies, with the benefits accruing to patients immediately. This report is the final in a series that explores how states that are seeking to lower the cost of care can also advance health equity as part of that effort, pursuing it through policy design and implementation rather than as an afterthought.6 The report begins by providing background on the inequitable impacts of high health care prices. After this, it describes three of the practices that drive up the cost of care for patients and payers. It ends by describing the policy tools that states can use to address these harmful hospital practices in a way that promotes health equity.

The Inequitable Burden of Affording Health Care

The health care industry suffers from a troubling lack of regulations governing pricing. This lack of regulation can pave the way for predatory hospital practices aimed at maximizing the price paid by patients; some of these practices include exploitative debt collection practices, high facility fees, and exploiting loopholes in legislation that protects patients from surprise bills.

Exploitative hospital behavior has serious implications for health care access and health outcomes. When policies, including the policies addressed by this report, are put in place that increase the cost burden on patients, people find themselves unable to afford essential medical services, and as a consequence often forgo needed medical care.7 This burden of expensive health care disproportionately affects people of color, those in worse health, and uninsured patients.

In 2022, 39 percent of Hispanic adults and 31 percent of Black adults delayed or skipped care due to cost, compared to 25 percent of white adults.8 Around 45 percent of patients who reported fair or poor health delayed or skipped care, compared to 25 percent of those who reported good or excellent health, and even more striking, nearly 60 percent of uninsured patients delayed or skipped care due to cost, while only 25 percent of insured patients did so.9 These disparities are shown in Figure 1.

Figure 1


Even among patients who received care, difficulty paying for medical bills is also inequitable. Black adults were 50 percent more likely than white adults to report that they or a family member had difficulty paying a medical bill, and Hispanic adults were 20 percent more likely.10 Similarly, patients with worse health were more than 140 percent more likely to report difficulty paying medical bills, and uninsured patients were twice as likely.11 Place-based disparities also exist for difficulties paying medical bills: rural patients were 20 percent more likely to report difficulty.12

Figure 2


Together, the impact of predatory hospital pricing behaviors not only contributes to financial strain, but also affects individuals’ health and well-being. Because of these practices, patients face greater barriers to achieving optimal health outcomes, delaying care and exacerbating health conditions.13

Predatory Hospital Practices Increase Health Care Prices

This report examines three hospital practices and how they contribute to higher health care prices and more inequitable outcomes. In particular, the report focuses on the following hospital practices, all of which states have the ability to address without additional federal intervention:

  • Imposing predatory debt collection practices,
  • driving up the cost of care through facility fees, and
  • the manipulation of surprise billing protections.

While addressing these issues will not solve the burden of unaffordable health care, ameliorating or eliminating these three hospital practices represent strong starting points for states.

Predatory Debt Collection Practices

Of those selected for this report, the first and most direct in their impact on patients of the three practices is how hospitals engage in debt collection. Around 100 million adults in the United States have medical debt, including around 20 million adults who owe more than $250, a threshold designated as “significant” medical debt.14 Patients that are in worse health or are living with a disability are more likely to report medical debt, as shown in Figure 3 below.15 These disparities are particularly insidious when one considers that medical debt is also the leading cause of personal bankruptcy.16

Figure 3


Medical debt is also, predictably, concentrated among lower-income patients. In 2021, 11 percent of adults with incomes below 200 percent of the federal poverty level (FPL)—$12,880 for a single adult or $26,500 for a family of four in 2021—held medical debt, as did 10 percent of those with income between 200 and 399 percent FPL.17 Seven percent of adults with incomes between 400 and 599 percent FPL held medical debt, compared to only 4 percent of those with incomes at or above 600 percent FPL.18

Figure 4


If unaddressed, medical debt can impact credit scores and limit individuals’ ability to access other essential services, such as housing and education. Health care’s unaffordability not only perpetuates existing health disparities, but also widens the socioeconomic gap between those who have the ability to afford health care and those who can not, making those disparities harder to close.

Health care’s unaffordability not only perpetuates existing health disparities, but also widens the socioeconomic gap between those who have the ability to afford health care and those who can not, making those disparities harder to close.

Compounding the issue of debt are many hospitals’ debt collection practices. Under the Affordable Care Act, non-profit hospitals are required to comply with a variety of conditions to maintain their tax exempt status, including conditions concerned with financial assistance and the collection of debt.19 One of these requirements is that hospitals must make “reasonable efforts” to determine whether a patient is eligible for patient assistance before taking extraordinary collections actions (ECAs) against them.20 ECAs include actions such as selling debt, reporting patients to credit agencies, denying care, requiring payment before providing care, or any other legal or judicial process.21

A 2022 investigation by KFF Health News found that the use of ECAs was widespread among hospitals, including for-profit, public, and non-profit hospitals.22 The investigation found that more than two-thirds of hospitals sue or take other legal action, such as placing a lien on property or garnishing wages, against patients, and a similar share reported outstanding bills to credit agencies. The widespread use suggests that hospitals are applying ECAs overly broadly, including to those who may be eligible for financial assistance.

Facility Fees Drive Up the Cost of Care

A second practice used by some hospitals and that harms patients is the imposition of facility fees. Facility fees are fees charged when patients receive care at outpatient and physician office settings owned by hospitals.23 While these fees can sometimes be justified when necessary to support fixed costs (such as standby capacity at rural hospitals), they are often charged for routine services that can be, and often are, safely provided at a physician office.24

The use of facility fees is only becoming more common, ratcheting up health premiums and out-of-pocket spending in the process. This increase has been driven by increasing provider consolidation: a 2018 study in the New England Journal of Medicine found that prices charged by physician practices increased by more than 14 percent after hospital acquisition.25 Even worse, these fees contribute to a vicious cycle of consolidation. Hospitals can leverage their market power to purchase competing physician offices, after which they can apply facility fees to drive up prices and purchase more of their competition.

A recent report by United States of Care highlights the outsized impact these fees have on marginalized communities.26 First, Black people are more likely to use hospital outpatient departments instead of primary care practices as their regular source of care than their white peers.27 These outpatient departments are much more likely to charge a facility fee, exposing Black patients to more of these often unnecessary fees.28 The report also highlighted differences in prices charged for treating chronic and complex health conditions, such as cancer, multiple sclerosis, and arthritis, finding that hospital outpatient departments charged nearly three times more than independent physician practices, with no evidence of improved quality of care.29

Less than half of states have taken any steps to address facility fees.30 Map 1 shows how many policy tools different states have adopted to limit facility fees’ impact on patients.

Map 1

Manipulation of Surprise Billing Protections

The final type of hospital behavior this report addresses is the manipulation surprise billing protections. Surprise billing is when a patient gets a bill for receiving care from an out-of-network provider in a situation they could not reasonably control.31 For example, a patient may undergo surgery at an in-network hospital and later receive a bill from their anesthesiologist, who was out-of-network.32 Another common example would be when a patient has a medical emergency and goes to the nearest hospital, regardless of its network status. More than one in five emergency visits resulted in a surprise bill before 2020, and between 9 and 16 percent of in-network hospitalizations resulted in a surprise bill.33

In response to this problem, Congress passed the No Surprises Act on December 27, 2020 as part of the Consolidated Appropriations Act, 2021.34 Under the legislation, providers are prohibited from charging patients more than the median in-network cost-sharing for a region.35 Importantly, the law includes post-emergency stabilization services—care necessary to ensure a patient is stable enough to transfer to an in-network hospital after an emergency—in its definition of emergency services.36 The law was primarily aimed at holding patients harmless from surprise bills, and it has been effective at achieving that goal.39 When issuing initial regulations for this process, the federal government expected few payments (around 22,000 in the first year) to be determined via the IDR process.40 Unfortunately, this was not the case: more than 490,000 IDR requests were filed through June 2023, and the Government Accountability Office found that 61 percent of these requests were unresolved at that time.41

These IDR requests are overwhelmingly filed by four private equity-backed provider organizations, some of which have a history of using surprise billing against patients.42 These requests are also largely decided in favor of the providers: in 2023, around 77 percent of IDR cases were decided in the providers’ favor. This trend of deciding in providers’ favor drives up costs: when insurers win the IDR case, the amount paid is usually the median in-network rate for a region, but when providers win, they were paid an average of 322 percent of that median rate.43

This trend of deciding in providers’ favor drives up costs: when insurers win the IDR case, the amount paid is usually the median in-network rate for a region, but when providers win, they were paid an average of 322 percent of that median rate.

These high provider prices drive up premiums, even when patients are shielded from the impacts. They also eat into workers’ wages, as employers will have to spend more on health benefits to cover the inflated costs that result from these dispute resolutions.

Policy Solutions That Will Rein In Predatory Hospital Behavior

States have the ability to address these predatory hospital practices, independent even of federal action. Each of the hospital practices discussed above have solutions that states can implement in an equity-focused way. The solutions include the following:

  • Reform charity care requirements and medical debt laws.
  • Reduce hospitals’ ability to impose facility fees.
  • Build on federal surprise billing protections.

Reform charity care requirements and medical debt laws.

While the Consumer Financial Protection Bureau has proposed prohibiting credit agencies from including medical debt in credit scores, the practice is still permitted, and a future presidential administration could withdraw this rule.44 Even worse, new research suggests that even if medical debt is forgiven, as many states are working to do, the impact may be limited. A working paper by Stanford economists found that forgiving debt after it has gone to collections did not improve finances, access to credit, or physical or mental health.45 As a result, policies should focus on both preventing debt in the first place, as well as relieving it after the fact. By implementing policies that regulate provider behavior and ensure fair pricing and billing practices, policy can mitigate the financial strain placed on patients and prevent harmful consequences associated with medical debt. There are several ways states can do so in a way that promotes health equity.

One of the most straightforward ways that states can prevent medical debt is through enhancing charity care requirements for hospitals. While charity care and other financial assistance requirements are usually thought of in the context of nonprofit hospitals, states have applied them to other hospital types as well.46 California has led on this issue: the state requires all hospitals to offer financial assistance to patients making up to four times the federal poverty level as a condition of licensure.47 In addition to expanded eligibility for these assistance programs, California requires hospitals to allow patients to pay their discounted prices over time, and hospitals must provide information on their charity care policies with any bill provided to patients.48

Colorado is another example that states could follow in enhancing their financial assistance requirements for hospitals. Colorado passed a law in 2021 requiring hospitals to limit their prices charged for patients making at or below 250 percent FPL to the greater of either the Medicaid or Medicare rate for that service.49 The law also limits the amount that can be charged to patients in a given month to no more than 4 percent of their income from a hospital, and no more than 2 percent of their income from a clinic.50

One benefit of such an approach is that it would help patients even if they live in a state that has not expanded Medicaid. Colorado’s law applies to all patients below 250 percent FPL, regardless of their insurance status, ensuring that the program is not unnecessarily limited to subsets of low-income households. While every state should expand their Medicaid programs under the ACA, steps like Colorado’s approach could prevent patients in non-expansion states from paying exorbitant prices in the meantime.51

In addition to preventing future medical debt from accruing, states should still work to address the negative consequences of existing medical debt for consumers. States have also led on this front. Last year, Colorado became the first state to ban medical debt from being reported to credit agencies.52 Importantly, Colorado’s law also includes a provision allowing consumers to have medical debt removed from their credit report, going beyond simply banning future reporting.53 States that follow this approach should include efforts to promote awareness of the change to patients, especially patients with lower financial and/or health literacy.

States can also leverage their Medicaid funds to limit the impact of medical debt on patients. The federal government recently approved North Carolina’s waiver request asking for the authority to require hospitals to adopt a variety of policies as a condition of eligibility for enhanced payments to stabilize hospital finances.54 The waiver is aimed at eliminating much of the $4 billion in debt that North Carolina hospitals currently hold, as well as providing discounts for patients below 300 percent FPL, streamlining financial assistance programs, and banning reporting medical debt to credit agencies.55 Medicaid funds often represent a significant portion of hospital revenues.56 Importantly, this waiver also requires the forgiveness of medical debt for many lower-income people who are not enrolled in Medicaid, which demonstrates the capacity for such initiatives to benefit patients beyond just those enrolled in Medicaid.

Reduce hospitals’ ability to impose facility fees.

Luckily, states have a variety of policies they can adopt to stop hospitals from weaponizing facility fees against patients. One approach a state could take is to simply prohibit facility fees at hospital-owned physician practices, a practice also referred to as site-neutral payments. The federal government has taken steps to implement this approach in the Medicare program: the Bipartisan Budget Act of 2015 (BBA) required site-neutral payments for hospital outpatient departments that a) started billing Medicare on or after the law was enacted (November 2, 2015), and b) are not located on a hospital’s campus.57

However, the BBA and subsequent legislation exempted several of these departments, limiting the scope of the reform: only around one-third of outpatient departments are subject to the site-neutral requirement. State efforts to enact site-neutral payments should take a broader approach to maximize their impact.

The National Academy for State Health Policy (NASHP) has proposed model legislation for states seeking to implement site-neutral payments.58 The legislation would impose two types of limitations on facility fees. First, the law imposes site-specific limits–a ban on facility fees if they are not charged for services provided at a hospital’s campus, a facility with a hospital emergency department, or a freestanding emergency facility. This approach is similar to the federal government’s site-neutral policy for Medicare.

The NASHP proposal goes beyond copying the federal government: the model law imposes service-specific limits, banning facility fees for services that could be provided at a physician’s office, even if they were provided at a facility exempt from the site-specific ban. The law explicitly names outpatient evaluation and management services in the service-specific limits, and it would require the state agency enforcing the law to develop a list of additional services that should be included in the service-specific ban.

States could build on the existing work that centers equity in cost-sharing design for health insurance plans and include these services in facility fee reforms. For example, states have recognized the value of a variety of services to health equity and cost-containment, such as diabetes screening and management services.59 By prioritizing such services among those that are included in a service-specific ban on facility fees, states can ensure that facility fee bans advance health equity and prevent growth in health care spending.

Another approach states could take if they are not interested in directly limiting facility fees is to require more transparency in billing practices. This approach may be more appealing to states looking to implement a more market-based solution to facility fees. For example, Washington and Minnesota require provider-based clinics to notify patients prior to providing non-emergency care that they may receive a facility fee bill.60 Texas’ transparency law goes further, requiring facilities not only to notify patients that they charge a facility fee, but also to include the median fee at the facility, the range of possible fees a patient may face, and the facility fee charged for each level of care.

One solution that has been proposed is to build on these transparency efforts by requiring that providers distinguish between care delivered at a hospital and at a hospital-owned physician’s office in their billing codes. Currently, the offices’ use of hospitals’ billing codes undermines insurers’ abilities to distinguish between facility type. By requiring different codes, as in the House-passed Lower Costs, More Transparency Act, insurers would be able to more effectively negotiate over these fees when hospitals acquire physician offices.61 Taking this approach would likely be more effective than simple transparency requirements, as patients are often not in a position to refuse care solely due to a fee.

Build on federal surprise billing protections.

The No Surprises Act explicitly allows states to establish their own processes for determining patient cost-sharing and payments to out-of-network providers, meaning states can go further than the federal law.62 States should begin by aligning their laws with the federal government, to avoid confusion by providers and patients, but they should also look to build on federal law to drive down health costs.

In particular, states should work to rein in the rate at which an IDR is chosen by providers, as well as the amount paid when an IDR is chosen. New York worked toward this goal: in 2022, the state amended its existing surprise billing law to require IDR processes to consider the median in-network rate paid by an insurer to comparable providers in the region.63 Explicitly requiring these rates to be included in the arbitration process can help avoid inflated payments to out-of-network providers by providing the rate used for all payers, rather than just the insurer in arbitration. However, New York law still requires these processes to consider the “usual and customary” rate charged by providers, which may undermine efforts to lower IDR payments.64 States should also consider removing references to amounts charged by providers when reforming their surprise billing laws.

States could also take a more direct approach and directly set the rates for reimbursement of surprise bills. For example, California enacted a surprise billing law in 2017 which, among other provisions, sets the payments to out-of-network providers at the greater of 125 percent of Medicare payments or the average in-network rate for a given service in the region.65 This approach would be far more effective at constraining the growth of health costs, and it would further encourage providers to contract with health insurers’ networks, because it removes the potential for high payments that incentivize remaining out of network from insurers.66

Maine has taken a hybrid approach on regulating IDR processes. The state maintains an independent dispute resolution process, as New York and the federal government’s laws do. Unlike those laws, however, Maine requires the arbitrator to use the median in-network rate as a factor, and does not require the billed charges, like New York does.67 This approach could be useful in states which face barriers to more direct rate setting like what California adopted.

An important caveat is that all of the laws mentioned thus far only apply to insured patients. In order to reform surprise billing loopholes most effectively, states should also work to protect uninsured patients from unexpected medical bills. Maine has also led here: the same bill that created state-level “hold harmless” protections for insurer patients included similar protections for uninsured patients.68 Uninsured patients cannot be charged more for emergency care than insured patients would be, and patients are able to dispute bills of $750 or more for a single visit using the same process as insured patients.69 Expanding surprise billing protections to uninsured patients is an essential step toward reforming surprise bills in an equitable manner, and can be done in concert with the other charity care reforms discussed earlier in this report.

Reforming Hospital Behavior Is a Crucial Part of Equitably Lowering Costs

The burden of high health costs does not fall equitably, and the burdens they create are driven in no small part by predatory hospital practices. Reforming hospital pricing and debt collection practices for low-income and uninsured patients can help ensure that patients do not face unaffordable hospital bills, or have their credit ruined by medical debt they should never have accrued. Prohibiting facility fees will stop patients from being charged more for the same service just because it is performed at a hospital-owned provider’s office. States can also supplement federal surprise billing laws with more aggressive state laws to ensure that hospitals cannot manipulate surprise billing protections to drive up the cost of care and premiums. By more precisely regulating these three aspects of hospital behavior, states can lower the cost of care and advance health equity.

Notes

  1. Lunna Lopes et al., “Americans’ Challenges with Health Care Costs,” KFF, March 1, 2024, https://www.kff.org/health-costs/issue-brief/americans-challenges-with-health-care-costs/.
  2. Ibid.
  3. “Health Insurance Coverage of the Total Population,” KFF, accessed August 1, 2024, https://www.kff.org/other/state-indicator/total-population/; “The Employment Situation – June 2024,” Bureau of Labor Statistics, July 5, 2024, https://www.bls.gov/news.release/pdf/empsit.pdf.
  4. Latoya Hill, Samantha Artiga, and Anthony Damico, “Health Coverage by Race and Ethnicity, 2010-2022,” KFF, January 11, 2024, https://www.kff.org/racial-equity-and-health-policy/issue-brief/health-coverage-by-race-and-ethnicity/.
  5. Patrick Drake et al., “How Many Uninsured Are in the Coverage Gap and How Many Could Be Eligible If All States Adopted the Medicaid Expansion?,” KFF, February 26, 2024, https://www.kff.org/medicaid/issue-brief/how-many-uninsured-are-in-the-coverage-gap-and-how-many-could-be-eligible-if-all-states-adopted-the-medicaid-expansion/.
  6. For the first reports in the series, see Tara Oakman and Thomas Waldrop, “Cost-Growth Benchmarks Can Make Health Care More Affordable and Equitable,” The Century Foundation, December 3, 2023, https://tcf.org/content/report/cost-growth-benchmarks-can-make-health-care-more-affordable-and-equitable/; Tara Oakman, Thomas Waldrop, and Lex Brierley, “How States Can Advance Equity When Addressing Health Care Consolidation,” The Century Foundation, March 6, 2023, https://tcf.org/content/report/how-states-can-advance-equity-when-addressing-health-care-consolidation/; and Thomas Waldrop and Lex Brierley, “State Reference Pricing Can Lower Health Care Costs Equitably,” The Century Foundation, August 13, 2024, https://tcf.org/content/report/state-reference-pricing-can-lower-health-care-costs-equitably/.
  7. Shameek Rakshit, Krutika Amin, and Cynthia Cox, “How Does Cost Affect Access to Healthcare?,” Peterson-KFF Health System Tracker, January 12, 2024, https://www.healthsystemtracker.org/chart-collection/cost-affect-access-care/.
  8. Ibid.
  9. Ibid.
  10. Ibid.
  11. Ibid.
  12. Ibid.
  13. Ibid.
  14. Noam N. Levey, “100 Million People in America Are Saddled with Health Care Debt,” KFF Health News, June 16, 2022, https://kffhealthnews.org/news/article/diagnosis-debt-investigation-100-million-americans-hidden-medical-debt/; Shameek Rakshit et al., “The Burden of Medical Debt in the United States,” Peterson-KFF Health System Tracker, February 12, 2024, https://www.healthsystemtracker.org/brief/the-burden-of-medical-debt-in-the-united-states/.
  15. Rakshit et al., “The Burden of Medical Debt in the United States.”
  16. Jesse Bedayn, “States Confront Medical Debt That’s Bankrupting Millions,” AP News, April 12, 2023, https://apnews.com/article/medical-debt-legislation-2a4f2fab7e2c58a68ac4541b8309c7aa.
  17. Rakshit et al., “The Burden of Medical Debt in the United States.”
  18. Ibid.
  19. “Requirements for 501(c)(3) Hospitals under the Affordable Care Act – Section 501(r),” Internal Revenue Service, July 1, 2024, https://www.irs.gov/charities-non-profits/charitable-organizations/requirements-for-501c3-hospitals-under-the-affordable-care-act-section-501r; “Billing and Collections – Section 501(r)(6),” Internal Revenue Service, July 1, 2024, https://www.irs.gov/charities-non-profits/billing-and-collections-section-501r6.
  20. “Billing and Collections – Section 501(r)(6),” Internal Revenue Service.
  21. Ibid.
  22. Noam Levey, “Investigation: Many U.S. Hospitals Sue Patients for Debts or Threaten Their Credit,” NPR, December 21, 2022, https://www.npr.org/sections/health-shots/2022/12/21/1144491711/investigation-many-u-s-hospitals-sue-patients-for-debts-or-threaten-their-credit.
  23.  Linda J. Blumberg and Christine H. Monahan, “Facility Fees 101: What Is All the Fuss About?,” Health Affairs Forefront, August 4, 2023, https://doi.org/10.1377/forefront.20230802.247953.
  24. “June 2022 Report to the Congress: Medicare and the Health Care Delivery System,” Medicare Payment Advisory Commission, June 15, 2022, https://www.medpac.gov/wp-content/uploads/2022/06/Jun22_MedPAC_Report_to_Congress_v4_SEC.pdf.
  25. Cory Capps, David Dranove, and Christopher Ody, “The Effect of Hospital Acquisitions of Physician Practices on Prices and Spending,” Journal of Health Economics 59 (May 2018): 139–52, https://doi.org/10.1016/j.jhealeco.2018.04.001.
  26. Behind the Bill: The Hidden Injustice of Hospital Facility Fees,” United States of Care, May 30, 2024, https://unitedstatesofcare.org/report-facility-fees-healthequity/.
  27. 1. M. J. Arnett et al., “Race, Medical Mistrust, and Segregation in Primary Care as Usual Source of Care: Findings from the Exploring Health Disparities in Integrated Communities Study,” Journal of Urban Health 93, no. 3 (May 18, 2016): 456–67, https://doi.org/10.1007/s11524-016-0054-9.
  28. “Behind the Bill: The Hidden Injustice of Hospital Facility Fees,” United States of Care.
  29. Ibid.
  30. Hanan Rakine, “Overall Picture of State Outpatient Facility Fee Billing Reforms for the Commercial Health Insurance Market,” Georgetown University Center on Health Insurance Reforms, July 8, 2024, https://facilityfeereform.chir.georgetown.edu/state-uptake-of-reforms/.
  31. “No Surprises Act,” George Washington University Hospital, accessed August 1, 2024, https://www.gwhospital.com/patients-visitors/no-surprises-act.
  32. Ibid.
  33. Ibid.
  34. “Surprise Medical Bills: New Protections for Consumers Take Effect in 2022,” KFF, February 4, 2021, https://www.kff.org/private-insurance/fact-sheet/surprise-medical-bills-new-protections-for-consumers-take-effect-in-2022/.
  35. Ibid.
  36. Ibid.
  39. Jack Hoadley et al., “No Surprises Act,” Urban Institute, April 18, 2023, https://www.urban.org/research/publication/no-surprises-act.37

    The No Surprises Act requires insurers and providers to negotiate over the amount paid to a provider, and if they cannot come to an agreement after thirty days, either party can request an independent dispute resolution (IDR).38“Surprise Medical Bills: New Protections for Consumers Take Effect in 2022,” KFF.

  40. John E. Dicken, “Roll Out of Independent Dispute Resolution Process for Out-of-Network Claims Has Been Challenging,” Government Accountability Office, December 2023, https://www.gao.gov/assets/d24106335.pdf.
  41. Ibid.
  42. ack Hoadley and Kevin Lucia, “Report Shows Dispute Resolution Process in No Surprises Act Favors Providers,” Dispute Resolution Process in No Surprises Act Favors Providers | Commonwealth Fund, March 1, 2024, https://www.commonwealthfund.org/blog/2024/report-shows-dispute-resolution-process-no-surprises-act-favors-providers.
  43. Ibid.
  44. Noam Levey, “Why a Financial Regulator Is Going after Health Care Debt,” NPR, March 1, 2024, https://www.npr.org/sections/health-shots/2024/03/01/1234998635/why-a-financial-regulator-is-going-after-health-care-debt.
  45. Raymond Kluender et al., The Effects of Medical Debt Relief: Evidence from Two Randomized Experiments, April 2024, https://doi.org/10.3386/w32315.
  46. Tara Oakman, Thomas Waldrop, and Lex Brierley, “How States Can Advance Equity When Addressing Health Care Consolidation.”
  47. California Health and Safety Code Section 127405.
  48. “Comparison of California and IRS Requirements Regarding Financial Assistance Policies,” California Hospital Association, March 2018, https://calhospital.org/wp-content/uploads/2018/03/appendix_fap_3.pdf.
  49. Colorado General Assembly, “HB 21-1198,” July 6, 2021, https://leg.colorado.gov/sites/default/files/2021a_1198_signed.pdf
  50. Ibid.
  51. Thomas Waldrop, “Mississippi Is Looking to Expand Medicaid. Other Holdout States Should Too.,” The Century Foundation, April 2, 2024, https://tcf.org/content/commentary/mississippi-is-looking-to-expand-medicaid-other-holdout-states-should-too/.
  52. Julia Char Gilbert, “Colorado’s Medical Debt Credit Reporting Law Takes Effect​,” Colorado Center on Law and Policy, August 15, 2023, https://copolicy.org/news/colorados-medical-debt-credit-reporting-law-takes-effect/.
  53. Ibid.
  54. “CMS Approves North Carolina’s Medical Debt Relief Incentive Program,” North Carolina Office of the Governor, July 29, 2024, https://governor.nc.gov/news/press-releases/2024/07/29/cms-approves-north-carolinas-medical-debt-relief-incentive-program; “Governor Cooper Takes Action to Lessen the Burden of Medical Debt for North Carolinians,” North Carolina Department of Health and Human Services, July 1, 2024, https://www.ncdhhs.gov/news/press-releases/2024/07/01/governor-cooper-takes-action-lessen-burden-medical-debt-north-carolinians.
  55. “Governor Cooper Takes Action to Lessen the Burden of Medical Debt for North Carolinians,” North Carolina Department of Health and Human Services.
  56. “Hospital Payor Mix by State,” Definitive Healthcare, April 10, 2023, https://www.definitivehc.com/resources/healthcare-insights/hospital-payor-mix-state.
  57. Zachary Levinson, Tricia Neuman, and Scott Hulver, “Five Things to Know About Medicare Site-Neutral Payment Reforms,” KFF, June 14, 2024, https://www.kff.org/medicare/issue-brief/five-things-to-know-about-medicare-site-neutral-payment-reforms/.
  58. “NASHP Model State Legislation to Prohibit Unwarranted Facility Fees,” National Academy for State Health Policy, August 24, 2020, https://nashp.org/nashp-model-state-legislation-to-prohibit-unwarranted-facility-fees/.
  59. Jamila Taylor and Thomas Waldrop, “Health Equity in Practice: A Framework to Assess Meaningful Implementation in Health Insurance Reforms,” The Century Foundation, September 21, 2022, https://tcf.org/content/report/health-equity-in-practice-a-framework-to-assess-meaningful-implementation-in-health-insurance-reforms/.
  60. Revised Code of Washington Section 70.01.040, https://app.leg.wa.gov/rcw/default.aspx?cite=70.01.040; Minnesota Statutes Section 62J.824, https://www.revisor.mn.gov/statutes/cite/62J.824.
  61. Lower Costs, More Transparency Act, H.R.5378, 118th Congress (2023), https://www.congress.gov/bill/118th-congress/house-bill/5378/text.
  62. Madeline O’Brien and Jack Hoadley, “States Act to Strengthen Surprise Billing Protections Even After Passage of No Surprises Act,” The Commonwealth Fund, March 16, 2023, https://www.commonwealthfund.org/blog/2023/states-act-strengthen-surprise-billing-protections-even-after-passage-no-surprises-act.
  63. New York State Senate, SB 8007, April 9, 2022, https://www.nysenate.gov/legislation/bills/2021/S8007
  64. Consolidated Laws of New York, Financial Services Law (FIS) Chapter 18-A, Article 6, Section 604, https://www.nysenate.gov/legislation/laws/FIS/604.
  65. California State Legislature, AB 72, September 23, 2016, https://leginfo.legislature.ca.gov/faces/billNavClient.xhtml?bill_id=201520160AB72.
  66. Mara Karlin et al., “California Saw Reduction in Out-of-Network Care from Affected Specialties after 2017 Surprise Billing Law,” Brookings Institute, September 26, 2019, https://www.brookings.edu/articles/california-saw-reduction-in-out-of-network-care-from-affected-specialties-after-2017-surprise-billing-law/.
  67. Maine Revised Statute, Title 24-A, Section 4303-E, https://legislature.maine.gov/legis/statutes/24-A/title24-Asec4303-E.html.
  68. Maine Legislature, LD 2015, March 18, 2020, https://legislature.maine.gov/legis/bills/bills_129th/billtexts/HP150101.asp .
  69. Ibid.

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