Despite the rushed way somecommittee members announced the agreement Dec. 8, it's now unlikelythat Congress will consider the package before it wraps up work forthe year.

After months of hearings and negotiations, millions of dollarsin attack ads, full-court press lobbying efforts and countlessrounds of negotiations, Congress appeared to be moving toward asolution to the nation's surprise medical bill problem. Sort of.

Surprise bills, the often-exorbitant medical bills that comewhen a patient doesn't realize they've been seen by a provideroutside their insurance network, have in recent months been viewedas public enemy No. 1 on Capitol Hill.

Related: A few more details in the latest surprise billinglegislation

Two committees, the Senate Health, Education, Labor and Pensions(HELP) Committee and the House Energy and Commerce Committee, havebeen working on plans and announced a compromise Dec. 8. Later thatweek, the House Ways and Means Committee followed suit byannouncing its solution, though details are few.

It's been a heavy lift for lawmakers in both parties who aretrying to balance the competing needs of powerful stakeholders,factions within their ranks and consumers stuck with high bills.With an election year fast approaching and polls consistently showing health care costs are a highpriority for voters, the push for action has intensified.

Time is not of the essence

Despite the rushed way some committee members announced theagreement Dec. 8 — issuing a press release on a Sunday beforeany official bill text was released — it's now unlikely thatCongress will consider the package before it wraps up work for theyear.

HELP Committee Chairman Lamar Alexander (R-Tenn.) signaled asmuch Monday in a press release in which he promised to doeverything he could to keep the surprise medical bill issue at thetop of the congressional to-do list for 2020 — until it's solved."The only people who don't want this fixed are the people whobenefit from these excessive fees," he said.

Still, the recent signs of progress are significant, even iffinal passage happens early next year, said Loren Adler, theassociate director of USC-Brookings Schaeffer Initiative for HealthPolicy, a research group.

Even if Congress punts it to February or March, "there's adecent shot of getting it done," Adler said. "It would be prettydarn embarrassing if Congress doesn't pass it after talking aboutit this long and it being such an egregious problem."

Compromise bill

The HELP/Energy and Commerce legislative outline shows movementtoward compromise on several fronts, from omitting thecontroversial "all-payer claims database" ― a federal repositoryfor health-pricing information ― to adding more public healthprovisions.

It includes Senate protections against surprise bills from airambulances, while adopting most of the House's approach to hospitalbills, down to preserving the House's title for that section.

"A sign of a compromise is that nobody particularly loves it,"Adler said.

Over the past few months, the biggest debate around remedies forsurprise bills has centered on how to determine payment forout-of-network doctors and hospitals. One group wanted anarbitration process while the other sought a benchmark system. Itseems neither side got exactly what they were seeking.

Under benchmarking, the government would set a compensation ratefor providers when they see out-of-network patients. The mostpopular proposition was one that paid a "median in-network" rate,when doctors are paid in the middle of the range of what others inthe area are paid by insurance companies for the same service.

The other idea was independent dispute resolution, orarbitration. The provider and insurer bring their best offer to athird party, who chooses between the two.

Generally, employers and consumer advocates favor benchmarking.Hospitals and doctors' groups, especially those backed by privateequity firms, pushed for arbitration.

The compromise approach tracks closely with legislation advancedby the House Energy and Commerce Committee: a median in-networkbenchmark with an arbitration "safety valve" where either side canbring a bill to arbitration if it's more than $750. Previousversions allowed arbitration only for charges over $1,250.

"I think what we've seen come out recently is probably what areasonable bettor would have predicted," said Benedic Ippolito, aresearch fellow in economic policy studies at the AmericanEnterprise Institute.

This proposal is seen as more favorable than earlier HELPCommittee drafts to providers because it allows them to go toarbitration for more bills, but to these stakeholders, it's notenough.

"Without an arbitration mechanism that applies to a legitimatenumber of claims, the concerns raised by the provider communitywill persist," read a statement from Envision Healthcare, aphysician staffing firm. A large number of surprise bills aregenerated by physicians employed by such staffing companies, whichare often backed by private equity firms. The business model allowsthese doctors ― often specialists including emergency medicine andradiology, among others ― to set their own rates because they don'twork for the hospital.

TheAmerican College of Surgeons, Federation of AmericanHospitals, Association of American Medical Colleges and GreaterNew York Hospital Association have also pushed back.

To be fair, plenty of groups have come out in support of thecompromise. A message from the Energy and Commerce Committee noted27 patient and consumer advocate groups that signed a letter ofsupport.

James Gelfand, a senior vice president at the ERISA IndustryCommittee, which represents large employers, said the compromiseisn't what his constituents would have written to solve surprisemedical billing, but he thinks it's still important to pass, andparties who keep demanding changes are just trying to stall.

"We hate arbitration, and we believe the changes made to please'team arbitration' will raise costs tens of billions of dollars,"Gelfand said. "But we support the bill. We want to get it acrossthe finish line."

The blueprint offered by the Ways and Means Committee isconsidered friendly to providers because it lays out a systemsimilar to arbitration and favors a go-slow approach. A pressrelease from panel Republicans indicated that stakeholders need to"stay at the table and debate these ideas" into the new year.

To some, it felt like a delay tactic.

"We know that pushing legislative action into 2020 pushes thework into a difficult presidential election year and makes itharder for Congress to act. This would dramatically increase theodds that Congress will fail to enact meaningful legislation to bansurprise medical bills and fail our nation's families," FrederickIsasi, executive director of the advocacy group Families USA, saidin a written statement.

Money and momentum

Political muscle could also factor into the measure'smomentum.

Money from private equity has been flowing into the debate, frommillions of dollars spent on commercials and online ads, to campaign donations.

According to Open Secrets data, Rep. Richard Neal (D-Mass.), thechairman of the Ways and Means Committee and one of the voicescalling for more time on surprise billing, received $29,000this year from Blackstone Group, the private equity firm thatowns TeamHealth, a physician-staffing firm. This was the first yearever that Blackstone was in Neal's top five donors.

Rep. Kevin Brady (R-Texas), that panel's ranking member,received $45,000 from Welsh, Carson, Anderson and Stowe, the privateequity firm that owns several staffing companies, including USAcute Care Solutions, U.S. Anesthesia Partners and US RadiologySpecialists. U.S. Anesthesia Partners was one of Brady's topcontributors last year as well, giving $56,250 in the 2017-18 cycle.

Sen. Bill Cassidy (R-La.) has been one of the strongestproponents of an arbitration safety valve on the HELP Committee. Hereceived $68,900 from Blackstone and $66,300 from Welsh, Carson,Anderson and Stowe.

Neither Alexander nor Sen. Patty Murray (D-Wash.), the ranking member of HELP,reported similar donations from private equity firms. The same wastrue for Rep. Frank Pallone (D-N.J.), the chairman of Energy andCommerce, and Rep. Greg Walden (R-Ore.), the ranking member of thatcommittee.

Looking to the future, many questions still need to be answeredabout how these proposals will shape up.

"Whether this is a good or bad solution to surprise medicalbilling will depend on how the arbitration system evolves overtime," Ippolito said.

Kaiser Health News isa nonprofit news service covering health issues. It is aneditorially independent program of the Kaiser Family Foundation,which is not affiliated with Kaiser Permanente.

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