The No Surprises Act left out ground ambulances. Here’s what’s happening now

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Minutes after Lainey Arebalo gave birth to her third child last September, hospital staff noticed her son was having trouble breathing. They recommended placing the infant in an ambulance so he could receive care at a better-equipped pediatric facility 23 miles away. Within days of receiving that extra care, Arebalo was able to bring her healthy baby home where their waiting family welcomed him.

But a few weeks later, as everyone adjusted to the newborn’s fickle schedule and Arebalo continued her own recovery, letters began to show up. They said she now owed $4,400 for her son’s ambulance ride.

She called her insurer, only to learn they did not cover transportation from this company. It was the only ambulance company in her county. Arebalo still tried to get the two parties to talk to each other. By October, the ambulance company threatened to turn her over to a collections agency if she did not pay.

“The ambulance bill was an actual surprise bill,” said Arebalo, 29, a special education teacher in San Luis Obispo County, California. “We did not think it was going to be as much as it was.”

Arebalo and her family are not alone. To access emergency care, one in 10 non-elderly people who are privately insured take an ambulance, according to the Peterson-KFF Health System Tracker. But in most places, there is virtually no way to know how much that ride will cost. While 13 states have taken steps to protect patients against surprise bills for ambulance care, there are no national protections.

When Congress passed the No Surprises Act in 2021 to curb such billing elsewhere in health care, lawmakers dropped measures that could have reined in how much an ambulance would cost. Some lawmakers and advocates feared the deal could collapse altogether if there was too much political haggling. As a result, the price of an ambulance trip can still vary widely for reasons that no patient can reasonably foresee or control.

In a study published this year in the journal Health Affairs, researchers looked at data of emergency trips via ground ambulance between 2014 and 2017 for people who were commercially insured. They found that 28 percent of those trips resulted in surprise bills.

Following a single ambulance ride, people could be confronted with astronomical bills, debt or even medical bankruptcy. To sidestep the risk of racking up costs, some people avoid ambulances altogether, gambling with time, transportation and their own health.

Ambulance providers are “eager to get the patient out of the middle of this scenario,” according to Wayne Jurecki, who serves on the board of directors for the American Ambulance Association, a trade organization. But insurance companies very often “have been under-reimbursing for critical life-saving services for quite a period of time” at rates that do not cover costs of having trained staff ready to respond to an emergency. So they turn to patients to foot the bill. This take-it-or-leave-it practice has continued even as major health insurance companies reported record profits, Jurecki said.

Ambulance companies also don’t choose who they pick up – in some states and jurisdictions, they are compelled by law to respond when they get a 911 call for a medical emergency, he explained.

“The model is ‘They call, and we show up,’” Jurecki said.

A 2022 report from AHIP, a lobbying group that advocates on behalf of health insurance companies, pointed out that too few ground ambulance providers participate in health plan networks, labeling that absence as a “market failure” and calling for more federal regulation. In the past, AHIP supported Congress’ decision to include price regulation for air ambulance services (i.e. emergency transportation on an airplane or helicopter) through the No Surprises Act.

Despite the lack of a ground ambulance provision in the final law, lawmakers agreed that they would pick up the matter at a later date. So Congress created the Ground Ambulance and Patient Billing Advisory Committee.

This week, that committee examined what can be done to reduce the systemic complexities and costs associated with ambulance services, and asked the public for input. Made up of experts on emergency health, transportation, state and local governments, and insurance regulation, in addition to consumer and patient advocates, the group is expected to issue a report with recommendations in November. (Members of the public have until Sept. 5 to submit comment via email at gapbadvisorycommittee@cms.hhs.gov).

When there is only one ambulance company serving a community (like in Arebalo’s case), individuals “can’t make a choice,” said Patricia Kelmar, a consumer advocate who directs health care campaigns for the U.S. Public Interest Research Group, during the committee’s Aug. 16 meeting. Patients are “doing the best they can to call the ambulance” when they are caught in a medical emergency, Kelmar said. They are in no position to choose who helps them – or whether an ambulance is considered out-of-network by their insurance – in a life-or-death situation, she said.

“The most important thing from the patient’s perspective is taking them out of the problem,” said Kelmar, who also serves on the committee.

So far, the panel has surveyed the complexities of the nation’s patchwork system of ambulatory care, as well as the existing rules that govern care and dictate who pays what. Typically, ambulance companies use trip mileage to charge patients, but those rates can vary between $20 per mile and $90 per mile, depending on where the patient was picked up and dropped off, Kelmar said.

The level of physical trauma, such as having a heart attack or sustaining multiple gunshot wounds, a person is experiencing during that ambulance ride can also add extra costs. Fire departments, hospitals, local governments or even private companies may offer these services, and those lines of responsibility may change by jurisdiction or availability at the time of an emergency dispatcher’s request for services. Some ambulance services are not reimbursed if crews who treat and stabilize a person on the scene no longer need to go to the hospital.

And as with so much in the U.S. health care system, an ambulance provider and its staff may or may not be considered in-network for those covered by insurance, which could inflate the price of a ride.. And In seven states, including California where the Arebalo family lives, more than two-thirds of ambulance rides included out-of-network related services, exposing patients to even greater risk of surprise bills.

Many standing rules are tied to outdated policies borne out of the 1960s, when the federal government launched Medicare. With so much variability, “there’s no one-size-fits-all for how emergency transportation is offered and paid for in the U.S.,” Kelmar said. The goal should be to drive toward the least costly forms of care, she added, but the system in place can foster “perverse incentives” to deliver care that doesn’t holistically meet a patient’s needs.

Roughly 13,000 ambulance providers operate nationwide, Jurecki said, and he said four in five of those providers carry less than 1,000 Medicare-billable trips per year. That means most ambulance providers may operate a pair of response vehicles driven by volunteers. That also often means these companies are too small to negotiate with major insurance companies, Jurecki said. Early on during the COVID pandemic, he noted, health care workers and first responders were revered for working so hard to keep people alive. Many first responders, including ambulance crews, are leaving the profession after years of working through a pandemic, Jurecki said.

Economist and health policy expert Loren Adler, who serves on the committee and worked to produce the study in Health Affairs, said that the hope is that their work will improve a system that is clearly broken.

There are many questions left for the panel to tackle. Should protections against surprise billing apply to all ambulance trips, emergency or not? What protections should be in place for transportation between health care facilities? When people are struggling in a medical emergency, should the concept of in-network versus out-of-network ambulance services be suspended altogether and instead be regarded as a universal benefit? These problematic scenarios – and the policy questions they pose – are pervasive, Kelmar said, and the public demands answers.

“The country is ready to solve” surprise billing on ground ambulances, she said.

It is hard to predict how a divided Congress will act. Adler, who serves as associate director for the USC-Brookings Schaeffer Initiative for Health Policy, said he remains “optimistic” that meaningful action can be taken on this issue, especially when so many people agree the current system is not working, including those who need it most.

Arebalo does not want anyone else to endure what she and her family have had to go through. While her insurance eventually agreed to pay for part of her son’s ambulance ride, that still left Arebalo on the hook for more than $2,000. As a teacher, she said she does not receive paid parental leave, so she had to cut short her time to recover at home with her son. She returned to the classroom a month early and has taught summer school to earn enough money to pay down that debt, $200 each month.

Because the ambulance company does not have a way for her to check how much of her bill is left, Arebalo said she will make those monthly payments until the ambulance company says the debt is satisfied.

“You get hit with a huge bill, and there’s nothing that can be done about it,” she said. “It’s not a good spot to be in financially. Some sort of heads-up would have been helpful.”

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