Abstract
Scholars and journalists have devoted considerable attention to understanding the circumstances in which Americans receive surprise medical bills. Previous research on this issue has focused on the scope of the problem, including the conditions that are most likely to lead to surprise bills. However, the existing literature has almost exclusively relied on claims data, limiting our understanding of consumer experiences and attitudes toward policy changes to address surprise billing. Using a survey administered to a nationally representative sample of 4998 Americans, we analyze consumer experiences with surprise billing, knowledge of the issue, how concerned Americans are about receiving surprise bills and how past experiences influence policy preferences toward federal action on surprise billing. Our analysis demonstrates that knowledge and concern about surprise billing are the highest among the educated and those who have previously received a surprise bill. These factors also predict support for federal policy action, with high levels of support for federal policy action across the population, including among both liberals and conservatives. However, more detailed federal policy proposals receive significantly less support among Americans, suggesting that stand-alone policy action may not be viable. Our results show bipartisan support among American consumers for federal action on surprise billing in the abstract but no consistent views on specific policy proposals.
Highlights
Over the last several years, scholars have devoted considerable attention to better understanding an increasingly common phenomenon in the U.S health care system: surprise medical billing
Recent opinion polling has made some progress in improving our understanding of public experiences, suggesting that surprise billing is common, that most Americans are concerned about the possibility of a surprise bill, and that the desire for federal policy change is widespread (Kirzinger et al, 2018; Families USA, 2019; Kirzinger et al, 2019)
We argue that more in-depth opinion-based research is needed to gage Americans’ perceptions of surprise medical billing
Summary
The emergence of surprise billing in the United States can be traced to an important transformation of private health insurance in the late 1970s and early 1980s: the shift in American insurance away from indemnity plans and toward managed care arrangements designed to reign in health care spending (Gabel et al, 2000; Gray 2006). Indemnity plans impose few restrictions on consumers, managed care coverage arrangements rely heavily on establishing provider networks that give preferential access to a subset of providers while excluding all others (Haeder et al, 2015b) Over time, as these managed care approaches have failed to reduce health costs as intended, insurers have started to pursue various cost containment strategies aggressively. When the Affordable Care Act eliminated these instruments, efforts shifted to focus on narrowing the composition and breadth of provider networks (Haeder et al, 2015a; Brown et al, 2016; Polsky et al, 2016; Jacobson et al, 2017; Feyman et al, 2019) This narrowing of provider networks was an effort to hold down costs, it has had an unintended consequence – increasing the probability that privately insured individuals will have a medical encounter not covered by their managed care insurance plan. As the late health economist Uwe Reinhardt put it, ‘It is hard to think of a more unfair financial arrangement between patients and the healthcare system, one in which the buy-side is virtually defenseless vis-à-vis the supply side, and it is hard to imagine that any other country would allow it’ (Reinhardt, 2019)
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