Congress Must Act to Safeguard the No Surprises Act from Industry Gaming

The No Surprises Act (NSA) represented a landmark bipartisan effort to protect patients from receiving surprise medical bills when it was passed in 2020, preventing an estimated 50 million surprise bills from reaching consumers as of September 2026. Despite that success, private-equity backed provider staffing firms and corporate middlemen have identified and abused a major loophole in the law — a gameable independent dispute resolution (IDR) process — driving more than $22 billion in additional health care costs since 2022, which insurers are beginning to pass on to consumers in the form of higher premiums across the United States.

In this issue brief, Families USA outlines how large corporations have turned the NSA into a profit engine and puts forward commonsense solutions that Congress can use to put the NSA back on track, including by establishing a fixed and default payment benchmark, extending protections to ground ambulance services, and increasing transparency and accountability for arbitration entities. If enacted, these solutions will help restore the law’s original promise of protecting families from surprise medical bills and runaway health care costs. Families USA also released a companion fact sheet spotlighting state solutions that have been effective in protecting patients and preventing inflated payments.