States Spotlight Promising Fixes to the No Surprises Act

The No Surprises Act has prevented an estimated 50 million surprise medical bills as of September 2026, but the law’s reliance on a gameable independent dispute resolution (IDR) process for setting out-of-network payments has created a costly loophole, allowing corporate provider groups to abuse the system and drive 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 highlights successful state surprise billing laws in California, Ohio, and Virginia that use key guardrails such as an evidence-based payment benchmark for out-of-network payments, a requirement to use insurers’ internal appeals processes prior to third-party arbitration, and a limit on the frequency of arbitration use. The fact sheet also cautions against the consideration of billed charges during arbitration, which states like New York allow, due to its inflationary impact. Families USA releases this fact sheet alongside a companion piece that unveils the major loophole in the NSA at the federal level and the threat that corporate abuse of this loophole poses to this critical patient protection.