One point drew clear agreement Tuesday during a House subcommittee hearing: When it comes to the problem of surprise medical bills, the solution must protect patients — not demand that they be great negotiators.

“It is the providers and insurers, not patients, who should bear the burden of settling on a fair payment,” said Frederick Isasi, the executive director of Families USA. He was one of the witnesses who testified before the House Health, Employment, Labor and Pensions Subcommittee of the Education & Labor Committee.

Surprise, or “balance,” bills happen when patients go to a hospital they think is in their insurance network, but are then seen by a doctor or specialist who isn’t. The patient is then on the hook for an often very high bill — sometimes exceeding thousands or even tens of thousands of dollars.

Stories in the Bill of the Month series by NPR and Kaiser Health News have drawn attention to the problem.

Surprise billing is one of the rare public policy problems that are both bipartisan and in need of a federal solution. Around 60 percent of people are covered by employer-sponsored insurance, which is regulated by the federal government, and aren’t protected by the nearly two dozen state laws governing balance billing.

“We have people on this committee that have done yeoman efforts to come up with solutions in their own states,” said Rep. Tim Walberg, R-Mich., the panel’s ranking member. “I think we have a head start in understanding some of the pitfalls to stay away from and some of the benefits we can go directly toward.”

Several policy solutions have been introduced in Congress and discussed at the White House, but the witnesses testifying before the panel were firm that any answer needed to be worked out between key stakeholders — providers and insurers — instead of forcing consumers to file complaints and go through arbitration processes.

The problem, according to testimony, needs to be solved at the root. Instead of allowing a situation in which patients must negotiate a payment plan after receiving a surprise bill, hospitals and insurers need to remove the incentives for doctors to remain out of network.

Right now, if doctors opt out of an insurance network, they can charge prices that are “largely made up,” said Christen Linke Young, a fellow at USC-Brookings Schaeffer Initiative for Health Policy.

“We need to limit how much they can be paid in out-of-network scenarios to make it less attractive,” Young said.

Experts offered a few solutions, like capping how much providers can be paid if they are out of network. Ilyse Schuman, senior vice president of health policy at the American Benefits Council, suggested capping reimbursement for out-of-network emergency services at 125 percent of what the physician would get from Medicare.

Rep. Phil Roe, R-Tenn., an obstetrician, expressed concerns that tying payments to Medicare would disadvantage rural communities like his, where Medicare reimburses doctors less.

“We pay our providers less and can keep less than 10 percent of nurses we train in the area because we can’t pay them,” Roe said.

Rep. Susan Wild, a Pennsylvania Democrat, acknowledged that surprise billing is one problem that both parties are motivated to solve, but she was skeptical that a path forward was on the horizon. “The solutions I’m hearing don’t sound workable in the context of our present medical system,” Wild said.

“Isn’t the real problem the fact that we’ve turned over our medical system to private market forces?” she asked.

While price transparency is often touted as the antidote to high medical bills, panelists were adamant that more information alone is not enough to stop balance bills.

Patients usually can’t shop around for an anesthesiologist, for instance, no matter how much information they have.

“Notice isn’t enough here; even if the consumer has perfect information, they can’t do anything with that information,” Young testified. “They can’t go across town to get their anesthesia and go back to the hospital.”

Kaiser Health News is a nonprofit news service and editorially independent program of the Kaiser Family Foundation. KHN is not affiliated with Kaiser Permanente. You can follow Rachel Bluth onTwitter: @RachelHBluth

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President Trump, bowing to political reality, says he is putting off his thoughts of finding a replacement for the Affordable Care Act until after the 2020 election.

In remarks to reporters Tuesday, Trump said, “I wanted to put it after the election because we don’t have the House.” But it became clear that he didn’t have support for a replacement to Obamacare in the GOP-led Senate, either.

Senate Majority Leader Mitch McConnell, R-Ky., said he “made it clear to [Trump] that we were not going to be doing that in the Senate.” Asked whether there were differences between him and Trump on the issue, McConnell replied succinctly, “Not any longer.”

McConnell recounted that he had a “good conversation” with the president on Monday and pointed out “the Senate Republicans’ view” that working on comprehensive health care legislation with a Democratic House was not something his party planned to do.

Trump surprised Republicans last week when he said he was going to make the GOP “the party of health care” and would revisit the issue that has frustrated Republicans and helped deliver the House to Democrats in the 2018 midterm election.

Even with GOP control of both chambers of Congress prior to that, Republicans were unable to agree on a plan to replace the ACA — something McConnell noted on Tuesday.

Senate Minority Leader Chuck Schumer, D-N.Y., said Trump’s reversal means he will “hold Americans hostage through 2020” on an issue that affects millions of people. Schumer said Trump “insists he has a magic plan that we can see if only the American people re-elect him.”

The administration continues to push for a court ruling that would invalidate the entire ACA, and it’s unclear what would happen if the courts were to rule in the president’s favor. Democrats have introduced a nonbinding resolution in the House that would tell the administration to drop its challenge to the law.

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Hospitals and nursing homes in California and Illinois are testing a surprisingly simple strategy to stop the dangerous, antibiotic-resistant superbugs that kill thousands of people each year: washing patients with a special soap.

The efforts — funded with roughly $8 million from the federal government’s Centers for Disease Control and Prevention — are taking place at 50 facilities in those two states.

This novel collaboration recognizes that superbugs don’t remain isolated in one hospital or nursing home but move quickly through a community, said Dr. John Jernigan, who directs the CDC’s office on health care-acquired infection research.

“No health care facility is an island,” Jernigan says. “We all are in this complicated network.”

At least 2 million people in the U.S. become infected with some type of antibiotic-resistant bacteria each year, and about 23,000 die from those infections, according to the CDC.

People in hospitals are vulnerable to these bugs, and people in nursing homes are particularly vulnerable. Up to 15 percent of hospital patients and 65 percent of nursing home residents harbor drug-resistant organisms, though not all of them will develop an infection, says Dr. Susan Huang, who specializes in infectious diseases at University of California, Irvine.

“Superbugs are scary and they are unabated,” Huang says. “They don’t go away.”

Some of the most common bacteria in health care facilities are methicillin-resistant Staphylococcus aureus, or MRSA, and carbapenem-resistant Enterobacteriaceae, or CRE, often called “nightmare bacteria.” E.Coli and Klebsiella pneumoniae are two common germs that can fall into this category when they become resistant to last-resort antibiotics known as carbapenems. CRE bacteria cause an estimated 600 deaths each year, according to the CDC.

CRE have “basically spread widely” among health care facilities in the Chicago region, says Dr. Michael Lin, an infectious-diseases specialist at Rush University Medical Center, who is heading the CDC-funded effort there. “If MRSA is a superbug, this is the extreme — the super superbug.”

Containing the dangerous bacteria has been a challenge for hospitals and nursing homes. As part of the CDC effort, doctors and health care workers in Chicago and Southern California are using the antimicrobial soap chlorhexidine, which has been shown to reduce infections when patients bathe with it.

Though hospital intensive care units frequently rely on chlorhexidine in preventing infections, it is used less commonly for bathing in nursing homes. Chlorhexidine also is sold over the counter; the FDA noted in 2017 it has caused rare but severe allergic reactions.

In Chicago, researchers are working with 14 nursing homes and long-term acute care hospitals, where staff are screening people for the CRE bacteria at admission and bathing them daily with chlorhexidine.

The Chicago project, which started in 2017 and ends in September, includes a campaign to promote hand-washing and increased communication among hospitals about which patients carry the drug-resistant organisms.

The infection-control protocol was new to many nursing homes, which don’t have the same resources as hospitals, Lin says.

In fact, three-quarters of nursing homes in the U.S. received citations for infection-control problems over a four-year period, according to a Kaiser Health News analysis, and the facilities with repeat citations almost never were fined. Nursing home residents often are sent back to hospitals because of infections.

In California, health officials are closely watching the CRE bacteria, which are less prevalent there than elsewhere in the country, and they are trying to prevent CRE from taking hold, says Dr. Matthew Zahn, medical director of epidemiology at the Orange County Health Care Agency

“We don’t have an infinite amount of time,” Zahn says. “Taking a chance to try to make a difference in CRE’s trajectory now is really important.”

The CDC-funded project in California is based in Orange County, where 36 hospitals and nursing homes are using the antiseptic wash along with an iodine-based nose swab. The goal is to prevent new people from getting drug-resistant bacteria and keep the ones who already have the bacteria on their skin or elsewhere from developing infections, says Huang, who is leading the project.

Huang kicked off the project by studying how patients move among different hospitals and nursing homes in Orange County — she discovered they do so far more than previously thought. That prompted a key question, she says: “What can we do to not just protect our patients but to protect them when they start to move all over the place?”

Her previous research showed that patients who were carriers of MRSA bacteria on their skin or in their nose, for example, who, for six months, used chlorhexidine for bathing and as a mouthwash, and swabbed their noses with a nasal antibiotic were able to reduce their risk of developing a MRSA infection by 30 percent. But all the patients in that study, published in February in the New England Journal of Medicine, already had been discharged from hospitals.

Now the goal is to target patients still in hospitals or nursing homes and extend the work to CRE. The traditional hospitals participating in the new project are focusing on patients in intensive care units and those who already carry drug-resistant bacteria, while the nursing homes and the long-term acute care hospitals perform the cleaning — also called “decolonizing” — on every resident.

One recent morning at Coventry Court Health Center, a nursing home in Anaheim, Calif., 94-year-old Neva Shinkle sat patiently in her wheelchair. Licensed vocational nurse Joana Bartolome swabbed her nose and asked if she remembered what it did.

“It kills germs,” Shinkle responded.

“That’s right — it protects you from infection.”

In a nearby room, senior project coordinator Raveena Singh from UCI talked with Caridad Coca, 71, who had recently arrived at the facility. She explained that Coca would bathe with the chlorhexidine rather than regular soap. “If you have some kind of open wound or cut, it helps protect you from getting an infection,” Singh said. “And we are not just protecting you, one person. We protect everybody in the nursing home.”

Coca said she had a cousin who had spent months in the hospital after getting MRSA. “Luckily, I’ve never had it,” she said.

Coventry Court administrator Shaun Dahl says he was eager to participate because people were arriving at the nursing home carrying MRSA or other bugs. “They were sick there and they are sick here,” Dahl says.

Results from the Chicago project are pending. Preliminary results of the Orange County project, which ends in May, show that it seems to be working, Huang says. After 18 months, researchers saw a 25 percent decline in drug-resistant organisms in nursing home residents, 34 percent in patients of long-term acute care hospitals and 9 percent in traditional hospital patients. The most dramatic drops were in CRE, though the number of patients with that type of bacteria was smaller.

The preliminary data also show a promising ripple effect in facilities that aren’t part of the effort, a sign that the project may be starting to make a difference in the county, says Zahn of the Orange County Health Care Agency.

“In our community, we have seen an increase in antimicrobial-resistant infections,” he says. “This offers an opportunity to intervene and bend the curve in the right direction.”

Kaiser Health News is a nonprofit news service and editorially independent program of the Kaiser Family Foundation. KHN is not affiliated with Kaiser Permanente.

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China has announced that all variants of fentanyl will be treated as controlled substances, after Washington urged Beijing to stop fueling the opioid epidemic in the United States.

Authorities in China already regulate 25 variants of fentanyl, a synthetic opioid linked to thousands of drug overdose deaths in the U.S. But some manufacturers in China, seeking to evade controls, have introduced slight changes to the molecular structure of their drugs, giving them the legal loophole to manufacture and export before the government can assess the products for safety and medical use.

The decision to regulate all fentanyl-related drugs as controlled substances “puts a wider array of substances under regulation,” Liu Yuejin, an official of China’s National Narcotics Control Commission, said at a press conference in on Monday. The regulation will take effect May 1.

Bryce Pardo, a drug policy researcher at Rand Corporation, tells NPR that in theory, the regulation “future-proofs the law” by including impending chemical modifications.

But China may not be able to enforce the new rules, Pardo says. “[Authorities] already have problems enforcing existing laws.” He says official reports show the country does not have enough inspectors for facilities, and law enforcement would have to “take a sample” from a facility and eventually “analyze whether it’s a fentanyl-related structure.”

Vanda Felbab-Brown, a senior fellow at The Brookings Institution who focuses on illegal economies, tells NPR the regulation is “a good step,” but whether China “will have the will and the capacity to do it is a big question.”

The United States and China have been negotiating for better drug control since the Obama era, she adds. In the midst of the trade war with the Trump administration, “China is looking for one area where it can still continue cooperating with the U.S.,” Felbab-Brown says.

The announcement comes after President Xi Jinping vowed in a December meeting with President Trump to classify fentanyl as a controlled substance. After the meeting, Trump called on China to seek the death penalty for fentanyl distributors.

Liu denied on Monday accusations that China is a major contributor to the U.S. opioid crisis, saying Chinese law enforcement has “solved several cases” of illegal fentanyl-related drug manufacturing and distribution. “They are all shipped to the U.S. by criminals through evasive means, through international packages,” Liu said. “The amount is extremely limited and cannot be the main source of the substance in the U.S.”

He said the U.S. opioid problem was mainly caused by “domestic reasons,” according to the South China Morning Post.

According to a 2018 report by the U.S.-China Economic and Security Review Commission, China remains “the largest source of illicit fentanyl and fentanyl-like substances” in the United States and “illicit manufacturers create new substances faster than they can be controlled.”

Chemical exporters in China secretly send drugs to the West through fake shipment labels and other tactics, the report stated.

Fentanyl is a synthetic opioid that relieves extreme pain. It is 50 to 100 times more potent than morphine, according to the Centers for Disease Control and Prevention. It also is the drug most often found in overdose deaths in the United States. In 2016, fentanyl was linked to more than 18,000 drug overdose deaths, 29 percent of drug overdose deaths that year, according to a National Vital Statistics System report.

Felbab-Brown says China’s new stance on fentanyl-related substances stems partially from a desire to be a global enforcer on drugs. “From a public relations perspective, it’s difficult for China to be accused of being a source of drugs,” she says.

China does not have a monopoly on fentanyl production, she adds. “Even if tomorrow the United States wouldn’t get fentanyl from China, others would step in. Most obviously India, a major source of addictive drugs.”

Jingnan Huo contributed to this report.

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