Montana lawmakers are trying to find a balance between the lifesaving air ambulance services, and the crippling debt those rides can bury patients in.
Two years ago, in September, Benjamin Power was taken to the hospital in his home town of Dillon. He was having a stroke:
"It was determined I needed a neurosurgical procedure that wasn’t available in Montana, and I was flown to Salt Lake City," Power said. "The procedure saved my life, but it nearly ruined my life as well. Within a few weeks of the procedure, when I was at my absolute worst, I received a bill in the mail for $56,000."
Power had insurance, but the air ambulance company wasn't in his network, so he got stuck with the bill. It was enough to bankrupt his family.
Similar stories were repeated throughout Tuesday’s hearing in the Senate Business, Labor and Economic Affairs committee. Patients and family members lined up to tell lawmakers about the health system they see as broken.
The Senate hearing focused on a bipartisan bill that came out of the legislative interim. It aims to protect patients from the huge costs that air ambulance companies charge, by requiring insurance companies to either pay the bill, negotiate a settlement, or fight the air ambulance companies in court.
"We have this gap," says Jesse Laslovich, who helped draft the proposed bill last year. At the time he worked for the State Auditor's office.
"What is being driven by this as I understand it, is money," Laslovich says. "It always comes down to money, right?"
When lawmakers debated the issue last summer, insurance and air ambulance representatives blamed each other for not shouldering more of the cost, leaving patients with big health care bills.
That continued in Tuesday’s hearing. Representatives of the state’s largest insurance companies testified against the proposed legislation.
Bill Lombardi, with Blue Cross and Blue Shield told lawmakers that some air ambulance companies are price-gouging Montanans at their time of greatest need:
"Over the past several years, some profit driven companies have moved into our state. They charge exorbitant prices for emergency air ambulances services and they refuse to negotiate with insurers and consumers to settle bills at affordable and reasonable prices."
Lombardi said that if the bill passes and insurance companies have to pay air ambulance companies or fight over the charges, it could hurt patients even more:
"It will have the unintended consequence of driving up costs for consumers, if they can do it for air ambulance services, what about providers for other services. Where does this stop? Senate Bill 44 has the real potential to encourage in-network providers to leave the networks we worked so hard to build."
Other health insurance companies from around the state also testified that this bill could push some providers out of network, increasing costs for patients.
Helena attorney Bruce Spencer, representing the national health insurance lobby, said the bill would break federal law because it classifies air ambulances as airlines, and states are not allowed to regulate airlines.
"Federal airline deregulation act prohibits states from imposing economic related regulations or statutes on air carriers. So any economic regulations that would impact an air carrier's rates, routes or services are preempted," Spencer said.
A potential conflict with federal law is a big question about this bill. Some lawmakers think that if it’s passed, it'll end up in court.
Bill Bryant, who represents a coalition of air ambulances companies doesn't think that will happen. He says it's insurance companies that need to take on more of the cost of these air ambulance rides:
"It simply makes the insurance companies stand in the shoes of the patient. So instead of having an action against the patient, it is against the insurance company, and eventually a court or an arbitrator's gonna work it out."
After the hearing, Montana lawmakers agreed to send another in a series of letters to Congress asking for a federal law removing air ambulances from laws that regulate airlines.
A proposal by Montana’s Democratic Senator Jon Tester to give states more power to regulate air ambulances has so far failed to move forward.
Tester says he thinks Congress needs to take action on this issue, but it's not a top priority for most lawmakers in D.C.
Governor Steve Bullock’s Administration said Tuesday it does not support the proposed legislation. A spokesperson said they empathize with the people who end up with big air ambulance bills, but this legislation isn’t the right solution, and it could increase the cost of state health plans.
The second air ambulance bill state lawmakers heard Tuesday would basically regulate air ambulance membership programs sold by for-profit companies.
Helena’s Elaine Eidum likes the idea. In 2014 her late husband, Perry, needed to be airlifted to Great Falls:
"I was a state employee. I had really good health insurance, so you wouldn't even – I mean – when I first got that $31,000 bill … you’re just in a state of disbelief," Eidum says.
Some for-profit air ambulance companies sell low-cost memberships. But the memberships don’t cover services by other ambulance companies and patients often don’t have a choice of who picks them up.
The idea is customers would not be billed for the difference between what the company charges and what insurance actually pays out.
Bill sponsor, Representative Ryan Lynch, says that difference can amount to tens of thousands of dollars and financially ruin people who are already facing a mountain of medical bills.
Lynch, a Butte Democrat, says his proposal would hold for-profit air ambulance companies accountable and prevent life-changing sticker shock for their customers:
"What this bill does is move that membership underneath the state Auditor’s office. If folks apply, it'll be regulated as such. It will make sure that they [air ambulance companies] disclose their contract, it'll enforce reciprocity with other providers, and it'll talk about what services are provided and actually provide maps to show what’s covered."
77-year-old retiree, Bob Gilbert, spoke in favor of Lynch's bill, saying he believes air ambulance membership programs are insurance policies in everything but name:
"I certainly couldn't afford a 20, 40, 60, 80, $100,000 bill because I didn’t buy their policy. You could almost call it blackmail; 'If you don’t buy it from me and you have to ride my airplane, you’re stuck.'"
Montana’s Deputy Insurance Commissioner doesn’t see it that way and opposes the proposed regulation.
Bob Biskupiak says state law explicitly spells out that air ambulance providers are not insurers, therefore memberships are not insurance policies.
"Reversing that position doesn't make sense, and we don't believe it's allowed," Biskupiak says.
Biskupiak also wonders where such a precedent would lead if this bill were to pass:
"Regulating insurance on its own is challenge enough, but where do we stop? One day it’s air ambulance memberships, the next it might be other non-insurance contract-based programs."
Furthermore, Montana Deputy State Auditor, Nancy Butler, cautions that regulating air ambulance memberships could run afoul of federal law:
"It could. The reason I say that is because the ADA – the Airline Deregulation Act – which says states may not pass laws that impact price, routes or services of air ambulances. That’s what we struggle with, how do we address issues we’re having without passing a law that is not valid."
Butler says Texas tried and failed to pass similar membership regulations in 2008. And an attempt to regulate air ambulance services on the federal level – one supported by Senator Jon Tester – failed in Congress just last spring.
Bill sponsor Ryan Lynch concedes that federal preemption is a sticking point, even if, he says insurance issues are typically regulated on the state level:
"I think if anything, this is a states rights [issue]. Some of our more conservative friends – Texas, North Dakota, Alaska — have all taken action in this arena. It’s a pretty simple fix, a pretty simple bill. The issue is very, very, very, very complex, but at the end of the day, this is an insurance product and should be treated as such."
The House Business and Labor Committee took no action on the bill.