No Surprises Act Cuts Patient Out-of-Pocket Costs but Leaves Premiums Unchanged
The No Surprises Act (NSA) has succeeded in lowering out-of-pocket spending for privately insured adults in states that previously lacked protections from surprise medical bills, though it has not significantly reduced premiums or overall financial strain, according to a study published in The BMJ.
Surprise medical bills arise when patients unknowingly receive out-of-network care and are charged the difference between provider fees and insurer payments, often amounting to thousands of dollars beyond out-of-pocket limits. Federal protections for publicly insured patients existed for years, but privately insured patients gained consistent safeguards only with the NSA, enacted in 2022. The bipartisan law bans most surprise billing, caps cost-sharing at in-network rates and created a dispute resolution process for insurers and providers.
The US Department of Health and Human Services released a 2023 report to Congress on the NSA, but there is limited information about changes in patient healthcare spending since its implementation. “Therefore, using a quasi-experimental difference-in-differences design, we comprehensively evaluated out-of-pocket, premium, and high burden medical spending among adults with direct purchase private insurance residing in states that gained surprise billing protections under the NSA compared with their counterparts residing in states with protections already in place,” explained Michael Liu, Section of Health Policy, Richard A and Susan F Smith Center for Outcomes Research, Beth Israel Deaconess Medical Center, and Department of Medicine, Brigham and Women’s Hospital in Boston, MA, USA, and coauthors.
Researchers used data from the US Census Bureau’s Current Population Survey Annual Social and Economic Supplement (2019–2024) to assess the NSA’s financial impact on adults aged 19 to 64 years with direct purchase private insurance. They compared outcomes in 18 states that gained protections under the NSA (“intervention states”) to 6 states that had already enacted comprehensive surprise billing laws (“control states”). The analysis included 17 351 adults, with adjustments made for demographics and socioeconomic status.
Out-of-pocket spending dropped substantially in intervention states after the NSA’s implementation. Average annual spending decreased from $3674 to $2922, a relative reduction of 16.5%. Compared with control states, intervention states saw an additional $567 reduction per household (P =.02). Premium spending also declined in both intervention and control states, but the reductions were nearly identical, suggesting no added benefit from the NSA in this category. Similarly, rates of “high burden medical spending,” defined as health costs exceeding 10% of family income, remained unchanged.
Sensitivity tests confirmed the main results: significant decreases in out-of-pocket spending but no changes in premiums or high-burden spending. Importantly, the findings held across demographic groups, including by race, income, and education level.
“These findings suggest that the NSA successfully shielded patients from surprise medical bills in the US, though additional efforts are needed to alleviate healthcare related financial strain,” concluded the study authors.
Reference
Liu M, Kadakia KT, Mein SA, Wadhera RK. Patient healthcare spending after the No Surprises Act: quasi-experimental difference-in-differences study. BMJ. 2025;390:e084803. Published 2025 Aug 27. doi:10.1136/bmj-2025-084803
