If you’ve ever been hit with a slew of confusing bills after a hospital stay, had a long wait for an insurance approval or struggled to pay an unexpectedly high medical bill, you know how frustrating health care in North Carolina can be.
In fact, by at least one measure, it’s the worst in the nation: A 2024 Forbes Advisor analysis found that the state had the highest average premium for employer-sponsored insurance that includes a worker and a “plus-one.”
This session, under growing pressure from patients and health care providers, lawmakers in Raleigh are considering a series of bills designed to trim health care costs and improve access.
Advocates say they are cautiously optimistic.
“There seems to be more of an appetite than ever before to try and address some of the pain points,” said Rebecca Cerese, health policy advocate for the North Carolina Justice Center. “It is heartening that they are looking at different mechanisms and trying to figure out some solutions.”
The Ledger/NC Health News has highlighted many of the issues that the General Assembly proposals address. Here’s a look at what’s on the table:
Prior authorization reform
Legislation approved by both chambers would make changes to prior authorization — the process insurers use to decide whether to pay for specific treatments ordered by providers. Doctors say prior authorization can delay essential care, sometimes leading to serious health consequences or even death. Insurers say the process is necessary because sometimes doctors will “upcode,” asking for more expensive treatments so that they can earn more reimbursement.
Bills originating from each chamber would require insurers to respond to urgent care requests within 24 hours, up from the current three business days. They would both also require the doctor reviewing a case for the insurer to be in the same specialty as the care, so a dermatologist, say, can’t deny care related to a knee injury.
House Bill 434 bill goes further, requiring the insurer’s doctor to be licensed to practice in North Carolina. And it says that if a provider has been approved for a specific treatment 80 percent of the time, insurers could no longer require prior authorization.
Senate Bill 316 includes a provision that artificial intelligence can’t be the “sole basis” for a denial.
Because the House and Senate approved different versions, members will be obliged to hash out their differences in a conference committee, a process that sometimes produces compromise and that sometimes produces deadlock.
Facility fee crackdown
As hospital systems buy medical practices and clinics, more North Carolinians are being hit with surprise hospital facility fees, even if their care didn’t take place on a hospital campus.
A Ledger/NC Health News story last year dug into the trend and told the story of a Charlotte breast cancer survivor whose regular $75 checkup jumped to $400 after her clinic was acquired by Novant Health.
North Carolina Senate members approved, by a bipartisan vote of 44-2, a bill that would ban facility fees for care delivered at places that aren’t on a hospital campus — such as your doctor’s office or outpatient clinic — unless it's at a remote location of a hospital, a facility that includes an emergency department or at an ambulatory surgical facility.
The North Carolina House of Representatives hasn’t approved a similar bill, but the topic will likely come up when the two chambers meet to negotiate differences in their health care bills.
More billing transparency
Medical bills are confusing, and part of the problem is that patients have no idea what their health care costs will be until the bills arrive.
Even then, billing statements are often hard to understand and contain errors. A 2024 Ledger/NC Health News story highlighted the case of a leukemia patient whose credit score was ruined due to a series of billing mistakes, miscommunication and delays in billing.
A provision in a bill from the North Carolina Senate would require health care systems to provide a plain-language, good-faith estimate of what your care will cost before a non-urgent procedure — and the final invoice couldn’t be more than five percent higher.
Senate Bill 316 also requires hospitals and ambulatory surgical facilities to send you an itemized list of charges “in language comprehensible to an ordinary layperson” before sending an unpaid bill to collections.
Finally, it would require hospitals and ambulatory surgical facilities to report to the state the costs for their 20 most common surgical procedures and the 20 most common imaging procedures at least once a quarter.
Other health-care related reforms
Other changes being considered in Raleigh would have a less direct impact on patients but could potentially help lower the cost of care and improve access. They include:
- Certificate of need law changes: Senate Bill 370 and House Bill 455 would repeal the system that requires health care providers to get state approval before opening certain types of health care facilities. Proponents say that would allow for more competition and lower prices in more kinds of health care settings, like ambulatory surgical clinics. Hospitals argue that removing those guardrails mean they’d be left holding the bag for less well-reimbursed, but necessary, services like emergency care and labor and delivery.
- More independence for certain nurses: House Bill 537 and Senate Bill 537 would expand the authority of advanced practice registered nurses such as nurse practitioners, nurse anesthetists and certified nurse midwives, allowing them to practice without physician supervision, which the nurses argue is superficial. Physicians’ groups say it’s a safety issue, even as dozens of other states have allowed for greater nurse autonomy without a problem.
- Limit on health insurance mandates: Among other provisions, Senate Bill 24 requires any new mandate for health benefit plans to be offset by the repeal of an existing one. Lawmakers said the bill would help control rising health care costs because they would have to consider the financial impact before expanding benefits.
It’s hard to say how much — if any — of this legislation will make it through both chambers and land on the governor’s desk. Similar proposals have stalled in the past.
Cerese says she’s hopeful, noting that her organization, which is left-leaning, and the conservative John Locke Foundation both support some of the proposals.
If you want to have a say in these bills or others, you can always reach out to your reps and senators by entering your address into the General Assembly's “Find Your Legislators” tool.
Ultimately, she says, as hospital systems continue to grow and consolidate, the state’s leaders will need to have “a much deeper conversation … because it's the system itself that puts profit at the center — rather than patient care — that is really the problem.”
(If you want to have a say in these bills or others, you can always reach out to your reps by entering your address into the General Assembly's “Find Your Legislators” tool.)
Even if they are approved, Cerese noted that proposed federal cuts could wipe out some of the recent progress North Carolina has made, including its 2023 expansion of Medicaid. Congress is considering cuts to the Medicaid program; the federal government pays two-thirds of North Carolina’s Medicaid tab.
“Unfortunately, while these transparency efforts are great, the bigger question is how much we’ll need to backfill if the federal cuts go through,” Cerese said. “There’s not much appetite here to use public money to cover those gaps — and that’s a real concern.”
This article is part of a partnership between The Charlotte Ledger and North Carolina Health News to produce original health care reporting.
You can support this effort with a tax-free donation.
This article first appeared on North Carolina Health News and is republished here under a Creative Commons Attribution-NoDerivatives 4.0 International License.
