Six years in, the No Surprises Act (NSA) has delivered on one critical promise: patients are protected from surprise out-of-network medical bills. But new Georgetown University research published in Health Affairs Forefront shows the law’s arbitration system is imposing staggering (and exponentially increasing) costs behind the scenes — more than $22.4 billion in estimated costs over just four years — with employers and workers ultimately absorbing the pressure.
The new analysis updates prior cost estimates and demonstrates that the NSA’s independent dispute resolution (IDR) process has not proven to be the cost saver lawmakers expected. Dispute volume, awards, and provider win rates continue to climb, turning a consumer protection law into a growing affordability challenge for employer-sponsored coverage.
- Costs are mounting fast. From Spring 2022 through 2025, the IDR process generated an estimated $22.4 billion in total costs, which researchers warn is already beginning to push premiums higher.
- Disputes are surging. IDR filings rose 77% from 2024 to 2025, far exceeding the modest caseload policymakers originally expected.
- Awards remain deeply out of balance. Providers continue to win roughly 85% of disputes, often at more than 4.5 times median in-network rates, with some specialties receiving far higher awards.
- Outcomes vary widely by arbiter. One IDR entity ruled for providers in nearly every dispute, while another did so in just over half, underscoring how inconsistent decisions are fueling uncertainty and higher costs.
This summer ERIC President and CEO James Gelfand spoke at a congressional briefing, calling attention to the IDR process’ impact on employers offering employer-sponsored coverage. He warned that the current arbitration framework is undermining the employer-sponsored system that covers millions of Americans:
“We like the No Surprises Act; we want to protect patients. But if we want to continue having a system where employers and unions work together to make sure 160 million people have health insurance through the private sector, not the government, we have to do something to restore accountability and balance to this system.”
Given the scale of the problem, Congress must recalibrate the IDR process to restore the law’s original cost-containment goals while preserving the consumer protections that remain essential. ERIC is actively advocating for change. Track ERIC’s push to restore balance to the NSA arbitration process at eric.org/nsa. The site includes policy one-pagers, ERIC’s letter opposing the No Surprises Act Enforcement Act, the latest media coverage, and more. If you’re an employer, you can join ERIC’s IDR Task Force.
Click the link to learn more.