Trends: Surprise Medical Billing, Robocalls, Elections Preview and More


German college students

Education: K-12 Energy Efficiency Moves to the Head of the Class

It takes energy to run a school. Literally. America’s K-12 education sector spends more than $6 billion a year on energy costs, according to the U.S. Department of Energy. That’s more than annual expenditures on all learning materials, including textbooks and computer equipment.

At least six states have now enacted laws requiring the use of energy efficiency measures in public schools. Several laws require that new construction or major renovation projects meet updated efficiency and sustainability standards, or adhere to a rating system such as LEED, developed by the U.S. Green Building Council. Maryland’s 2017 School Facilities Act, for example, directed the state’s Green Building Council to create guidelines to ensure that new K-12 facilities would be LEED Silver certified.

A couple of states have gone further. Hawaii lawmakers passed a 2016 bill requiring public schools to reach net-zero energy status by 2035, combining high efficiency with on-site renewable energy generation. This year, the Virginia General Assembly enacted similar legislation, requiring new and renovated school buildings to be energy-positive, generating more electricity than they consume.

Other states have instead used incentives to encourage the use of energy-efficient or renewable technologies in school buildings. As part of a 2019 omnibus energy bill, Maine lawmakers created power purchase agreements for solar energy in newly constructed schools. In New York, a 2016 bill formed a collaboration among the state’s power authorities, utilities and school administrators to increase energy-efficient projects throughout the public K-12 system.

The push toward energy efficiency can support other policy goals as well. California’s Clean Energy Job Creation Fund, established in 2018, not only supports clean-energy and energy-efficient projects in public schools, but also creates local jobs. Hawaiian lawmakers hope that 2018 legislation authorizing spending for efficiency upgrades will keep classrooms cool enough to foster better learning and improved academic success.

While the policies differ by state, the benefits of energy efficiency improvements in schools are universal. The Energy Department estimates that reducing energy consumption by just 20% can yield more than $3 billion in savings—money that can instead be spent educating students. To learn more, check out the agency’s Better Buildings initiative, which offers resources for K-12 schools.

—Kate Bell, intern in NCSL’s Energy Program

Health Care: The Best Medical Billing Surprise Is No Surprise

After falling off a ladder, Jerry was taken by ambulance to a hospital within his insurance network. Over the course of 10 days he had surgery and received care from six different doctors, along with X-rays and an MRI.

After returning home, he was surprised to receive bills for thousands of dollars on top of his $5,000 deductible. No one told him that even though the hospital was in the network, the doctors and the lab weren’t. The billing company told him to appeal to his insurance carrier to pay the bill. If the company refused, however, he would be responsible for the charges.

Jerry’s experience is not unusual. Surprise billing, known in the industry as balance billing, affects all demographics. In fact, 18% of all emergency visits and 16% of in-network hospital stays had at least one out-of-network charge, according to a Kaiser Family Foundation survey. In addition, 4 in 10 respondents said they had received an unexpected medical bill in the last 12 months; 1 in 10 reported receiving a surprise bill from an out-of-network provider. And, according to another report in the journal Health Affairs, 1 in 5 patients received care at an emergency department outside their provider’s network.

No One Is Immune

You can incur charges even before you get to the hospital. Transportation provided by land or air ambulances can lead to enormous out-of-network bills. A 2014 study found that 26% of ambulance trips were considered outside the patient’s private insurance network.

Health insurers limit their networks to help control costs. But if there are not enough in-network doctors and services, patients are likely to need out-of-network health care, especially in an emergency.

The National Association of Insurance Commissioners, which oversees carriers, created a model act for state lawmakers to use as a road map for protecting patients against balance billing. To date, Colorado, Georgia, Hawaii and Maryland have adopted the NAIC model act.

Currently, nine states have comprehensive consumer protection laws against surprise billing, while another 16 have partial protections in place, according to researchers at the Georgetown University Center for Health Insurance Reform. The laws vary by state but generally:

  • Prohibit balance billing.
  • Extend consumer protections to include both emergency department and in-network hospitals.
  • Apply to all types of insurance.
  • Prohibit consumers from being held responsible for any extra charges.
  • Set reimbursement standards on how much insurers should pay providers.
  • Establish a process for resolving disputes between providers and insurers.

A Federalism Factor

States’ rates of surprise billing vary as well. According to the Kaiser foundation, emergency care for people with large employer coverage resulted in at least one out-of-network charge 38% of the time in Texas, but only 4% of the time in Nebraska, Alabama and Mississippi.

Variations in rates and laws are why some call for federal action. State laws also do not apply to the roughly 60% of insured Americans enrolled in “self-insured” health plans, which are regulated by the federal Employee Retirement Income Security Act.

Congress is considering several bills. Some support an independent dispute resolution system that would allow doctors and insurers to negotiate out-of-network payment disputes. Others want to use a benchmarking approach that would limit what insurers can charge patients and set reimbursement rates. The Trump administration has pledged to support surprise billing legislation. Now it’s up to Congress to decide which way to go.

—Colleen Becker, policy specialist in NCSL’s Health Program

Telecommunications: States, Industry Take on Robocalls

Your phone rings. You don’t recognize the number but you pick up anyway. Sure enough, you hear a recorded message instead of a live person.

Hello, robocall.

The average person gets about 15 such calls a month. Nearly 5 billion of these so-called unsolicited commercial communications were made in July 2019 alone, the YouMail Robocall Index estimates.

In August, AT&T, Sprint, Verizon and nine other telecommunications companies joined the attorneys general of all 50 states plus the District of Columbia to announce a new pact to eliminate illegal robocalls.

Their agreement, which is set out in a list of anti-robocall principles, includes call-blocking technology that will be merged into the phone networks’ existing infrastructure, at no charge to customers. The technology, known in the industry by the acronym SHAKEN/STIR, will allow a phone network receiving a call to verify that the phone number is legitimate before it reaches the customer.

Arkansas, Kentucky, Nebraska and North Dakota enacted legislation to restrict caller ID spoofing, while Tennessee and Virginia increased penalties for using false caller ID information. New Hampshire amended its prohibition on automated telephone dialing systems that use call blocking. Nationwide, at least 140 bills and resolutions related to robocalls were pending as of June 30.

—Heather Morton

Elections: 2019 Preview

The national news media are fixated on next year’s presidential and congressional races, but in less than two months voters in five states will weigh in on legislative and gubernatorial contests, providing an early reading of the nation’s political mood.

Four states—Louisiana, Mississippi, New Jersey and Virginia—will have legislative races Nov. 5, with Kentucky, Louisiana and Mississippi also holding gubernatorial elections. Of the nation’s 7,383 state legislative seats, 538 will be up for election.

If there’s drama on election night, it’s likely to be in Virginia. Republicans control both chambers of the General Assembly, but by tight margins—just 21-19 in the Senate and 51-49 in the House. If Democrats flip both chambers, Virginia would become the 14th state government under Democratic control. Republicans currently control 22 states.

Polling data in the three states with gubernatorial elections suggests the races will be competitive. Louisiana will hold a first round of voting Oct. 12 and a runoff Nov. 16, if necessary. In Kentucky, incumbent Governor Matt Bevin (R) faces a stiff test from Attorney General Andy Beshear (D). And Mississippi Lieutenant Governor Tate Reeves (R) squares off against Attorney General Jim Hood (D).

Beyond choosing candidates, voters will decide on 23 ballot measures this fall. Louisianans will vote on four measures during their October primary. The rest go to voters on Nov. 5. Nineteen of the measures would amend state constitutions, four propose statutory changes. Two of the measures—both from Washington state—are citizen initiatives. The remaining 21 were referred by legislatures.

Texas, with 10, has the most—and the most heartwarming. Lawmakers are letting voters decide whether to let county law enforcement dogs retire with their handlers when their service is over.

—John Mahoney and Theresa Nelson

Energy: Do You Take Your Energy ‘Clean’ or ‘Renewable’?

The debate over how to reduce carbon emissions across the energy sector has increasingly turned on two words: “renewable” versus “clean.”

After all, while most renewables are clean, clean isn’t necessarily renewable.

It’s a small, technical distinction that will have substantial, real-world effects on how the electric grid transforms in the coming decade as states consider upping the amount of electricity that must come from these resources. This year, lawmakers have been particularly active, with close to a dozen states debating and setting targets at or near 100%.

Hawaii—a state that is highly dependent on imported fossil fuels for electric generation—was the first to push the envelope to 100%. The Legislature passed a law in 2015 requiring 100% of its electricity to come from renewable resources by 2045. This includes wind, solar, hydroelectric, geothermal and biomass. Maine and Puerto Rico recently passed 100% renewable power targets for 2050, while the District of Columbia set the same requirement for 2032.

Discussions elsewhere, however, appear to be moving increasingly toward “clean” energy standards. California, New Mexico and Washington all passed bills in the past 12 months that require 100% carbon-free electricity by 2045. New York requires the same by 2040. Nevada established a voluntary 100% carbon-free goal for 2050. And Illinois, Minnesota, New Jersey, North Carolina and Wisconsin debated similar requirements.

Clean energy standards focus primarily on carbon emissions. They tend to aim for “carbon-neutral” or “carbon-free” electric systems. Washington’s recently enacted law, for example, sets a 2030 carbon-neutrality target, which would allow utilities to offset remaining carbon emissions by purchasing renewable energy credits or paying a fee through 2045, at which point all electricity would have to come from carbon-free resources.

These policies will determine which resources utilities choose to invest in.

Not all carbon-free resources are defined as renewable under state laws. Hydroelectricity provides a little more than 20% of the nation’s carbon-free power, but its status as a qualifying renewable resource varies by state. Meanwhile, nuclear power, which provides around 55% of the carbon-free power in the U.S., does not qualify as renewable. Nuclear and hydro, however, do qualify under recently passed clean energy standards in California, Nevada, New Mexico, New York and Washington.

On the flip side, not all renewables are carbon-free. Most states with renewable portfolio standards include biomass as a renewable, and some also include landfill gas. Both of these produce carbon and other emissions, fueling an ongoing debate.

To confuse matters further, there’s the question of energy storage and advanced battery systems. A battery is itself carbon-free, but if it’s charged by electricity from a coal- or natural gas-fired plant, that electricity has a carbon footprint. And, depending on the technology, its materials may not necessarily be renewable.

These distinctions are important but not necessarily pressing. There are a lot of legislative sessions between now and 2045, and it seems inevitable that changes will be made as the grid transforms and new technologies arise.

It’s worth noting that a clean energy standard does not weaken renewable standards. The conversation has simply turned increasingly carbon-centric. Even in state clean energy standards, the renewables goal is a central pillar. California’s bill requires 60% renewable power by 2030. New Mexico’s is up to 80% by 2040. And Nevada and New York require 50% and 70%, respectively, by 2030.

So, while the conversation over clean versus renewable is ongoing, it is by no means exclusive.

—Daniel Shea, policy specialist in NCSL’s Energy Program

Additional Resources

NCSL Resources