Across America, when people declare bankruptcy, medical bills are the reason they cite most often. It was true well before the Affordable Care Act. But in recent months, the role of surprise, out-of-network medical bills has rocketed to the top of the legislative agenda in Washington DC.

Tennessee has taken a prominent role in this national conversation, both for bringing proposed solutions to the table and, some say, for helping host the problem in the first place.

Surprise medical bills from emergency visits

Most people would never guess that the doctor on staff in the emergency room usually doesn’t work for the hospital at all. Due to long-standing rules in most states against corporations controlling medical decision-makers, the ER doctor probably works for a separate firm that provides doctors to the hospital.

As Nashville Public Radio reports, the two biggest physician staffing firms are both based in Tennessee. The reasons such firms lead to surprise bills are complex and disputed.

When patients get procedures, they’re usually able to shop around and look for in-network doctors. You don’t schedule a routine colonoscopy for weeks from now with an out-of-network doctor. As a result, the doctors and staffing firms rarely get paid out-of-network prices for such procedures.

However, you may take your sudden heart attack to the nearest hospital, or perhaps even to the nearest in-network hospital. Once there, you probably don’t go one step further and ask if the doctor in the ER is personally in-network.

Critics suspect staffing firms rely on situations of patient vulnerability to boost their profits. They’re accused of billing the patient’s insurance company as much as they can get away with and practice what’s known as “balance billing” on the patient’s wallet.

A Tennessee senator looks to pass a fix

The chair of the Senate Committee on Health, Education, Labor and Pensions is Tennessee’s own Lamar Alexander. The senator is retiring in 2020 and hopes to squeeze through some health care legislation before he’s done.

A major goal for his proposal is to essentially force doctors to match the in-network prices at their hospitals.

The CEO of one of the Tennessee staffing companies tells public radio that these rates are not high enough and that insurance companies have too much leverage to drive down rates. Somehow, he says, a way to drive up the contract rates for his company must be built into Alexander’s scheme.