When President Donald Trump signed the No Surprises Act, he delivered a real victory for American patients. For the first time, families couldn’t be ambushed by crippling out-of-network bills after an emergency they never chose. It was the commonsense, pro-patient reform Washington had promised for decades and never delivered. Trump got it done.But a law is only as good as its implementation. The Biden administration failed to implement it properly, leaving loopholes that benefit their friends and donors in the hospital industry. Bureaucrats and well-funded special interests turned one of Trump’s signature healthcare achievements into a money machine at the expense of the families it was meant to protect.The culprit is the law’s arbitration system, the Independent Dispute Resolution process. Designed as a last resort to settle payment fights between insurers and out-of-network providers, it has instead been captured by a handful of private equity-backed provider groups and arbitration “middlemen.” There have been roughly 1.2 million disputes in just the first half of 2025 — more than double the year before, and far beyond the 17,000 annual disputes regulators originally projected. Providers now initiate 99.9% of all cases and win 88% of them, routinely collecting three to nine times the in-network rate. Some groups’ awards exceed more than 900% of the benchmark price.