HR1157-119

What This Bill Does

The ACCESS Act allows low-to-moderate income people who buy health insurance through the Affordable Care Act (ACA) marketplaces to choose a different form of government subsidy. Instead of getting automatic discounts when they visit the doctor or fill prescriptions (called "cost-sharing reductions"), they can opt to receive that same dollar value deposited monthly into a Health Savings Account (HSA). To choose this option, they must enroll in a high-deductible health plan. The bill requires all insurance companies offering mid-tier ("silver level") plans on the exchanges to also offer a high-deductible version, and appropriates federal funds to reimburse insurers who make these HSA contributions starting in 2026.

Who Benefits and How

Financial institutions and banks benefit by gaining new customers for HSA accounts, which generate account fees and investment management revenue. Medical debit card processors benefit from the requirement that HSA funds be spent only through special debit cards, creating new transaction fee revenue. Insurance companies offering high-deductible health plans benefit from federal reimbursement for HSA contributions they make, creating a new government-funded revenue stream, though they also face new compliance requirements to offer HDHP alternatives and track monthly contributions. Higher-income eligible individuals (those closer to 250% of the federal poverty level) who can afford to delay medical care and manage savings strategically may benefit from the flexibility of controlling their own healthcare dollars in an HSA.

Who Bears the Burden and How

Low-income enrollees with chronic conditions or immediate healthcare needs bear the greatest burden, as switching from traditional cost-sharing reduction (which provides instant discounts at the point of care) to a high-deductible plan means paying full price for medical services until reaching the deductible, even though money sits in their HSA. Healthcare providers may see increased bad debt from patients who face higher upfront costs before their deductibles are met. The Department of the Treasury and IRS must build and administer an entirely new system to track monthly HSA contribution elections, reimburse insurers, enforce the medical debit card requirement, and apply complex tax credit recapture rules when people's incomes change mid-year. ACA exchanges (both federal and state) must educate enrollees about this complex new option and coordinate enrollment elections with insurers.

Key Provisions

• Creates an opt-in program allowing ACA subsidy recipients to receive monthly HSA contributions instead of traditional cost-sharing discounts, calculated to equal the actuarial value of their foregone subsidies based on household income
• Mandates that insurance companies offering any silver-level plan on ACA exchanges must also offer an actuarially equivalent high-deductible health plan to anyone who would qualify for cost-sharing subsidies
• Restricts how HSA funds can be spent during months when government contributions are received - enrollees can only use a special "qualified medical debit card" issued by a bank and encoded to block non-medical purchases
• Applies tax credit recapture rules so that if someone's actual annual income differs from their estimated income, they must pay back excess HSA contributions just like excess premium tax credits
• Appropriates unlimited funding ("necessary amounts") to the Treasury Department to reimburse insurance companies for all HSA contributions they make to enrollees who elect this option, effective for coverage starting January 2026