HR6538-119

What This Bill Does

The More Affordable Care Act creates a new ACA section 1335 health-freedom waiver program for plan years beginning on or after January 1, 2026. A State may waive selected ACA exchange, subsidy, and tax provisions if it maintains an invisible high-risk pool or similar premium-risk mitigation program and files notice at least 90 days before participation. If a waiver structure means eligible residents or small employers no longer receive premium tax credits, cost-sharing reductions, or small business credits through an exchange, the bill requires equivalent amounts to be paid into Trump Health Freedom Accounts for eligible residents, calculated using national average silver benchmark premiums in nonwaiver States. Waiver States may operate an exchange, allow private commercial platforms, or rely on a federal exchange applying State law. HHS and Treasury must issue implementing regulations within one year, while preexisting-condition and other Public Health Service Act consumer protections are preserved. The bill also amends section 223 to define Trump Health Freedom Accounts as HSA-like accounts for waiver-State residents, restricts account spending on abortion services and gender-transition procedures, modifies the small-employer health insurance credit in waiver States, and requires HHS, Treasury, and Labor within 90 days to update price-transparency rules so hospitals, health plans, and providers disclose actual prices, standardized comparable data, enforcement policies, and outcomes data.

Who Benefits and How

States benefit from a broader waiver pathway if they want to replace ACA exchange rules with high-risk-pool-backed alternatives. Eligible waiver-State residents benefit from direct Trump Health Freedom Account deposits tied to forgone premium and cost-sharing subsidies. Small employers in waiver States benefit from modified health-insurance credit rules, including expanded employee-count treatment and removal of some limits. Private exchange platforms benefit from a State-authorized role selling approved health plans. Patients benefit from actual-price and outcomes reporting that can make hospital and health-plan comparisons more meaningful.

Who Bears the Burden and How

HHS waiver staff and Treasury tax administrators must coordinate waiver approvals, account payments, API access, regulations, and tax rules. States seeking waivers must maintain high-risk insurance pools or similar programs and file notices at least 90 days before participation. Health insurers and private platforms must operate under State waiver rules. Hospitals, health plans, and providers must comply with updated price and outcomes reporting. Federal taxpayers bear subsidy transfers into accounts and revenue effects from modified credits. Account users must comply with spending restrictions or face tax consequences.

Key Provisions

• Establishes a health-freedom waiver program for States beginning in plan year 2026.
• Requires waiver States to maintain invisible high-risk pools or similar premium-risk programs.
• Provides Trump Health Freedom Account payments equal to forgone premium tax credits and cost-sharing reductions.
• Authorizes State exchanges, State-approved commercial platforms, or federal exchanges applying State waiver law.
• Creates HSA-like tax rules and spending restrictions for Trump Health Freedom Accounts.
• Modifies the small-employer health insurance credit in waiver States.
• Requires updated actual-price, comparable-pricing, enforcement, and outcomes-data reporting by health care entities.