Medicare Expansion and Lowering Costs Now Act
- Sponsor
- Rep. Krishnamoorthi, Raja [D-IL-8]
- Committees
- Ways and Means Committee (primary)
- Last action
- Mar 12, 2026
Bottom line
The bill aims to expand access to Medicare benefits, reduce healthcare costs for beneficiaries, and stabilize the individual health insurance market through a combination of new programs, subsidies, and regulatory changes.
What it actually does
This bill establishes a Medicare buy-in option for individuals aged 50 to 64, provides for a Medicare Direct Supplemental Insurance Option (Medigap-like coverage), authorizes the Secretary to negotiate lower Part D drug prices, creates an Individual Market Reinsurance Fund to stabilize health insurance markets, reauthorizes risk corridors, and expands eligibility for premium tax credits under the Affordable Care Act. It also repeals certain reconciliation health provisions from a prior public law.
Proponents argue
Supporters argue that this legislation will significantly lower healthcare costs for millions of Americans, particularly those nearing retirement age who face high premiums. They contend it strengthens the Affordable Care Act's marketplaces, ensures more comprehensive coverage, and leverages Medicare's purchasing power to negotiate better drug prices, ultimately making healthcare more affordable and accessible.
Opponents contend
Critics might contend that expanding Medicare eligibility could strain the program's long-term financial solvency, despite the proposed buy-in premiums. They may also argue that increased government intervention in drug pricing could stifle pharmaceutical innovation and that the expansion of federal subsidies and programs could lead to market distortions in the private insurance sector.
The bill is moderately complex, requiring careful reading due to its multiple titles, amendments to existing acts, and intricate financial mechanisms. An informed reader would need adequate time to fully grasp its implications.
Sec. 3, Title XVIII of the Social Security Act, new Sec. 1899D
Medicare Buy-In Option for Ages 50-64
This provision allows individuals aged 50 to 64 who are not otherwise eligible for Medicare to buy into the program. Enrollees would receive the same benefits and protections as traditional Medicare beneficiaries (Parts A, B, and D), including access to Medicare Advantage plans. Premiums would be actuarially determined to cover costs, with adjustments for geographic factors and potentially age, and financial assistance similar to ACA premium tax credits and cost-sharing reductions would be available.
Supporters argue
Supporters argue this provision addresses a critical gap in coverage for older Americans who may struggle to afford private insurance before Medicare eligibility, providing a stable, comprehensive, and potentially more affordable option.
Critics contend
Critics might argue that this expansion could lead to adverse selection in the ACA marketplaces by drawing healthier individuals to Medicare, or that it represents an undue expansion of government's role in healthcare, potentially increasing long-term federal liabilities.
Tradeoffs
The provision balances the goal of expanding access and lowering costs for a specific age group against concerns about the fiscal impact on Medicare and potential disruption to the existing individual health insurance market.
Sec. 4, Title XVIII of the Social Security Act, new Sec. 1882A
Medicare Direct Supplemental Insurance Option (Medigap)
This section establishes a voluntary federal program to supplement traditional Medicare benefits, covering deductibles, copayments, and other cost-sharing amounts, including balance billing, subject to a $100 annual deductible. Enrollment periods are specified, and premiums are community-rated, with a late enrollment penalty. The program aims to provide a standardized, federally-administered Medigap-like option.
Sec. 5, Section 1860D-11(i) of the Social Security Act
Negotiation of Lower Covered Part D Drug Prices
This section amends current law to authorize the Secretary of Health and Human Services to negotiate with pharmaceutical manufacturers for lower prices on covered Part D prescription drugs. It explicitly removes the non-interference clause that previously prevented such negotiations, while clarifying that the Secretary cannot establish or require a particular formulary. The negotiated prices would apply to prescription drug plans and MA-PD plans.
Sec. 6, Individual Market Reinsurance Fund
Individual Market Reinsurance Fund
This section establishes an Individual Market Reinsurance Fund, administered by the Secretary, to provide payments to health insurance issuers for high-cost individuals enrolled in qualified health plans (QHPs) in the individual market. The program would cover 80% of claims exceeding a specified attachment point ($50,000 for 2026-2028, $100,000 thereafter) up to a cap ($450,000 for 2026-2028, $400,000 thereafter), with dollar amounts indexed annually. The fund is financed by fees charged to participating QHPs.
Sec. 7, Section 1342(a) of the Patient Protection and Affordable Care Act
Reauthorization of Risk Corridors
This section reauthorizes the Affordable Care Act's (ACA) risk corridors program for calendar years 2028 through 2031. The risk corridors program is designed to protect health insurance issuers from excessive losses or gains by transferring funds between plans with higher-than-expected costs and those with lower-than-expected costs, thereby stabilizing premiums in the individual and small group markets.
Sec. 9, Subtitle B of title VII of Public Law 119-21
Repeal of Reconciliation Health Provisions
This section repeals Subtitle B of Title VII of Public Law 119-21, an Act to provide for reconciliation pursuant to title II of H. Con. Res. 14. It specifies that any law or regulation referred to in that subtitle shall be applied as if the repealed subtitle and its amendments had never been enacted. The specific content of the repealed provisions is not detailed within this bill.
Sec. 10, Section 36B(c)(1)(A) and 36B(b)(3)(A) of the Internal Revenue Code of 1986
Increase in Eligibility for Premium Tax Credit
This section significantly expands eligibility for the Affordable Care Act's (ACA) premium tax credits by striking the 400 percent of poverty line income cap. It also revises the 'applicable percentages' used to calculate the tax credit, effectively lowering the percentage of household income individuals are expected to pay for health insurance premiums across all income tiers, including those above 400% of the federal poverty line.
This clause specifies detailed requirements for the Secretary to determine the amount of financial assistance transferred to the Medicare Buy-In Trust Fund. It mandates calculations on a per-enrollee basis, considering age, income, geographic differences, health status for risk adjustment and reinsurance, and potential reconciliation of credits/reductions, with a special focus on enrollees below 200% of poverty.
Sec. 3(g)(2)(C)(ii), new Sec. 1899D(g)(2)(C)(ii) of the Social Security Act
Why it matters:This level of detail is standard for complex financial mechanisms in legislation, ensuring precise calculation and preventing unintended fiscal consequences. It's not necessarily evasive but requires expert interpretation.
Case for: Proponents would argue that these detailed requirements are crucial for ensuring the financial integrity of the Medicare Buy-In program, accurately reflecting the value of subsidies, and preventing adverse selection by accounting for various risk factors.
Case against: Critics might argue that the complexity of these calculations could lead to administrative challenges and potential inaccuracies, making it difficult to predict the true cost and impact of the financial assistance mechanism.
Estimated impact: This provision directly influences the accuracy and sufficiency of federal transfers to subsidize the Medicare Buy-In, impacting billions of dollars in potential federal outlays and the financial viability of the program.
This clause prohibits States from buying their Medicaid beneficiaries (ages 50-64) into Medicare under this new section. An exception is made for Medicaid beneficiaries whose coverage does not meet the definition of minimum essential coverage under federal regulations.
Sec. 3(h)(3), new Sec. 1899D(h)(3) of the Social Security Act
Why it matters:This is a standard legislative practice to prevent states from cost-shifting their Medicaid populations to a new federal program, which could have significant fiscal implications for the federal government. It's a technical detail to manage program boundaries.
Case for: Proponents would argue this prevents states from offloading their Medicaid responsibilities onto the federal Medicare Buy-In program, ensuring that the new program serves its intended population without becoming a substitute for existing state-funded coverage.
Case against: Critics might argue that allowing states to buy into Medicare for their Medicaid populations could streamline administration and potentially offer better benefits to some beneficiaries, and this prohibition limits state flexibility.
Estimated impact: Prevents potentially billions in state cost-shifting to the federal government, maintaining the fiscal separation between Medicaid and the new Medicare Buy-In program.
This subsection mandates the Secretary to request the National Association of Insurance Commissioners (NAIC) to revise Medigap standards. The revisions must include requirements for Medigap policies to accept every individual eligible for the new Medicare Buy-In option during a 30-day enrollment period following their buy-in enrollment, and during a transition period from buy-in to traditional Medicare eligibility.
Sec. 3(aa), Section 1882 of the Social Security Act
Why it matters:This is a technical but crucial detail to ensure that individuals buying into Medicare have access to supplemental coverage, mirroring existing Medigap protections for traditional Medicare enrollees. Its placement is typical for amendments to existing law.
Case for: Proponents would argue that this ensures comprehensive coverage for Medicare Buy-In enrollees, preventing them from facing gaps in coverage or being denied supplemental policies due to pre-existing conditions, which is a key protection for traditional Medicare beneficiaries.
Case against: No specific opposition is typically raised against ensuring Medigap access for new Medicare populations, as it aligns with existing policy principles, though private insurers might have concerns about the financial implications of guaranteed issue for this new group.
Estimated impact: Ensures access to Medigap for potentially millions of Medicare Buy-In enrollees, providing financial protection against out-of-pocket costs and impacting the private Medigap market by expanding the guaranteed-issue population.
This clause grants the Secretary flexibility to substitute higher dollar amounts for the specified attachment points and caps in the reinsurance program, provided the Secretary certifies that such substitutions, considered together, neither increase nor decrease the total projected payments under the subsection (i.e., are budget neutral).
Sec. 6(b)(5), Individual Market Reinsurance Program
Why it matters:This provision grants the Secretary significant administrative discretion to adapt the reinsurance program's parameters to changing market conditions without requiring new legislation, while maintaining fiscal guardrails. It's a common way to provide flexibility in complex programs.
Case for: Proponents would argue that this flexibility is essential for the Secretary to effectively manage the reinsurance program in a dynamic healthcare market, allowing adjustments to optimize its impact on premiums and market stability without exceeding budgetary limits.
Case against: Critics might argue that granting such broad administrative discretion could lead to less transparency and accountability in how the program is managed, potentially allowing for adjustments that could subtly shift burdens or benefits without direct congressional oversight.
Estimated impact: This provision impacts the operational effectiveness and financial distribution of potentially billions of dollars in reinsurance payments, allowing the Secretary to fine-tune the program's parameters to achieve budget neutrality and market stabilization goals.