Lowering Health Care Costs for Americans Act
- Sponsor
- Sen. Marshall, Roger [R-KS]
- Committees
- Finance Committee (primary)
- Last action
- Dec 9, 2025
Bottom line
The bill aims to reduce healthcare costs through transparency and market-based reforms while incorporating social policy restrictions on federal healthcare subsidies and accounts.
What it actually does
This bill proposes significant changes to the Affordable Care Act (ACA), primarily by extending enhanced premium tax credits with a phasedown, introducing Healthcare Affordability Accounts (HAAs) with restrictions on their use for abortion and gender transition procedures, and mandating extensive price transparency requirements across hospitals, laboratories, imaging centers, and ambulatory surgical centers. It also streamlines state innovation waivers, increases group health plan access to health data, and requires itemized bills and detailed explanations of benefits for consumers.
Proponents argue
Proponents argue that the bill will empower consumers with unprecedented price transparency, allowing them to shop for healthcare services and drive down costs through market competition. They contend that extending premium tax credits, even with a phasedown, provides continued affordability, while the introduction of HAAs promotes personal responsibility in healthcare spending. Supporters also emphasize the importance of ensuring federal funds are not used for services deemed morally objectionable by a segment of the population, such as abortion and gender transition procedures.
Opponents contend
Opponents contend that the bill's restrictions on Healthcare Affordability Accounts and qualified health plans regarding abortion and gender transition procedures are discriminatory and undermine access to essential healthcare services. Critics also argue that while transparency is laudable, the administrative burden on providers and plans could be significant, and the phasedown of enhanced premium credits could lead to increased costs for many Americans. Concerns may also be raised about the potential for state waivers to weaken consumer protections or reduce coverage adequacy.
The bill is lengthy and technically dense, requiring substantial time to read and understand its numerous provisions and their implications, especially given the detailed definitions and amendments to existing law.
Sec. 101, Title I
Minimum Monthly Premium Payments
This provision amends the Internal Revenue Code to establish minimum monthly premium payments for individuals receiving premium assistance amounts under the Affordable Care Act. The minimum payment ranges from $10 to $40, depending on the taxpayer's household income as a percentage of the poverty line, effectively reducing the maximum premium tax credit available. This change applies to taxable years beginning after December 31, 2025.
Supporters argue
Proponents argue that requiring a minimum premium payment encourages greater personal responsibility in healthcare choices and ensures that individuals have some financial stake in their coverage, potentially reducing moral hazard.
Critics contend
Opponents contend that imposing minimum premium payments, even small ones, could create a barrier to coverage for the lowest-income individuals, potentially leading to a decrease in health insurance enrollment among vulnerable populations.
Tradeoffs
This provision balances the goal of reducing federal subsidy costs and promoting individual financial responsibility against the risk of making health insurance less affordable for those who rely on premium tax credits.
Sec. 102, Title I
Requiring Biometric and ID Verification for ACA Enrollment
This section amends the Patient Protection and Affordable Care Act to require government-issued photo identification for each enrollee over the age of 18, along with any other documentation the Administrator of the Centers for Medicare & Medicaid Services (CMS) deems necessary for enrollment verification. This adds a new layer of identity verification to the ACA enrollment process.
Sec. 103 & 104, Title I
Facilitating Enrollment in and Payment into Healthcare Affordability Accounts (HAAs) with Restrictions
These sections establish 'Healthcare Affordability Accounts' (HAAs) as a type of health savings account (HSA) for individuals receiving ACA premium tax credits. For plan years 2027-2031, premium tax credits will be paid directly into these HAAs. Crucially, amounts in HAAs cannot be used to pay for gender transition procedures or abortions, with specific definitions provided for both terms. Individuals with an HAA cannot have any other HSA, though rollovers into an HAA are permitted.
Sec. 105, Title I
Extension and Phasedown of Temporary Enhanced Premium Credits
This section extends the temporary enhanced premium tax credits, which were set to expire, through January 1, 2032. It also expands eligibility for these credits by raising the household income limitation to 700% of the poverty line for taxable years 2027-2031. However, it introduces a phasedown mechanism, reducing the enhanced amount by 20% increments annually from 2028 to 2031, gradually decreasing the subsidy over time.
Sec. 106 & 107, Title I
Special Rules for Abortion Coverage in Qualified Health Plans and Premium Tax Credits
These sections modify rules for qualified health plans (QHPs) that cover abortion services. Federal funds (including cost-sharing reductions and premium tax credits) cannot be used for the portion of a QHP premium attributable to abortion coverage. Issuers must provide clear notice to enrollees at the time of enrollment that the plan includes abortion coverage, the premium amount for such coverage, and that this amount is not eligible for premium tax credits. The bill also requires detailed reporting of these amounts to the IRS.
Sec. 109, Title I
Exclusion of Gender Transition Procedures from Qualified Health Plans
This section amends the Patient Protection and Affordable Care Act to explicitly state that a qualified health plan (QHP) 'does not provide coverage for gender transition procedures.' It includes a comprehensive definition of 'gender transition procedure,' listing numerous hormonal and surgical interventions, and also defines 'gender transition,' 'sex,' 'female,' and 'male' based on biological characteristics. Certain exclusions are provided for medically verifiable disorders of sex development or precocious puberty.
Sec. 110, Title I
Funding Cost Sharing Reduction Payments with Abortion Coverage Limitation
This section appropriates necessary sums from the Treasury for cost-sharing reduction (CSR) payments for plan years beginning on or after January 1, 2026. However, it explicitly limits these appropriated funds, stating they 'may not be used for purposes of making payments under this section for a qualified health plan that provides health benefit coverage that includes coverage of abortion,' with an exception for abortions necessary to save the life of the mother or in cases of rape or incest.
Sec. 111, Title I
Waivers for State Innovation (1332 Waivers)
This section significantly streamlines and expands the flexibility for states to obtain '1332 waivers' under the ACA. It allows states to submit a certification from the Governor instead of a law, shortens the federal approval timeline to 120 days (or 45 days for expedited cases), and provides more funding flexibility, including specific appropriations for state reinsurance and invisible high-risk pools. Waivers are granted for 6 years and can be renewed indefinitely, with termination only for material non-compliance. It also rescinds previous regulations and guidance on 1332 waivers.
Sec. 201, Title II
Strengthening Hospital Price Transparency Requirements
This section significantly strengthens existing hospital price transparency rules. Hospitals must publicly disclose all standard charges (gross, discounted cash, payer-specific negotiated, and de-identified maximum/minimum negotiated charges) for all items and services in a machine-readable format monthly. They must also provide a consumer-friendly list of at least 300 shoppable services (expanding to all shoppable services by 2027). The bill mandates a uniform method and format, requires attestation from senior officials, and imposes substantially increased civil monetary penalties for non-compliance, with no waivers or mitigation allowed.
Sec. 202, Title II
Increasing Price Transparency of Clinical Diagnostic Laboratory Tests
Beginning July 1, 2027, applicable clinical diagnostic laboratories must publicly disclose on their websites detailed price information for all specified tests. This includes plain language descriptions, billing codes, gross charges, discounted cash prices, payer-specific negotiated charges, and de-identified maximum/minimum negotiated charges. The information must be updated monthly and presented in a uniform, machine-readable format. Non-compliant laboratories face civil monetary penalties up to $300 per day.
Sec. 203, Title II
Imaging Transparency
Starting July 1, 2027, providers and suppliers of specified imaging services (excluding those covered by hospital transparency rules) must publicly disclose detailed price information on their websites. This includes plain language descriptions, billing codes, gross charges, discounted cash prices, payer-specific negotiated charges, and de-identified maximum/minimum negotiated charges. Information must be updated annually and provided in a uniform, machine-readable format. Non-compliant entities face civil monetary penalties up to $300 per day, with no waivers.
Sec. 204, Title II
Ambulatory Surgical Center Price Transparency Requirements
Effective July 1, 2027, specified ambulatory surgical centers (ASCs) – those with an ownership or control interest by a hospital – must comply with new price transparency rules. They must publicly disclose standard charges for all items and services in a machine-readable format, and a consumer-friendly list of at least 300 shoppable services. This includes gross charges, discounted cash prices, payer-specific negotiated charges, and de-identified maximum/minimum negotiated charges. Non-compliant ASCs face civil monetary penalties up to $300 per day, with no waivers.
Sec. 205, Title II
Strengthening Health Coverage Transparency Requirements
This section significantly enhances transparency requirements for health plans. Beginning January 1, 2026, plans must provide a self-service tool (online, paper, or phone) that offers real-time, accurate information on in-network rates, maximum allowed amounts for out-of-network care, individual cost-sharing, accumulated deductible/out-of-pocket maximums, and any frequency/volume limitations. The tool must hold members harmless for discrepancies. Additionally, by January 1, 2027, plans must submit and publicly disclose monthly machine-readable files containing in-network rates for all items/services, historical net prices for drugs, and billed/allowed amounts for out-of-network services. These disclosures require executive attestation and are subject to audits and civil monetary penalties.
Sec. 206, Title II
Increasing Group Health Plan Access to Health Data
This section amends ERISA to ensure that contracts between group health plans and 'Covered Service Providers' (including providers, networks, TPAs, PBMs) are only considered 'reasonable' if they allow the plan fiduciary access to all claims and encounter information, supporting documentation, and pricing terms for value-based arrangements. It prohibits contract terms that unreasonably limit or delay access to this data, including gag clauses. It also mandates specific data formats (e.g., ASC X12N 837 for claims) and imposes civil penalties of $10,000 per day for violations.
Sec. 207, Title II
Oversight of Administrative Service Providers
This section expands on data access requirements, mandating that 'health plan service providers' (including TPAs, PBMs, providers) provide group health plans and issuers with quarterly disclosures of detailed information. This includes claims data, contractual calculation methodologies, all remuneration received (rebates, fees, discounts), and payment data for alternative compensation arrangements (e.g., ACOs, value-based programs). It prohibits contractual provisions that limit or delay this disclosure and imposes a civil penalty of $100,000 per day for non-compliance. These requirements apply to ERISA plans and self-funded non-Federal governmental plans.
Sec. 209, Title II
Requirement for Explanation of Benefits
Beginning January 1, 2026, group health plans and health insurance issuers must provide participants/beneficiaries with a detailed Explanation of Benefits (EOB) within 45 days of receiving a payment request. This EOB must be in plain language, itemized, and include whether the provider is in-network, all applicable billing codes, the amount the plan is paying, the individual's cost-sharing, accumulated deductible/out-of-pocket maximums, and the site of service. This aims to provide clear, post-service financial information.
Sec. 210, Title II
Provision of Itemized Bills
This section requires healthcare providers and facilities to provide individuals with a written, itemized bill for each service within 30 days of receiving final payment from a third party. The bill must include plain language descriptions, all billing codes, prices/billed amounts, payments already made, language assistance information, contact details for billing questions, and charity care policies. Importantly, providers cannot take collection actions if they fail to comply or if the billed amount exceeds a good faith estimate (unless medically necessary due to unforeseen complications), with the burden of proof on the provider. Penalties up to $10,000 per instance of non-compliance are imposed.
The bill includes highly detailed and extensive definitions for 'gender transition procedure,' 'gender transition,' 'sex,' 'female,' and 'male' within the context of Healthcare Affordability Accounts. The definition of 'gender transition procedure' lists 33 specific hormonal or surgical interventions that cannot be paid for with HAA funds, along with specific exclusions.
Sec. 104(a), adding new IRC Sec. 223(i)(7)
Why it matters:The extensive detail in these definitions is likely intended to be legally precise and comprehensive in restricting the use of HAA funds. The biological definitions of sex are a specific policy choice that might be less prominent if not for the detailed list of procedures.
Case for: Proponents argue that precise definitions are necessary to ensure the clear and consistent application of the law, preventing ambiguity and potential loopholes in the restriction of HAA funds for certain procedures. The biological definitions provide a clear framework for the policy.
Case against: Critics contend that such detailed and restrictive definitions, particularly those related to gender and sex, are discriminatory, medically inaccurate, and could be used to deny care beyond the stated intent. They argue that the level of detail makes the provision difficult to navigate and potentially overreaching.
Estimated impact: This provision would directly impact individuals seeking gender-affirming care by explicitly prohibiting the use of their Healthcare Affordability Account funds for a wide range of related medical services.
The bill provides a specific definition for 'abortion' within the context of Healthcare Affordability Accounts, including 'drugs or procedures used with the primary intent to end the life of the human being in the womb,' 'pre-viable delivery not described in clause (ii),' and 'post-viable delivery with intentional death of the fetus.' It also lists specific exclusions, such as separation of mother and embryo/fetus to prevent mother's death or irreversible bodily harm, treatment of ectopic/molar pregnancy, treatment of miscarriage, or in cases of rape or incest.
Sec. 104(a), adding new IRC Sec. 223(i)(7)(F)
Why it matters:The detailed definition is crucial for the legal application of the HAA restrictions, aiming to be precise about what is covered and what is excluded. The exclusions are important concessions that might be less visible if not explicitly detailed.
Case for: Proponents argue that a clear and comprehensive definition of abortion, along with specific exceptions, is essential for the consistent and legally sound implementation of the HAA funding restrictions, ensuring that funds are not used for procedures deemed objectionable while allowing for critical medical interventions.
Case against: Critics may argue that even with exclusions, the definition is overly broad or could be subject to interpretation that limits access to reproductive healthcare. They might also contend that the very act of defining and restricting abortion in this context is an undue interference in healthcare decisions.
Estimated impact: This definition would directly govern which reproductive health services are eligible for payment through Healthcare Affordability Accounts, impacting individuals seeking abortion services and the providers offering them.
This section explicitly states, 'The Secretary shall not grant or extend any waiver, delay, tolling, or other mitigation of a civil monetary penalty for violation of this subsection.' This applies to hospital price transparency requirements.
Sec. 201(e)(5)(C), Public Health Service Act
Why it matters:This provision is a strong signal of intent regarding strict enforcement, ensuring that the penalties for non-compliance with price transparency are applied without administrative discretion, which might be politically difficult to pass if highlighted as a standalone measure.
Case for: Proponents argue that this 'no waiver' clause is essential to demonstrate the government's commitment to enforcing price transparency, preventing hospitals from seeking exemptions or delays that would undermine the policy's effectiveness. It ensures accountability.
Case against: Opponents might argue that a complete prohibition on waivers or mitigation removes necessary flexibility for unforeseen circumstances, technical difficulties, or good-faith efforts to comply, potentially leading to unfair penalties for hospitals facing legitimate challenges.
Estimated impact: This provision ensures that hospitals found in violation of price transparency rules will face penalties without administrative leniency, potentially leading to higher aggregate fines and stricter compliance pressure.
This section mandates that regulations for health plan transparency files (machine-readable files) must provide that the Secretary of HHS shall audit no fewer than 20 group health plans or health insurance issuers, and the Secretary of Labor shall audit no fewer than 200 group health plans or service providers furnishing third-party administrator services. Findings and enforcement actions must be reported annually to Congress.
Sec. 205(b), adding new PHSA Sec. 1311(e)(3)(E)(iii)(V)
Why it matters:The specific numerical targets for audits signal a strong intent for robust enforcement, which might be politically sensitive if highlighted. Burying it within rulemaking details allows for a strong enforcement signal without drawing immediate attention to the resource implications or potential industry pushback.
Case for: Proponents argue that explicit audit targets are essential to ensure that the extensive new transparency requirements for health plans are actually enforced, preventing non-compliance and ensuring the integrity of the disclosed data. Annual reporting provides accountability.
Case against: Opponents might argue that setting specific numerical audit targets in statute could be inflexible, potentially diverting resources from more impactful enforcement actions or creating an arbitrary burden on agencies. They may also question the capacity of the agencies to conduct such a large number of audits effectively.
Estimated impact: This provision would significantly increase the audit workload for HHS and the Department of Labor, requiring substantial resources to meet the mandated targets and potentially leading to more enforcement actions against non-compliant health plans and service providers.