H.R. 6538

[Congressional Bills 119th Congress]
[From the U.S. Government Publishing Office]
[H.R. 6538 Introduced in House (IH)]

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119th CONGRESS
1st Session
H. R. 6538

To establish a health freedom waiver program, to promote better price 
reporting and outcomes, and for other purposes.

_______________________________________________________________________

IN THE HOUSE OF REPRESENTATIVES

December 9, 2025

Mr. Pfluger (for himself, Mr. Bean of Florida, Mrs. Fedorchak, Mr. 
Baird, and Mr. Clyde) introduced the following bill; which was referred 
to the Committee on Energy and Commerce, and in addition to the 
Committee on Ways and Means, for a period to be subsequently determined 
by the Speaker, in each case for consideration of such provisions as 
fall within the jurisdiction of the committee concerned

_______________________________________________________________________

A BILL

To establish a health freedom waiver program, to promote better price 
reporting and outcomes, and for other purposes.

Be it enacted by the Senate and House of Representatives of the 
United States of America in Congress assembled,

SECTION 1. SHORT TITLE.

This Act may be cited as the ``More Affordable Care Act''.

SEC. 2. HEALTH FREEDOM WAIVER PROGRAM.

Part 4 of subtitle D of title I of the Patient Protection and 
Affordable Care Act (42 U.S.C. 18051 et seq.) is amended by adding at 
the end the following:

``SEC. 1335. HEALTH FREEDOM WAIVER PROGRAM.

``(a) In General.--
``(1) Waiver program.--The Secretary shall waive all or any 
requirements described in paragraph (4), as determined by the 
applicable State, for plan years beginning on or after January 
1, 2026, with respect to health insurance coverage within any 
State that submits a notification under paragraph (2), provided 
that the State maintains an invisible high-risk insurance pool 
or another program designed to mitigate risk to insurance 
premium costs.
``(2) Notification.--A State entity described in paragraph 
(3) desiring a waiver under this section for any plan year 
beginning on or after January 1, 2026, shall notify the 
Secretary of its intent to participate in the waiver program 
with respect to all or any requirements described in paragraph 
(4). Such notification shall be filed at such time, not later 
than 90 days before the State intends to begin participation in 
the waiver program, and in such manner as the Secretary may 
require, and contain such information as the Secretary may 
require, including the requirements under paragraph (4) that 
the State intends to waive and evidence that the State 
maintains a high-risk insurance pool.
``(3) State submission.--A notification with respect to a 
State may be submitted by--
``(A) the governor of the State; or
``(B) the legislature of the State, upon a majority 
vote by the State legislature.
``(4) Requirements.--The requirements described in this 
paragraph with respect to health insurance coverage within the 
State are as follows:
``(A) Part 1 of subtitle D.
``(B) Part 2 of subtitle D.
``(C) Section 1402.
``(D) Sections 36B and 5000A of the Internal 
Revenue Code of 1986.
``(5) Money follows the person.--
``(A) In general.--With respect to a State waiver 
under paragraph (1), under which, due to the structure 
of the State plan, individuals and small employers in 
the State would not qualify for the premium tax 
credits, cost-sharing reductions, or small business 
credits under sections 36B of the Internal Revenue Code 
of 1986 or under part I of subtitle E for which they 
would otherwise be eligible, the Secretary shall 
provide for an alternative means by which the aggregate 
amount of such credits or reductions that would have 
been paid on behalf of participants in the Exchanges 
established under this title had the State not received 
such waiver, shall be paid into the Trump Health 
Freedom Accounts established under section 223(i) of 
the Internal Revenue Code of 1986 of eligible residents 
of the State.
``(B) Payments to trump health freedom accounts.--
The Secretary shall pay into the Trump Health Freedom 
Account of each eligible resident of a State for which 
a waiver is in effect for a plan year the amount equal 
to the total amount for which the resident would have 
been eligible in premium tax credit amounts under 
section 36B of the Internal Revenue Code of 1986 and 
cost-sharing reduction amounts under section 1402 for 
the year, had the State not had such waiver in effect. 
In determining the appropriate payment amount under 
this subparagraph, the Secretary shall calculate 
premium tax credit amounts and cost-sharing reduction 
amounts based on the national average annual premium 
amount for a silver tier benchmark plan among States 
that do not have such waivers in effect for the 
applicable year. The Secretary shall make payments into 
the Trump Health Freedom Accounts of eligible residents 
on a monthly basis, quarterly basis, or in one lump sum 
at the beginning of the year, at the option of each 
eligible resident.
``(6) Coordinated waiver process.--The Secretary shall 
develop a process for coordinating and consolidating the State 
waiver processes applicable under the provisions of this 
section, and the existing waiver processes applicable under 
section 1332 and titles XVIII, XIX, and XXI of the Social 
Security Act, and any other Federal law relating to the 
provision of health care items or services. Such process shall 
permit a State to submit a single application for a waiver 
under any or all of such provisions.
``(7) Exchanges.--
``(A) In general.--In the case of a State in which 
a waiver is in effect under this section for a plan 
year--
``(i) the State may--
``(I) operate an Exchange 
established as described in section 
1311(b); or
``(II) allow one or more private 
entities to run commercial platforms 
that sell health plans approved by the 
State insurance commissioner; or
``(ii) if the State does not operate an 
Exchange as described in clause (i)(I) or allow 
for one or more commercial platforms described 
in clause (i)(II), the Secretary shall operate 
a Federal Exchange, as described in section 
1321(c), provided that any State laws regarding 
the availability of health plans on, and the 
operation of, such Exchange shall apply in lieu 
of any provision under part 1 or part 2 that 
such State has waived.
``(B) Application program interface.--The Secretary 
shall make available to any State that allows for 
commercial platforms described in subparagraph 
(A)(i)(II), the application program interface used for 
operating Federal and State Exchanges, for use by any 
private entity running such a platform under State 
authority.
``(8) Definitions.--In this section:
``(A) Eligible resident.--The term `eligible 
resident' means, with respect to a State for which a 
waiver is in effect under this section, a resident 
who--
``(i) in the absence of such a waiver in 
the State, would be eligible for a premium tax 
credit under section 36B of the Internal 
Revenue Code of 1986 or a cost-sharing 
reduction under section 1402, if the resident 
enrolled in a qualified health plan offered on 
the Exchange of such State; and
``(ii) enrolls in a plan offered on the 
Exchange described in paragraph (7) for the 
applicable plan year.
``(B) Secretary.--Term `Secretary' means--
``(i) the Secretary of Health and Human 
Services with respect to waivers relating to 
the provisions described in subparagraph (A) 
through (C) of paragraph (4); and
``(ii) the Secretary of the Treasury with 
respect to waivers relating to the provisions 
described in paragraph (4)(D).
``(b) Waiver Period.--Each waiver under this section shall be in 
effect beginning on January 1 of the plan year for which a timely 
notice is submitted by the State under subsection (a)(2), and 
continuing until the entity of the State described in subparagraph (A) 
or (B) of subsection (a)(3) that submitted the notification under 
subsection (a)(2) submits to the Secretary a notification of intent to 
discontinue participation in the waiver program under this section.
``(c) Limitation.--The Secretary may not permit a waiver under this 
section of any Federal law or requirement this is not within the 
authority of the Secretary.
``(d) Availability of Plans.--
``(1) In general.--Any health insurance coverage offered in 
a State for which a waiver under this section is in effect, and 
authorized by the insurance commissioner of the State, shall be 
made available on, as applicable, the Federal or State Exchange 
or commercial platforms described in subsection (a)(7), of all 
States for which such a waiver is in effect, subject to the 
laws of each such State.
``(2) Child-only plans.--In any State for which a waiver 
under this section is in effect, a health insurance issuer may 
offer a plan in which the only individuals eligible to enroll 
are individuals who, as of the beginning of a plan year, have 
not yet attained the age of 21.
``(e) Regulations.--Not later than 1 year after the date of 
enactment of the More Affordable Care Act, the Secretary of Health and 
Human Services, in coordination with the Secretary of the Treasury, 
shall promulgate regulations to carry out this section.
``(f) Rule of Construction Regarding Consumer Protections, 
Including the Pre-Existing Condition Protection.--Nothing in this 
section shall be construed to allow a State to waive the requirements 
of title XXVII of the Public Health Service Act, including sections 
2701, 2702, 2703, 2704, 2705, 2708, 2711, 2712, and 2718 of such 
Act.''.

SEC. 3. TRUMP HEALTH FREEDOM ACCOUNTS.

(a) In General.--Section 223 of the Internal Revenue Code of 1986 
is amended by adding at the end the following new subsection:
``(i) Trump Health Freedom Accounts.--For purposes of this 
section--
``(1) In general.--In the case of a Trump Health Freedom 
Account, this section shall be applied as provided in 
paragraphs (3) through (8).
``(2) Trump health freedom account.--The term `Trump Health 
Freedom Account' means a health savings account (determined as 
provided in this subsection) established by or on behalf of an 
individual residing in a State for which a waiver under section 
1335 of the Patient Protection and Affordable Care Act is in 
effect which receives deposits of amounts transferred to the 
individual pursuant to section 1335(a)(5) of such Act.
``(3) Eligible individual.--Any individual covered under a 
health plan authorized to be made available on an Exchange by 
section 1335(d) of such Act shall be treated as an eligible 
individual.
``(4) Treatment of transferred contributions.--Amounts 
transferred to a Trump Health Freedom Account pursuant to 
section 1335(a)(5) of such Act shall not be taken into account 
in determining the deduction allowed by subsection (a).
``(5) Health insurance may be purchased from account.--
Subsection (d)(2)(B) shall not apply.
``(6) Account must be only hsa of individual.--
``(A) In general.--An individual who has a Trump 
Health Freedom Account shall not be treated as an 
eligible individual with respect to any health savings 
account other than such Trump Health Freedom Account.
``(B) Rollover of existing account permitted.--An 
individual on whose behalf a Trump Health Freedom 
Account is established may roll over the balance of any 
other health savings account of the individual to such 
Trump Health Freedom Account according to the rules of 
subsection (f)(5).
``(7) No rollovers permitted.--Except as provided in 
paragraph (6)(B), subsection (f)(5) shall not apply and no 
amount shall be contributed from a Trump Health Freedom Account 
to any health savings account other than a Trump Health Freedom 
Account.
``(8) Restriction on use of amounts.--No amounts in a Trump 
Health Freedom Account may be used--
``(A) to pay premiums for a health plan that 
covers--
``(i) gender transition procedures, or
``(ii) abortion services; or
``(B) to pay for any service described in clause 
(i) or (ii) of subparagraph (A).
``(9) Definitions.--For purposes of paragraph (8)--
``(A) Gender transition procedure.--
``(i) In general.--The term `gender 
transition procedure' means any hormonal or 
surgical intervention for the purpose of gender 
transition, including--
``(I) gonadotropin-releasing 
hormone (GnRH) agonists or other 
puberty-blocking or suppressing drugs 
to stop or delay normal puberty;
``(II) testosterone, estrogen, 
progesterone, or other androgens to an 
individual at doses that are 
supraphysiologic to what would normally 
be produced endogenously in a healthy 
individual of the same age and sex;
``(III) castration;
``(IV) orchiectomy;
``(V) scrotoplasty;
``(VI) implantation of erection or 
testicular prostheses;
``(VII) vasectomy;
``(VIII) hysterectomy;
``(IX) oophorectomy;
``(X) ovariectomy;
``(XI) reconstruction of the fixed 
part of the urethra with or without a 
metoidioplasty or a phalloplasty;
``(XII) metoidioplasty;
``(XIII) penectomy;
``(XIV) phalloplasty;
``(XV) vaginoplasty;
``(XVI) clitoroplasty;
``(XVII) vaginectomy;
``(XVIII) vulvoplasty;
``(XIX) reduction 
thyrochondroplasty;
``(XX) chondrolaryngoplasty;
``(XXI) mastectomy;
``(XXII) tubal ligation;
``(XXIII) sterilization;
``(XXIV) any plastic, cosmetic, or 
aesthetic surgery that feminizes or 
masculinizes the facial or other 
physiological features of an 
individual;
``(XXV) any placement of chest 
implants to create feminine breasts;
``(XXVI) any placement of fat or 
artificial implants in the gluteal 
region;
``(XXVII) augmentation mammoplasty;
``(XXVIII) liposuction;
``(XXIX) lipofilling;
``(XXX) voice surgery;
``(XXXI) hair reconstruction;
``(XXXII) pectoral implants; and
``(XXXIII) the removal of any 
otherwise healthy or non-diseased body 
part or tissue.
``(ii) Exclusions.--The term `gender 
transition procedure' does not include the 
following when furnished to an individual by a 
health care provider with the consent of such 
individual or, if applicable, such individual's 
parents or legal guardian:
``(I) Services to individuals born 
with a medically verifiable disorder of 
sex development, including an 
individual with external sex 
characteristics that are irresolvably 
ambiguous, such as an individual born 
with 46 XX chromosomes with 
virilization, an individual born with 
46 XY chromosomes with 
undervirilization, or an individual 
born having both ovarian and testicular 
tissue.
``(II) Services provided when a 
physician has otherwise diagnosed a 
disorder of sexual development in which 
the physician has determined through 
genetic or biochemical testing that the 
individual does not have normal sex 
chromosome structure, sex steroid 
hormone production, or sex steroid 
hormone action for a healthy individual 
of the same sex and age.
``(III) The treatment of any 
infection, injury, disease, or disorder 
that has been caused by or exacerbated 
by the performance of gender transition 
procedures, whether or not the gender 
transition procedure was performed in 
accordance with State and Federal law 
or whether or not funding for the 
gender transition procedure is 
permissible under this section.
``(IV) Any procedure undertaken 
because the individual suffers from a 
physical disorder, physical injury, or 
physical illness (but not mental, 
behavioral, or emotional distress or a 
mental, behavioral, or emotional 
disorder) that would, as certified by a 
physician, place the individual in 
imminent danger of death or impairment 
of major bodily function, unless the 
procedure is performed.
``(V) Puberty suppression or 
blocking prescription drugs for the 
purpose of normalizing puberty for a 
minor experiencing precocious puberty.
``(VI) Male circumcision.
``(B) Gender transition.--The term `gender 
transition' means the process in which an individual 
goes from identifying with or presenting as his or her 
sex to identifying with or presenting a self-proclaimed 
identity that does not correspond with or is different 
from his or her sex, and may be accompanied with 
social, legal, or physical changes.
``(C) Sex.--The term `sex', when referring to an 
individual's sex, means to refer to either male or 
female, as biologically determined.
``(D) Female.--The term `female', when used to 
refer to a natural person, means an individual who 
naturally has, had, will have, or would have, but for a 
congenital anomaly, historical accident, or intentional 
or unintentional disruption, the reproductive system 
that at some point produces, transports, and utilizes 
eggs for fertilization.
``(E) Male.--The term `male', when used to refer to 
a natural person, means an individual who naturally 
has, had, will have, or would have, but for a 
congenital anomaly, historical accident, or intentional 
or unintentional disruption, the reproductive system 
that at some point produces, transports, and utilizes 
sperm for fertilization.
``(F) Abortion services.--
``(i) In general.--The term `abortion 
services' means--
``(I) drugs or procedures used with 
the primary intent to end the life of 
the human being in the womb,
``(II) pre-viable delivery not 
described in clause (ii), and
``(III) post-viable delivery with 
intentional death of the fetus.
``(ii) Exclusions.--Such term does not 
include--
``(I) separation of the mother and 
her embryo or fetus to prevent the 
mother's death or immediate 
irreversible bodily harm, which cannot 
be mitigated in any other way,
``(II) treatment of ectopic or 
molar pregnancy,
``(III) treatment of miscarriage, 
or
``(IV) any service described in 
clause (i) in the case of a pregnancy 
which is the result of an act of rape 
or incest.''.
(b) Effective Date.--The amendment made by this section shall apply 
to taxable years beginning after December 31, 2025.

SEC. 4. CREDIT FOR EMPLOYEE INSURANCE EXPENSES OF SMALL EMPLOYERS IN 
WAIVER STATE.

(a) In General.--Subsection (g) of section 45R of the Internal 
Revenue Code of 1986 is amended to read as follows:
``(g) Credit for Small Employers in Waiver State.--For purposes of 
this section--
``(1) In general.--In the case of an eligible small 
employer (determined with the modifications provided in this 
subsection) located in a State for which a waiver under section 
1335 of the Patient Protection and Affordable Care Act is in 
effect, this section shall be applied as provided in paragraphs 
(2) through (7).
``(2) Health insurance credit amount.--Subsection (b) shall 
be applied by substituting `50 percent' for `50 percent (35 
percent in the case of a tax-exempt eligible small employer)'.
``(3) Qualified plans.--Subsections (b) and (d)(4) shall be 
applied by treating any health plan authorized to be made 
available on an Exchange in such State by section 1335(d) of 
such Act as a qualified health plan offered through an 
Exchange.
``(4) Phaseout not to apply.--Subsection (c) shall not 
apply.
``(5) Eligible small employer.--Subsection (d) shall be 
applied--
``(A) by substituting `50' for `25' in paragraph 
(1)(A) thereof, and
``(B) without regard to subparagraph (B) of 
paragraph (1) thereof.
``(6) Employee.--Subsection (e)(1)(A) shall be applied 
without regard to clause (i) thereof.
``(7) Credit period.--Subsection (e)(2) shall not apply, 
and the credit period with respect to any such employer shall 
be the period consisting of the 1st taxable year in which the 
employer (or any predecessor) offers 1 or more qualified health 
plans to its employees, and any subsequent taxable year.
``(8) Tax-exempt rules not to apply.--Subsection (f) shall 
not apply.''.
(b) Effective Date.--The amendment made by this section shall apply 
to taxable years beginning after December 31, 2025.

SEC. 5. PROMOTING BETTER PRICE REPORTING AND OUTCOMES DATA.

Not later than 90 days after the date of enactment of this Act, the 
Secretary of Health and Human Services, in coordination with the 
Secretary of the Treasury and the Secretary of Labor, shall update all 
regulations and guidance issued by such secretaries pursuant to 
Executive Order 13877 (84 Fed. Reg. 30849 (June 24, 2019)), including 
by--
(1) requiring the disclosure of the actual prices of items 
and services, not price estimates;
(2) issuing updated guidance or regulations ensuring 
pricing information is standardized and easily comparable 
across hospitals and health plans;
(3) issuing guidance or proposed regulatory action updating 
enforcement policies designed to ensure compliance with the 
transparent reporting of complete, accurate, and meaningful 
data; and
(4) requiring the public reporting of outcomes data by 
providers.
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