This bill establishes a state-based health freedom waiver program allowing states to opt out of certain ACA requirements while creating special Health Savings Accounts and offering small business tax credits in participating states, alongside new price transparency mandates.
August Pfluger
Representative
TX-11
This bill establishes the "More Affordable Care Act," allowing states to waive certain federal health insurance requirements if they maintain a high-risk pool, with residents potentially receiving equivalent federal funds in "Trump Health Freedom Accounts." These accounts function as specialized Health Savings Accounts with unique contribution and spending rules, including restrictions on funding gender transition procedures and abortion services. Additionally, the legislation creates a 50% premium tax credit for small employers in waiver states and mandates enhanced public reporting of actual medical prices and patient outcomes data.
Proposed 'More Affordable Care Act' Lets States Drop ACA Exchanges, Creates Restricted 'Trump Health Freedom Account' for Residents
This bill, dubbed the “More Affordable Care Act,” is a massive overhaul of the Affordable Care Act (ACA) structure. Starting in 2026, it creates a “Health Freedom Waiver” program that lets states opt out of major federal ACA requirements—specifically, the rules governing health insurance exchanges, premium tax credits, and cost-sharing reductions. The catch? States choosing this route must maintain a high-risk insurance pool for their residents, and they cannot waive core consumer protections like the ban on denying coverage for pre-existing conditions (Sec. 2).
The State Opt-Out and the New Savings Account
If a state decides to go rogue and waive these federal rules, its residents would lose access to the current federal premium tax credits and cost-sharing reductions. To replace that lost subsidy, the federal government must pay an equivalent amount into a new savings vehicle for those residents: the “Trump Health Freedom Account” (Sec. 2). This payment is based on the national average cost of a benchmark silver plan. The money can be paid out monthly, quarterly, or in a lump sum, giving residents flexibility, but it’s a big shift: instead of subsidies going to insurers, the money goes directly to the individual’s account.
Your New Health Savings Account, With Rules
The “Trump Health Freedom Account” is essentially a special type of Health Savings Account (HSA) with some major modifications (Sec. 3). For the first time, people can use this money to pay for health insurance premiums, which is usually a no-go for standard HSAs. This is a huge benefit for people trying to manage monthly costs. However, these new accounts come with a serious restriction: the funds cannot be used to pay premiums for, or directly pay for, any gender transition procedures or abortion services. The bill provides detailed definitions for both prohibited procedures, though it carves out exceptions for things like treating ectopic pregnancies, miscarriages, or procedures related to rape or incest (Sec. 3).
A 50% Tax Break for Small Businesses
For small business owners—those with 50 or fewer full-time equivalent employees—in a state that adopts the waiver, the bill offers a substantial financial incentive (Sec. 4). It simplifies and beefs up the existing small employer health insurance tax credit, raising it to a flat 50 percent of the premiums the employer pays. Crucially, the current rules that phase out this credit based on employee wages are eliminated, meaning more small businesses could qualify for this major tax break simply for offering a state-approved health plan.
Price Tags and Outcomes on the Table
Beyond the insurance market changes, the bill takes a swing at healthcare transparency. It mandates that the Secretaries of HHS, Treasury, and Labor update regulations to require the disclosure of actual prices for medical items and services, not just estimates (Sec. 5). This is aimed at making prices easily comparable across different hospitals and plans. Furthermore, providers will be required to publicly report patient outcomes data. For consumers, this means you might finally be able to shop around with real price tags and see how effective different providers actually are, which could be a game-changer for budgeting and quality control.
The Real-World Trade-Off
This legislation presents a clear trade-off: states gain significant flexibility to design their own insurance markets, and small businesses get a massive tax credit. However, for residents, the shift from federal subsidies to a restricted personal account is a high-stakes gamble. If your state’s new high-risk pool system isn’t well-managed, or if you rely on the specific services excluded from the new account’s use, the “freedom” might feel more like a restriction. The bill is betting that state innovation, combined with direct consumer payments and radical price transparency, will lead to lower costs and better coverage, but the stability of the insurance market now hinges entirely on how well each state manages its new system.