Congress quietly bans transgender care and abortion from health plans while extending subsidies.
S. 3389 — Lowering Health Care Costs for Americans Act · Filed by Roger Marshall (R-KS) · Introduced Dec 9, 2025 · Referred to committee
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What it does
This bill restructures ACA premium tax credits by routing them into Health Savings Accounts (HSAs) called 'Healthcare Affordability Accounts' starting in 2027, extends enhanced premium subsidies through 2031 with a phasedown, and adds sweeping restrictions: it prohibits coverage of gender transition procedures and abortion in qualified health plans, requires hospitals to publish detailed pricing monthly, and gives states broad new waiver authority to establish high-risk pools and reinsurance programs. The bill also mandates clinical lab price transparency and imposes strict reporting requirements on abortion coverage.
Why we flagged it
While the bill's title and opening sections emphasize cost reduction and transparency (hospital pricing, lab pricing), the substantive bulk of the legislation imposes categorical exclusions on gender transition procedures and abortion coverage in qualified health plans, coupled with structural changes to premium credit delivery. The transparency provisions are real but secondary to the coverage restrictions.
- Sections 104 and 109 impose detailed categorical exclusions on gender transition procedures in HSAs and qualified health plans. These are substantively unrelated to the bill's stated purpose of lowering costs through premium credit restructuring and price transparency.
- Sections 106, 107, and 110 impose detailed restrictions on abortion coverage, including prohibition of federal funds for plans covering abortion (with narrow exceptions), separate premium accounting, and reporting requirements. These are substantively unrelated to cost reduction or price transparency.
What the text implies
- The HSA routing of premium credits (Section 104) may reduce effective subsidies for lower-income enrollees who cannot afford to front-load HSA contributions, effectively shifting cost burden downward over time.
- The phasedown of enhanced premium credits from 2027–2031 (Section 105) will increase out-of-pocket costs for millions of ACA enrollees as subsidies decline by 20–80%, potentially pricing lower-income individuals out of coverage.
The full analysis lists 5 implications of this text.
Who stands to gain
Health insurance issuers (reduced claims for excluded services); Hospitals (potential cost savings from reduced gender transition and abortion-related claims); HSA administrators and custodians (increased account volume)