“A bill to establish a public health plan.”
No CRS summary available for this bill.
This section establishes a new title XXII of the Social Security Act to create the Medicare Exchange health plan—a public, low-cost qualified health plan (QHP) available through American Health Benefit Exchanges (including Small Business Health Options Program Exchanges) in all rating areas of the individual and small group markets beginning plan year 2028. The section (1) limits eligibility to individuals qualified under ACA section 1312 who are not eligible for Medicare; (2) requires compliance with QHP standards under ACA title I subtitle D and Public Health Service Act title XXVII, including silver and gold coverage levels (with up to two versions per level authorized) and zero cost-sharing for primary care services; (3) authorizes the Secretary of Health and Human Services (HHS) to contract for administrative functions akin to Medicare Advantage authorities under SSA section 1874A (without transferring insurance risk, except under specified alternative payment models); and (4) directs HHS to collect data from state insurance commissioners (subject to HIPAA privacy rules) to set geographically varying premiums covering full actuarial costs (including administration) and to address health disparities. The section further establishes in the Treasury (1) a Plan Reserve Fund, with $1 billion appropriated for FY2027 (available through FY2036) to establish and administer the plan; and (2) a Data and Technology Fund, with $1 billion appropriated for FY2027 (available through FY2036) for technology updates and data collection to set premiums. HHS must issue implementing regulations within 180 days of enactment (finalized within 270 days).
This section establishes a new basis for permissive exclusion from Medicare, Medicaid, and other federal health care programs under SSA §1128(b)(18) for any individual or entity that imposes restrictions on patients accepted for treatment but fails to either (1) exempt enrollees in the Medicare Exchange health plan established under title XXII or (2) apply such restrictions equally to those enrollees. (As background, SSA §1128(b) authorizes the HHS Secretary to exclude providers and others from federal health care programs for conduct adversely affecting program integrity.)
This section directs the Secretary of Health and Human Services to establish a nationwide reinsurance program pooling costs of high-cost patients in the individual health insurance market (on or off Exchanges)—to the extent such costs are not already pooled under the ACA's temporary reinsurance program (42 U.S.C. 18063)—to reduce premiums in that market. (As background, ACA reinsurance programs cover a portion of claims costs above specified attachment points for high-cost enrollees to stabilize insurer risk pools and premiums.) It authorizes $10 billion for FY2028, $10 billion for FY2029, and $10 billion for FY2030 to implement the program.
This section expands eligibility for the premium tax credit (PTC)—which subsidizes purchase of qualified health plans on ACA Exchanges for individuals without affordable minimum essential coverage—by eliminating the 400% federal poverty level (FPL) household income cap (previously limited to 400% FPL), for taxable years beginning after December 31, 2025. The section (1) revises the applicable percentage table used to calculate the credit to provide a sliding scale premium contribution cap of 8.5% of household income for those above 400% FPL (previously no subsidy above 400% FPL, with tiers up to 8.5% through 2025); (2) adds a $5,000 cap on excess advance PTC recapture for households above 400% FPL; and (3) fixes the "family glitch" by treating family members as ineligible for employer-sponsored coverage—and thus eligible for PTC—if the employee's required family contribution exceeds 9.5% of household income (previously based solely on affordability of self-only coverage).
This section strikes subsection (i) of Section 1860D–11 of the Social Security Act (42 U.S.C. 1395w–111(i)), known as the noninterference provision, which prohibits the Secretary from (1) interfering in negotiations between drug manufacturers and pharmacies and prescription drug plan (PDP) sponsors and (2) requiring a particular formulary or price structure for covered Part D drugs. (Medicare Part D provides optional outpatient prescription drug coverage to approximately 50 million Medicare enrollees through private PDPs and Medicare Advantage prescription drug plans; thus, repeal authorizes the Secretary to negotiate drug prices directly with manufacturers.)
This section authorizes appropriations of $150 million annually for FY2027 through FY2031, to remain available until expended, for studying health care markets—including anticompetitive practices—and antitrust enforcement, allocated as follows: (1) $50 million to the Antitrust Division of the Department of Justice; and (2) $100 million to the Federal Trade Commission.
This section directs the Antitrust Division of the Department of Justice and the Federal Trade Commission to submit two reports to Congress on their use of funds authorized under section 7. (1) Not later than one year after enactment, detailing activities on which those funds were spent; and (2) not later than September 30, 2032, including (A) findings of any studies conducted on or after enactment, (B) activities on which those funds were spent, and (C) the impact of enforcement actions taken on or after enactment on improving consumer access to affordable health care.