House Republicans released legislation Friday aimed at lowering healthcare costs through expanded insurance options for small businesses and unprecedented transparency requirements for pharmacy benefit managers, setting up a crucial vote next week as enhanced Obamacare subsidies expire at year’s end.
The Lower Health Care Premiums for All Americans Act, introduced by Rep. Mariannette Miller-Meeks (R-Iowa-01), is the GOP’s alternative to Democratic proposals as Democrats push to extend expiring ACA premium tax credits that help 22 million Americans purchase insurance.
Speaker Mike Johnson announced the measure would receive a floor vote next week, though GOP leadership indicated moderate Republicans seeking subsidy extensions may get an amendment vote designed to provide political cover without realistic chances of passage.
Association Health Plans Return
The bill’s centerpiece codifies association health plans, reviving a Trump-era initiative that federal courts struck down in 2019. The Biden administration formally rescinded the association health plan regulations back in 2024, dismissing pending appeals.
Under the legislation, groups or associations of employers could band together to offer health insurance regardless of industry, provided they:
- Existed for at least two years for purposes other than providing insurance
- Establish formal governance with employer-controlled boards
- Cover at least 51 employees total
- Offer coverage to all employees of member employers
Self-employed individuals could join as both employers and employees if they work at least 10 hours weekly or 40 hours monthly in their business, with at least 20 self-employed members needed to form a group.
The bill includes protections requiring plans to follow ACA nondiscrimination rules, prohibiting denial of coverage for pre-existing conditions and health status-based premium variations. Plans could establish base premiums using modified community rating across all participants, then adjust individual employer contributions based on specific risk profiles.
Stop-Loss Deregulation
Section 102 clarifies that stop-loss insurance purchased by self-insured group health plans doesn’t constitute “health insurance coverage” under federal law, preempting state regulation of these policies.
The provision makes it easier for smaller employers to self-insure by allowing the purchase of stop-loss coverage with lower attachment points, effectively letting companies assume direct claims responsibility while protecting against catastrophic costs without state-imposed minimum thresholds.
Individual Coverage HRAs Expanded
The legislation expands health reimbursement arrangements that let employers fund employee purchases of individual market coverage instead of offering traditional group plans.
Employers could offer different HRA amounts by employee class—full-time versus part-time, geographic location, union status, or seasonal workers—with amounts varying up to 3-to-1 based on age and dependent coverage. The arrangements must be offered on identical terms within each class, and employers generally cannot offer both HRAs and traditional group coverage to the same employee class.
Employees participating in these arrangements could use cafeteria plans to purchase ACA exchange coverage with pre-tax dollars, and employers must report HRA benefits on W-2 forms.
Pharmacy Benefit Manager Transparency
Title II imposes extensive reporting requirements on pharmacy benefit managers, the intermediaries managing prescription drug benefits for insurers and employers, effective 30 months after enactment.
PBMs must provide detailed reports to group health plans at least twice yearly, including:
For large employers (100+ employees):
- Drug-by-drug compensation paid to PBMs versus amounts paid to pharmacies
- The “spread” between these amounts
- All rebates and manufacturer payments received
- Formulary placement rationales for expensive drugs
- Pricing comparisons between PBM-owned and network pharmacies
For all plans:
- Aggregate spending and rebate data
- Payments to brokers for referrals
- Requirements to use PBM-affiliated pharmacies
Plans must provide summary documents to participants upon request, plus the spread pricing on individual prescription claims. Violations carry penalties up to $10,000 daily for failure to provide information, and up to $100,000 per item for knowingly false information.
Cost-Sharing Reductions Funded
The bill appropriates funding for Obamacare cost-sharing reductions beginning in 2027, reversing the Trump administration’s 2017 decision to end these payments.
Cost-sharing reductions lower deductibles and out-of-pocket costs for ACA enrollees earning 100-250 percent of poverty level who purchase silver plans. When Trump ended federal payments in October 2017, insurers responded by “silver loading”—dramatically increasing silver plan premiums to compensate for lost subsidies, which paradoxically increased federal costs because premium tax credits rose correspondingly.
GOP leadership aides told reporters appropriating CSR funding would reduce premiums by approximately 12 percent.
Political Dynamics
The bill does not include any extension of enhanced ACA premium tax credits set to expire December 31. Those subsidies, expanded during COVID-19, help millions afford marketplace coverage but face fierce conservative opposition.
House Minority Leader Hakeem Jeffries criticized the package before its release, telling reporters he expected it “to be a disaster and actually not enhance the health care of the American people.”
Johnson defended the GOP approach: “While Democrats demand that taxpayers write bigger checks to insurance companies to hide the cost of their failed law, House Republicans are tackling the real drivers of health care costs to provide affordable care, increase access and choice, and restore integrity to our nation’s health care system for all Americans.”
President Trump told reporters at a White House event Friday, “I want to see the billions of dollars go to people, not to the insurance companies. And I want to see the people go out and buy themselves great healthcare.”
GOP leaders said the Rules Committee would meet Tuesday to finalize amendment procedures, potentially allowing moderate Republicans who signed discharge petitions seeking subsidy extensions an amendment vote. Such amendments would need near-unanimous Democratic support to pass and would likely kill the broader bill among conservative Republicans.
Congress enters the final days of its 2025 legislative session with 22 million Americans facing potential premium increases. The fate of both the GOP package and enhanced ACA subsidies remains uncertain.
