Amendment
Introduced on 12/8/25
The Health Care Freedom for Patients Act of 2025 represents a comprehensive restructuring of federal healthcare policy with three primary objectives: establishing a new Health Savings Account contribution program for individual market insurance purchasers, restricting federal funding for gender transition medical procedures, and tightening citizenship and immigration status verification requirements for Medicaid and CHIP eligibility. The legislation fundamentally redefines the scope of essential health benefits under the Affordable Care Act while creating a federally-funded HSA program designed to reduce healthcare costs through consumer-directed healthcare mechanisms. The bill imposes strict biological definitions of sex and comprehensively restricts coverage of gender-affirming medical procedures across federal healthcare programs. Additionally, it establishes new barriers to healthcare access for immigrants by requiring verified citizenship or immigration status before federal financial participation in Medicaid and CHIP programs can occur.
The legislation creates an Exchange plan HSA program under Section 223 of the Internal Revenue Code, providing age-tiered federal contributions of $1,000 annually for individuals aged 18-49 and $1,500 for those aged 50-64 who purchase bronze level qualified health plans or catastrophic plans through ACA exchanges. The program applies to plan years beginning after January 1, 2027, with $10 billion appropriated for each of fiscal years 2026 and 2027, available through September 30, 2028. Section 301 amends the ACA to exclude gender transition procedures from essential health benefits in exchange plans, while Section 302 prohibits federal financial participation in Medicaid and CHIP for coverage of specified gender transition procedures. The bill defines gender transition procedures comprehensively to include surgical interventions such as castration, sterilization, hysterectomy, and mastectomy when performed to alter primary or secondary sexual characteristics, as well as hormone treatments and cosmetic procedures. Section 202 restricts federal Medicaid and CHIP funding for individuals without verified citizenship or immigration status, though states retain the option to continue medical assistance during verification periods. The legislation establishes strict binary definitions of biological sex based on reproductive system capabilities, defining male and female exclusively by reference to gamete production capacity.
The Department of Health and Human Services serves as the primary implementing agency, with the Secretary responsible for administering the Exchange plan HSA contribution program and establishing verification procedures for citizenship and immigration status. Health insurance exchanges must report participant information to facilitate HSA contributions, which are to be made as early as possible after eligibility determination. The Internal Revenue Service administers the tax treatment of HSA contributions, which are excluded from gross income. Enrollees must provide social security numbers and, if applicable, attestations of alien status under the Immigration and Nationality Act. The Centers for Medicare & Medicaid Services enforces restrictions on federal financial participation for Medicaid and CHIP, requiring states to verify citizenship and immigration status before receiving federal matching funds. Funding flows directly from Treasury appropriations to individual HSA accounts for eligible enrollees. The legislation does not establish explicit reporting requirements for compliance monitoring or enforcement mechanisms for the gender transition procedure restrictions beyond the denial of federal financial participation.
The legislation directly benefits individuals aged 18-64 who purchase bronze level or catastrophic health plans through ACA exchanges and meet citizenship or immigration status requirements, providing them with federal HSA contributions totaling between $1,000 and $1,500 annually. The $20 billion appropriation over two fiscal years represents substantial federal investment in consumer-directed healthcare. However, the bill significantly restricts healthcare access for transgender individuals by eliminating coverage for gender-affirming medical procedures across federal programs, affecting both exchange plans and Medicaid/CHIP beneficiaries. Immigrants face new barriers to healthcare access through citizenship verification requirements, potentially delaying or denying medical assistance during verification periods. The administrative burden on states increases substantially through new verification requirements for Medicaid and CHIP eligibility. Health insurance exchanges face additional reporting obligations and must modify plan offerings to exclude gender transition procedures from essential health benefits. The legislation creates narrow exceptions for medical procedures related to precocious puberty, medically verified disorders of sex development, and specific chromosomal conditions, but these exceptions require parental consent for minors. The funding mechanism includes a sunset provision with appropriations available only through September 30, 2028, creating uncertainty about program continuation beyond that date.
The legislation operates under Congress's constitutional authority to regulate interstate commerce and its spending power to condition federal funding on state compliance with federal requirements. The bill amends multiple foundational healthcare statutes including the Patient Protection and Affordable Care Act, the Social Security Act governing Medicaid and CHIP, and the Internal Revenue Code establishing HSA rules. The statutory framework creates federal preemption of state laws that would require coverage of gender transition procedures as essential health benefits in exchange plans or mandate such coverage in Medicaid programs receiving federal financial participation. States retain limited flexibility to continue medical assistance during citizenship verification periods using state-only funds, but federal matching funds remain unavailable until verification occurs. The legislation does not explicitly provide for judicial review, though affected individuals and states may challenge the law's constitutionality and implementation through standard Administrative Procedure Act mechanisms. The strict binary definition of biological sex and comprehensive restrictions on gender-affirming medical procedures create potential conflicts with existing anti-discrimination laws and constitutional equal protection principles. The citizenship verification requirements interact with existing immigration law frameworks under the Immigration and Nationality Act, creating new eligibility barriers that may face legal challenges under due process grounds.
The legislation faces substantial constitutional challenges on multiple grounds. The strict binary definition of biological sex and comprehensive exclusion of gender transition procedures from federal healthcare programs raise equal protection concerns under the Fifth Amendment, particularly given evolving judicial recognition of transgender individuals as a protected class. The citizenship verification requirements may violate due process rights by denying healthcare access during verification periods, potentially affecting lawfully present individuals and creating life-threatening delays in medical care. Implementation challenges include the administrative complexity of verifying citizenship and immigration status across millions of Medicaid and CHIP beneficiaries, imposing significant costs on state agencies already facing resource constraints. The narrow medical exceptions for gender transition procedures create ambiguity in clinical practice, as providers must determine whether procedures qualify under exceptions for disorders of sex development or chromosomal conditions, potentially leading to inconsistent application and litigation. The $20 billion cost estimate may prove insufficient given uncertain enrollment projections and the potential for adverse selection if healthier individuals disproportionately benefit from HSA contributions. The legislation creates perverse incentives by encouraging individuals to purchase minimal coverage bronze or catastrophic plans to access HSA contributions rather than more comprehensive coverage. Unintended consequences include potential increases in uncompensated care costs as immigrants lose Medicaid eligibility, shifting financial burdens to safety-net providers and state budgets. The sunset of appropriations in 2028 creates program instability and may strand beneficiaries who rely on HSA contributions for healthcare financing. Opposition arguments center on discrimination against transgender individuals, barriers to immigrant healthcare access, federal overreach into medical practice decisions, and the potential for increased healthcare costs through emergency room utilization by individuals denied preventive and routine care.
On the Cloture Motion S. 3386 RC# 643
51 Yea
RRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRRR48 Nay
DDDDDIDIDDDDDDDDDDDDDDDDDDDDDDDDDDDDDRDDDDDDDDDD1 Absent
R