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S 3386 — Congress 119

Health Care Freedom for Patients Act of 2025

Official source: https://www.congress.gov/bill/119th-congress/senate-bill/3386

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Issues impacted: Immigration & Border (taxonomy, high), Taxes & Government Spending (taxonomy, medium), Healthcare (taxonomy, high), Abortion & Reproductive Policy (taxonomy, high)

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119 S3386 PCS: Health Care Freedom for Patients Act of 2025 
 U.S. Senate 
 2025-12-08 
 text/xml 
 EN 
 Pursuant to Title 17 Section 105 of the United States Code, this file is not subject to copyright protection and is in the public domain. 
 
 
 
 II Calendar No. 285 119th CONGRESS 1st Session S. 3386 IN THE SENATE OF THE UNITED STATES December 8 (legislative day, December 4), 2025 Mr. Crapo (for himself and Mr. Cassidy ) introduced the following bill; which was read the first time December 8, 2025 Read the second time and placed on the calendar A BILL To provide a health savings account contribution to certain enrollees, to reduce health care costs, and for other purposes. 1. Short title; table of contents (a) Short title This Act may be cited as the Health Care Freedom for Patients Act of 2025 . (b) Table of contents The table of contents for this Act is as follows: Sec. 1. Short title; table of contents. TITLE I—Increasing choice and reducing premiums Sec. 101. Exchange plan HSAs. Sec. 102. Exchange plan HSA contribution program. Sec. 103. Funding cost-sharing reduction payments. Sec. 104. Allowing all individuals purchasing health insurance in the individual market the option to purchase a lower premium plan. TITLE II—Putting American patients first Sec. 201. Expansion FMAP for certain States providing payments for health care furnished to certain individuals. Sec. 202. Prohibiting Federal financial participation under Medicaid and CHIP for individuals without verified citizenship, nationality, or satisfactory immigration status. TITLE III—Preventing wasteful spending Sec. 301. Prohibiting coverage of gender transition procedures as an essential health benefit under plans offered by Exchanges. Sec. 302. Prohibiting Federal Medicaid and CHIP funding for certain items and services. I Increasing choice and reducing premiums 101. Exchange plan HSAs (a) In general Section 223 of the Internal Revenue Code of 1986 is amended by adding at the end the following new subsection: (i) Exchange plan HSAs For purposes of this section— (1) In general In the case of an Exchange plan HSA, this section shall be applied as provided in paragraphs (3) through (4). (2) Exchange plan HSA The term Exchange plan HSA means a health savings account which is designated as an Exchange plan HSA upon the establishment of such account. (3) No rollovers permitted Except in the case of a contribution from one Exchange plan HSA to another Exchange plan HSA, subsection (f)(5) shall not apply. (4) Restriction on use of amounts For purposes of subsection (d)(2)(A), amounts paid for— (A) abortion, other than— (i) if the pregnancy is the result of an act of rape or incest, or (ii) in the case where a woman suffers from a physical disorder, physical injury, or physical illness, including a life-endangering physical condition caused by or arising from the pregnancy itself, that would, as certified by a physician, place the woman in danger of death unless an abortion is performed, or (B) any sex trait modification procedure or service (as defined in section 156.400 of title 45, Code of Federal Regulations, as in effect on the date of the enactment of this subsection), shall not be treated as paid for medical care. . (b) Treatment of governmental contributions Paragraph (4) of section 223(b) of the Internal Revenue Code of 1986 is amended by striking and at the end of subparagraph (B), by striking the period at the end of subparagraph (C) and inserting , and , and by inserting after subparagraph (C) the following new subparagraph: (D) the aggregate amount contributed to an Exchange plan HSA pursuant to section 102(a) of the Health Care Freedom for Patients Act of 2025 which is excludable from the taxpayer's gross income for the taxable year under section 102(f) of such Act (and such amount shall not be allowed as a deduction under subsection (a)). . (c) Effective date The amendments made by this section shall apply to taxable years beginning after December 31, 2025. 102. Exchange plan HSA contribution program (a) In general As soon as administratively feasible, the Secretary of Health and Human Services shall make payments to the Exchange plan HSA of each individual who is an eligible enrollee, for each month which is an eligible month with respect to such individual, in the amount described in subsection (c). (b) Eligible month For purposes of this section, the term eligible month with respect to an individual means a calendar month— (1) occurring in calendar year 2026 or 2027, and (2) for which the individual is enrolled in a bronze level qualified health plan or a catastrophic plan through an Exchange established under subtitle D of title I of the Patient Protection and Affordable Care Act ( 42 U.S.C. 18021 et seq. ). (c) Payment amount The amount of each payment under subsection (a) for any individual for an eligible month is 1/12 of— (1) $1,000, in the case of an eligible enrollee who has attained age 18, and has not attained age 50, as of the first day of the calendar year which includes such month, and (2) $1,500, in the case of an eligible enrollee who has attained age 50, and has not attained age 65, as of the first day of such calendar year. (d) Eligible enrollee For purposes of this section, with respect to months occurring during a calendar year, the term eligible enrollee means an eligible individual (as defined in section 223(c)(1) of the Internal Revenue Code of 1986)— (1) who has attained age 18, and has not attained age 65, as of the first day of such calendar year, (2) in the case of an alien, who is an eligible alien, as defined in section 36B(e)(2)(B) of such Code (as in effect for taxable years beginning after December 31, 2026, applied by substituting for which the payment under section 102(a) of the Health Care Freedom for Patients Act of 2025 is made for for which the credit under this section is being claimed ), and (3) whose household income, expressed as a percent of the poverty line for the family size involved, does not exceed 700 percent. (e) Determination of eligibility (1) In general Upon election pursuant to paragraph (2) by an individual enrolling in a plan described in subsection (b)(2), the Secretary of Health and Human Services shall make a determination of the individual's status as an eligible enrollee on the basis of the latest determination pursuant to section 1412 of the Patient Protection and Affordable Care Act ( 42 U.S.C. 18082 ) of the individual's eligibility for the advance payment of the premium tax credits under section 36B of the Internal Revenue Code of 1986 and cost-sharing reductions under section 1402 of such Act ( 42 U.S.C. 18071 ). (2) Election At such time and in such manner as the Secretary of Health and Human Services shall provide, an eligible enrollee shall notify the Secretary of such enrollee's election to receive the payments under subsection (a) and shall provide— (A) the social security number of such eligible enrollee, (B) in the case of an alien, an attestation that the individual is an eligible alien, and (C) sufficient information to allow for the identification of, and deposit of the payments under subsection (a) into, the Exchange plan HSA of the eligible enrollee. (3) Reporting by Exchange The Exchange through which an individual is enrolling in a plan described in subsection (b)(2) shall provide to the Secretary of Health and Human Services the information provided by the individual which is necessary for the determination under paragraph (1). (4) Timing of payments The payments under subsection (a) with respect to any eligible months occurring before the determination under paragraph (1) is completed shall be made as early as possible after the completion of such determination. (f) Tax treatment of contributions For purposes of the Internal Revenue Code of 1986, payments under subsection (a) shall not be included in gross income of an eligible enrollee. (g) Definitions For purposes of this section— (1) Exchange plan HSA The term Exchange plan HSA has the meaning given such term in section 223(i) of the Internal Revenue Code of 1986. (2) Household income; poverty line The terms household income , poverty line , and family size have the same respective meanings and shall be determined in the same manner as for purposes of section 36B of the Internal Revenue Code of 1986. (3) Bronze level qualified health plan The term bronze level qualified health plan means a qualified health plan, as defined in section 1301(a) of the Patient Protection and Affordable Care Act ( 42 U.S.C. 18021(a) ), in the bronze level, as defined in section 1302(d)(1)(A) of such Act ( 42 U.S.C. 18022(d)(1)(A) ). (4) Catastrophic plan The term catastrophic plan means a plan described in section 1302(e) of such Act ( 42 U.S.C. 18022(e) ). (h) Regulatory authority The Secretary of Health and Human Services shall prescribe such regulations or other guidance as are necessary to carry out the purposes of this section. (i) Funding In addition to amounts otherwise available, there is appropriated to the Secretary of Health and Human Services, out of any money in the Treasury not otherwise appropriated, $10,000,000,000 for each of fiscal years 2026 and 2027, to remain available until September 30, 2028, to carry out the purposes of this section. (j) Information sharing Paragraph (21) of section 6103(l) of the Internal Revenue Code of 1986 is amended— (1) by striking or a basic health program under section 1331 of Patient Protection and Affordable Care Act in subparagraph (A) and inserting a basic health program under section 1331 of the Patient Protection and Affordable Care Act, or a payment under section 102(a) of the Health Care Freedom for Patients Act of 2025 , (2) by inserting , program, or payment after (and the amount thereof) in subparagraph (A)(v), and (3) by striking State programs in subparagraph (C)(ii) and inserting State programs or payment . 103. Funding cost-sharing reduction payments Section 1402 of the Patient Protection and Affordable Care Act ( 42 U.S.C. 18071 ) is amended by adding at the end the following: (h) Funding (1) In general There are appropriated, out of any monies in the Treasury not otherwise appropriated, such sums as may be necessary for purposes of making payments under this section for plan years beginning on or after January 1, 2027. (2) Use of funds (A) In general The amounts appropriated under paragraph (1) may not be used for purposes of making payments under this section for a qualified health plan that provides health benefit coverage that includes coverage of abortion. (B) Exception Subparagraph (A) shall not apply to payments for a qualified health plan that provides coverage of abortion only if necessary to save the life of the mother or if the pregnancy is a result of an act of rape or incest. . 104. Allowing all individuals purchasing health insurance in the individual market the option to purchase a lower premium plan (a) In general Section 1302(e) of the Patient Protection and Affordable Care Act ( 42 U.S.C. 18022(e) ) is amended— (1) in paragraph (1)— (A) by redesignating clauses (i) and (ii) of subparagraph (B) as subparagraphs (A) and (B), respectively, and adjusting the margins accordingly; (B) by striking plan year if— and all that follows through the plan provides— and inserting plan year if the plan provides— ; and (C) in subparagraph (A), as redesignated by paragraph (1), by striking clause (ii) and inserting subparagraph (B) ; (2) by striking paragraph (2); and (3) by redesignating paragraph (3) as paragraph (2). (b) Risk pools Section 1312(c)(1) of the Patient Protection and Affordable Care Act ( 42 U.S.C. 18032(c)(1) ) is amended by inserting and including enrollees in catastrophic plans described in section 1302(e) after Exchange . (c) Conforming amendment Section 1312(d)(3)(C) of the Patient Protection and Affordable Care Act ( 42 U.S.C. 18032(d)(3)(C) ) is amended by striking , except that in the case of a catastrophic plan described in section 1302(e), a qualified individual may enroll in the plan only if the individual is eligible to enroll in the plan under section 1302(e)(2) . (d) Effective date The amendments made by subsections (a), (b), and (c) shall apply with respect to plan years beginning on or after January 1, 2027. II Putting American patients first 201. Expansion FMAP for certain States providing payments for health care furnished to certain individuals Section 1905 of the Social Security Act ( 42 U.S.C. 1396d ) is amended— (1) in subsection (y)— (A) in paragraph (1)(E), by inserting (or, for calendar quarters beginning on or after October 1, 2027, in the case such State is a specified State with respect to such calendar quarter, 80 percent) after thereafter ; and (B) in paragraph (2), by adding at the end the following new subparagraph: (C) Specified State The term specified State means, with respect to a quarter, a State that— (i) provides any form of financial assistance from a State general fund during such quarter, in whole or in part, whether or not made under a State plan (or waiver of such plan) under this title or under another program established by the State, to or on behalf of an alien who is not a qualified alien and is not a child or pregnant woman who is lawfully residing in the United States and eligible for medical assistance pursuant to section 1903(v)(4) or for child health assistance or pregnancy-related assistance pursuant to section 2107(e)(1)(Q), for the purchasing of health insurance coverage (as defined in section 2791(b)(1) of the Public Health Service Act) for an alien who is not a qualified alien and is not such a child or pregnant woman; or (ii) provides any form of comprehensive health benefits coverage, except such coverage required by Federal law, during such quarter, whether or not under a State plan (or waiver of such plan) under this title or under another program established by the State, and regardless of the source of funding for such coverage, to an alien who is not a qualified alien and is not such a child or pregnant woman. (D) Immigration terms (i) Alien The term alien has the meaning given such term in section 101(a) of the Immigration and Nationality Act. (ii) Qualified alien The term qualified alien has the meaning given such term in section 431 of the Personal Responsibility and Work Opportunity Reconciliation Act of 1996, except that the references to (in the opinion of the agency providing such benefits) in subsection (c) of such section 431 shall be treated as references to (in the opinion of the State in which such comprehensive health benefits coverage or such financial assistance is provided, as applicable) . ; and (2) in subsection (z)(2)— (A) in subparagraph (A), by striking for such year and inserting for such quarter ; and (B) in subparagraph (B)(i)— (i) in the matter preceding subclause (I), by striking for a year and inserting for a calendar quarter in a year ; and (ii) in subclause (II), by striking for the year and inserting for the quarter for the State . 202. Prohibiting Federal financial participation under Medicaid and CHIP for individuals without verified citizenship, nationality, or satisfactory immigration status (a) In general (1) Medicaid Section 1903(i)(22) of the Social Security Act ( 42 U.S.C. 1396b(i)(22) ) is amended— (A) by adding and at the end; (B) by striking to amounts and inserting "to— (A) amounts ; and (C) by adding at the end the following new subparagraph: (B) in the case that the State elects under section 1902(a)(46)(C) to provide for making medical assistance available to an individual during— (i) the period in which the individual is provided the reasonable opportunity to present satisfactory documentary evidence of citizenship or nationality under section 1902(ee)(2)(C) or subsection (x)(4); (ii) the 90-day period described in section 1902(ee)(1)(B)(ii)(II); or (iii) the period in which the individual is provided the reasonable opportunity to submit evidence indicating a satisfactory immigration status under section 1137(d)(4), amounts expended for such medical assistance, unless the citizenship or nationality of such individual or the satisfactory immigration status of such individual (as applicable) is verified by the end of such period; . (2) CHIP Section 2107(e)(1)(O) of the Social Security Act ( 42 U.S.C. 1397gg(e)(1)(O) ) is amended by striking and (17) and inserting (17), and (22) . (b) Eliminating State requirement to provide medical assistance during reasonable opportunity period (1) Documentary evidence of citizenship or nationality Section 1903(x)(4) of the Social Security Act ( 42 U.S.C. 1396b(x) ) is amended— (A) by striking under clauses (i) and (ii) of section 1137(d)(4)(A) and inserting under section 1137(d)(4) ; and (B) by inserting , except that the State shall not be required to make medical assistance available to such individual during the period in which such individual is provided such reasonable opportunity if the State has not elected the option under section 1902(a)(46)(C) before the period at the end. (2) Social Security data match Section 1902(ee) of the Social Security Act ( 42 U.S.C. 1396a(ee) ) is amended— (A) in paragraph (1)(B)(ii)— (i) in subclause (II), by striking (and continues to provide the individual with medical assistance during such 90-day period) and inserting and, if the State has elected the option under subsection (a)(46)(C), continues to provide the individual with medical assistance during such 90-day period ; and (ii) in subclause (III), by inserting , or denies eligibility for medical assistance under this title for such individual, as applicable after under this title ; and (B) in paragraph (2)(C)— (i) by striking under clauses (i) and (ii) of section 1137(d)(4)(A) and inserting under section 1137(d)(4) ; and (ii) by inserting , except that the State shall not be required to make medical assistance available to such individual during the period in which such individual is provided such reasonable opportunity if the State has not elected the option under section 1902(a)(46)(C) before the period at the end. (3) Individuals with satisfactory immigration status Section 1137(d)(4) of the Social Security Act ( 42 U.S.C. 1320b–7(d)(4) ) is amended— (A) in subparagraph (A)(ii), by inserting (except that such prohibition on delay, denial, reduction, or termination of eligibility for benefits under the Medicaid program under title XIX shall apply only if the State has elected the option under section 1902(a)(46)(C)) after has been provided ; and (B) in subparagraph (B)(ii), by inserting (except that such prohibition on delay, denial, reduction, or termination of eligibility for benefits under the Medicaid program under title XIX shall apply only if the State has elected the option under section 1902(a)(46)(C)) after status . (c) Option to continue providing medical assistance during reasonable opportunity period (1) Medicaid Section 1902(a)(46) of the Social Security Act ( 42 U.S.C. 1396a(a)(46) ) is amended— (A) in subparagraph (A), by striking and at the end; (B) in subparagraph (B)(ii), by adding and at the end; and (C) by inserting after subparagraph (B)(ii) the following new subparagraph: (C) provide, at the option of the State, for making medical assistance available— (i) to an individual described in subparagraph (B) during the period in which such individual is provided the reasonable opportunity to present satisfactory documentary evidence of citizenship or nationality under subsection (ee)(2)(C) or section 1903(x)(4), or during the 90-day period described in subsection (ee)(1)(B)(ii)(II); or (ii) to an individual who is not a citizen or national of the United States during the period in which such individual is provided the reasonable opportunity to submit evidence indicating a satisfactory immigration status under section 1137(d)(4); . (2) CHIP Section 2105(c)(9) of the Social Security Act ( 42 U.S.C. 1397ee(c)(9) ) is amended by adding at the end the following new subparagraph: (C) Option to continue providing child health assistance during reasonable opportunity period Section 1902(a)(46)(C) shall apply to States under this title in the same manner as it applies to a State under title XIX. . (d) Effective date The amendments made by this section shall apply beginning on October 1, 2026. III Preventing wasteful spending 301. Prohibiting coverage of gender transition procedures as an essential health benefit under plans offered by Exchanges (a) In general Section 1302(b)(2) of the Patient Protection and Affordable Care Act ( 42 U.S.C. 18022(b)(2) ) is amended by adding at the end the following new subparagraph: (C) Gender transition procedures For plan years beginning on or after January 1, 2027, the essential health benefits defined pursuant to paragraph (1) may not include items and services furnished for a gender transition procedure. . (b) Gender transition procedure defined Section 1304 of the Patient Protection and Affordable Care Act ( 42 U.S.C. 18024 ) is amended by adding at the end the following new subsection: (f) Gender transition procedure (1) In general In this title, except as provided in paragraph (2), the term gender transition procedure means, with respect to an individual, any of the following when performed for the purpose of intentionally changing the body of such individual (including by disrupting the body’s development, inhibiting its natural functions, or modifying its appearance) to no longer correspond to the individual’s sex: (A) Performing any surgery, including— (i) castration; (ii) sterilization; (iii) orchiectomy; (iv) scrotoplasty; (v) vasectomy; (vi) tubal ligation; (vii) hysterectomy; (viii) oophorectomy; (ix) ovariectomy; (x) metoidioplasty; (xi) clitoroplasty; (xii) reconstruction of the fixed part of the urethra with or without a metoidioplasty or a phalloplasty; (xiii) penectomy; (xiv) phalloplasty; (xv) vaginoplasty; (xvi) vaginectomy; (xvii) vulvoplasty; (xviii) reduction thyrochondroplasty; (xix) chondrolaryngoplasty; (xx) mastectomy; and (xxi) any plastic, cosmetic, or aesthetic surgery that feminizes or masculinizes the facial or other body features of an individual. (B) Any placement of chest implants to create feminine breasts or any placement of erection or testicular prosthesis. (C) Any placement of fat or artificial implants in the gluteal region. (D) Administering, prescribing, or dispensing to an individual medications, including— (i) gonadotropin-releasing hormone (GnRH) analogues or other puberty-blocking drugs to stop or delay normal puberty; and (ii) testosterone, estrogen, or other androgens to an individual at doses that are supraphysiologic than would normally be produced endogenously in a healthy individual of the same age and sex. (2) Exception Paragraph (1) shall not apply to the following: (A) Puberty suppression or blocking prescription drugs for the purpose of normalizing puberty for an individual experiencing precocious puberty. (B) Medically necessary procedures or treatments to correct for— (i) a medically verifiable disorder of sex development, including— (I) 46,XX chromosomes with virilization; (II) 46,XY chromosomes with undervirilization; and (III) both ovarian and testicular tissue; (ii) sex chromosome structure, sex steroid hormone production, or sex hormone action, if determined to be abnormal by a physician through genetic or biochemical testing; (iii) infection, disease, injury, or disorder caused or exacerbated by a previous procedure described in paragraph (1), or a physical disorder, physical injury, or physical illness that would, as certified by a physician, place the individual in imminent danger of death or impairment of a major bodily function unless the procedure is performed, not including procedures performed for the alleviation of mental distress; or (iv) procedures to restore or reconstruct the body of the individual in order to correspond to the individual’s sex after one or more previous procedures described in paragraph (1), which may include the removal of a pseudo phallus or breast augmentation. (3) Sex For purposes of this subsection, the term sex means either male or female, as biologically determined and defined by subparagraph (A) and subparagraph (B). (A) Female The term female means an individual who naturally has, had, will have, or would have, but for a developmental or genetic anomaly or historical accident, the reproductive system that at some point produces, transports, and utilizes eggs for fertilization. (B) Male The term male means an individual who naturally has, had, will have, or would have, but for a developmental or genetic anomaly or historical accident, the reproductive system that at some point produces, transports, and utilizes sperm for fertilization. . 302. Prohibiting Federal Medicaid and CHIP funding for certain items and services (a) Medicaid Section 1903(i) of the Social Security Act ( 42 U.S.C. 1396b(i) ) is amended— (1) in paragraph (26), by striking ; or and inserting a semicolon; (2) in paragraph (27), by striking the period at the end and inserting ; or ; (3) by inserting after paragraph (27) the following new paragraph: (28) with respect to any amount expended for specified gender transition procedures (as defined in section 1905(ll)) furnished to an individual enrolled in a State plan (or waiver of such plan). ; and (4) in the flush left matter at the end, by striking and (18), and inserting (18), and (28) . (b) CHIP Section 2107(e)(1)(O) of the Social Security Act ( 42 U.S.C. 1397gg(e)(1)(O) ), as amended by this Act, is further amended by striking and (22) and inserting (22), and (28) . (c) Specified gender transition procedures defined Section 1905 of the Social Security Act ( 42 U.S.C. 1396d ) is amended by adding at the end the following new subsection: (ll) Specified gender transition procedures (1) In general For purposes of section 1903(i)(28), except as provided in paragraph (2) , the term specified gender transition procedure means, with respect to an individual, any of the following when performed for the purpose of intentionally changing the body of such individual (including by disrupting the body’s development, inhibiting its natural functions, or modifying its appearance) to no longer correspond to the individual’s sex: (A) Performing any surgery, including— (i) castration; (ii) sterilization; (iii) orchiectomy; (iv) scrotoplasty; (v) vasectomy; (vi) tubal ligation; (vii) hysterectomy; (viii) oophorectomy; (ix) ovariectomy; (x) metoidioplasty; (xi) clitoroplasty; (xii) reconstruction of the fixed part of the urethra with or without a metoidioplasty or a phalloplasty; (xiii) penectomy; (xiv) phalloplasty; (xv) vaginoplasty; (xvi) vaginectomy; (xvii) vulvoplasty; (xviii) reduction thyrochondroplasty; (xix) chondrolaryngoplasty; (xx) mastectomy; and (xxi) any plastic, cosmetic, or aesthetic surgery that feminizes or masculinizes the facial or other body features of an individual. (B) Any placement of chest implants to create feminine breasts or any placement of erection or testicular prosthesis. (C) Any placement of fat or artificial implants in the gluteal region. (D) Administering, prescribing, or dispensing to an individual medications, including— (i) gonadotropin-releasing hormone (GnRH) analogues or other puberty-blocking drugs to stop or delay normal puberty; and (ii) testosterone, estrogen, or other androgens to an individual at doses that are supraphysiologic than would normally be produced endogenously in a healthy individual of the same age and sex. (2) Exception Paragraph (1) shall not apply to the following when furnished to an individual by a health care provider if the individual is a minor with the consent of such individual’s parent or legal guardian: (A) Puberty suppression or blocking prescription drugs for the purpose of normalizing puberty for an individual experiencing precocious puberty. (B) Medically necessary procedures or treatments to correct for— (i) a medically verifiable disorder of sex development, including— (I) 46,XX chromosomes with virilization; (II) 46,XY chromosomes with undervirilization; and (III) both ovarian and testicular tissue; (ii) sex chromosome structure, sex steroid hormone production, or sex hormone action, if determined to be abnormal by a physician through genetic or biochemical testing; (iii) infection, disease, injury, or disorder caused or exacerbated by a previous procedure described in paragraph (1), or a physical disorder, physical injury, or physical illness that would, as certified by a physician, place the individual in danger of death or impairment of a major bodily function unless the procedure is performed, not including procedures performed for the alleviation of mental distress; or (iv) procedures to restore or reconstruct the body of the individual in order to correspond to the individual’s sex after one or more previous procedures described in paragraph (1), which may include the removal of a pseudo phallus or breast augmentation. (3) Sex For purposes of paragraph (1), the term sex means either male or female, as biologically determined and defined in paragraphs (4) and (5), respectively. (4) Female For purposes of paragraph (3), the term female means an individual who naturally has, had, will have, or would have, but for a developmental or genetic anomaly or historical accident, the reproductive system that at some point produces, transports, and utilizes eggs for fertilization. (5) Male For purposes of paragraph (3), the term male means an individual who naturally has, had, will have, or would have, but for a developmental or genetic anomaly or historical accident, the reproductive system that at some point produces, transports, and utilizes sperm for fertilization. . December 8, 2025 Read the second time and placed on the calendar

Plain-English summary

Confidence: high · Complexity: complex · Model: grok-4.5

This bill is a big health package that would put federal cash into special savings accounts for some marketplace shoppers, open cheaper catastrophic plans to more people, tighten Medicaid rules around immigration status, and limit federal support for certain abortion coverage and gender-transition care.

On the choice-and-money side: for 2026 and 2027, if you’re 18–64, on a bronze or catastrophic ACA marketplace plan, and your household income is at or under 700% of the poverty line, HHS would pay into a special “Exchange plan” health savings account (HSA)—a tax-favored pot for medical costs. That’s about $1,000 a year if you’re under 50, and $1,500 if you’re 50–64. The bill sets aside $10 billion each of those years for this. You couldn’t spend that HSA money on most abortions (with the usual life-of-the-mother, rape, or incest exceptions) or on sex-trait modification care. Starting in 2027, anyone in the individual market could buy catastrophic plans, not just young or hardship cases. It would also fund cost-sharing reduction payments (the subsidies that lower deductibles and copays for many enrollees) from 2027 on—except for plans that cover abortion beyond those narrow exceptions.

On Medicaid, CHIP, and immigration status: from October 2026, federal matching money generally couldn’t pay for care during the “reasonable opportunity” window to prove citizenship or satisfactory immigration status unless the state opts in and status is verified in time. States that use their own funds to cover or help non-qualified immigrants get comprehensive coverage or insurance help would see their enhanced ACA expansion match drop from 90% to 80% in those quarters.

Title III bars gender-transition surgeries, implants, puberty blockers, and cross-sex hormones from counting as essential health benefits on marketplace plans (plan years 2027 on), and blocks federal Medicaid/CHIP payment for those services, with limited exceptions such as certain disorders of sex development or restoring the body after prior procedures.

The Senate held a cloture vote on the motion to proceed—cloture is the 60-vote step to end a filibuster and start real debate—and it failed 51–48, so the bill did not advance that way.

Related issues

How a vote maps to positions

Impartial mapping: which issue position a Yea vs Nay advances. When a bill has multiple floor votes, each roll can have its own mapping. Bill-level entries (no roll listed) apply as a default when a roll has no specific map. Used for legislator alignment.

All rolls (bill default)

IssueYea advancesNay advancesNote
HealthcareMarket choice and cost competitionStatus quo / reject this changeYea advances HSA contributions, wider catastrophic-plan access, and CSR funding design; also bars gender-transition items as EHBs and from Medicaid/CHIP. Nay keeps prior marketplace, HSA, and coverage rules.
Abortion & Reproductive PolicyFederal restrictions or limited federal fundingFederal protections for accessYea blocks Exchange HSA funds and CSR appropriations for plans/coverage of abortion beyond life/rape/incest exceptions. Nay opposes those federal funding limits.
Immigration & BorderEnforcement- and deterrence-firstStatus quo / reject this changeYea ties federal Medicaid/CHIP dollars to verified status, makes reasonable-opportunity coverage optional, and cuts expansion FMAP for states funding care for non-qualified aliens. Nay keeps prior verification and match practice.
Taxes & Government SpendingTargeted credits and industrial policyStatus quo / reject this changeYea creates a large time-limited federal HSA contribution program and new CSR appropriations while reducing some Medicaid match spending for specified states. Nay rejects that fiscal package.

Official citations

Member votes on this bill

MemberPositionRoll call
Baldwin, Tammy
D-WI
Naysenate #643 · Official roll call
Cruz, Ted
R-TX
Yeasenate #643 · Official roll call
Warren, Elizabeth
D-MA
Naysenate #643 · Official roll call
Cassidy, Bill
R-LA
Yeasenate #643 · Official roll call
Scott, Tim
R-SC
Yeasenate #643 · Official roll call
Murray, Patty
D-WA
Naysenate #643 · Official roll call
Grassley, Chuck
R-IA
Yeasenate #643 · Official roll call
Schiff, Adam B.
D-CA
Naysenate #643 · Official roll call
Booker, Cory A.
D-NJ
Naysenate #643 · Official roll call
Mullin, Markwayne
R-OK
Yeasenate #643 · Official roll call
Young, Todd
R-IN
Yeasenate #643 · Official roll call
Wyden, Ron
D-OR
Naysenate #643 · Official roll call
Wicker, Roger F.
R-MS
Yeasenate #643 · Official roll call
Whitehouse, Sheldon
D-RI
Naysenate #643 · Official roll call
Welch, Peter
D-VT
Naysenate #643 · Official roll call
Warnock, Raphael G.
D-GA
Naysenate #643 · Official roll call
Warner, Mark R.
D-VA
Naysenate #643 · Official roll call
Van Hollen, Chris
D-MD
Naysenate #643 · Official roll call
Tuberville, Tommy
R-AL
Yeasenate #643 · Official roll call
Tillis, Thomas
R-NC
Yeasenate #643 · Official roll call
Thune, John
R-SD
Yeasenate #643 · Official roll call
Sullivan, Dan
R-AK
Yeasenate #643 · Official roll call
Smith, Tina
D-MN
Naysenate #643 · Official roll call
Slotkin, Elissa
D-MI
Naysenate #643 · Official roll call
Sheehy, Tim
R-MT
Yeasenate #643 · Official roll call
Shaheen, Jeanne
D-NH
Naysenate #643 · Official roll call
Scott, Rick
R-FL
Yeasenate #643 · Official roll call
Schumer, Charles E.
D-NY
Naysenate #643 · Official roll call
Schmitt, Eric
R-MO
Yeasenate #643 · Official roll call
Schatz, Brian
D-HI
Naysenate #643 · Official roll call
Sanders, Bernard
I-VT
Naysenate #643 · Official roll call
Rounds, Mike
R-SD
Yeasenate #643 · Official roll call
Rosen, Jacky
D-NV
Naysenate #643 · Official roll call
Risch, James E.
R-ID
Yeasenate #643 · Official roll call
Ricketts, Pete
R-NE
Yeasenate #643 · Official roll call
Reed, Jack
D-RI
Naysenate #643 · Official roll call
Peters, Gary C.
D-MI
Naysenate #643 · Official roll call
Paul, Rand
R-KY
Naysenate #643 · Official roll call
Padilla, Alex
D-CA
Naysenate #643 · Official roll call
Ossoff, Jon
D-GA
Naysenate #643 · Official roll call
Murphy, Christopher
D-CT
Naysenate #643 · Official roll call
Britt, Katie Boyd
R-AL
Yeasenate #643 · Official roll call
Murkowski, Lisa
R-AK
Yeasenate #643 · Official roll call
Moreno, Bernie
R-OH
Yeasenate #643 · Official roll call
Moran, Jerry
R-KS
Yeasenate #643 · Official roll call
Merkley, Jeff
D-OR
Naysenate #643 · Official roll call
McCormick, David
R-PA
Yeasenate #643 · Official roll call
McConnell, Mitch
R-KY
Yeasenate #643 · Official roll call
Marshall, Roger
R-KS
Yeasenate #643 · Official roll call
Markey, Edward J.
D-MA
Naysenate #643 · Official roll call
Lummis, Cynthia M.
R-WY
Yeasenate #643 · Official roll call
Luján, Ben Ray
D-NM
Naysenate #643 · Official roll call
Lee, Mike
R-UT
Yeasenate #643 · Official roll call
Lankford, James
R-OK
Yeasenate #643 · Official roll call
Klobuchar, Amy
D-MN
Naysenate #643 · Official roll call
King, Angus S., Jr.
I-ME
Naysenate #643 · Official roll call
Kim, Andy
D-NJ
Naysenate #643 · Official roll call
Kennedy, John
R-LA
Yeasenate #643 · Official roll call
Kelly, Mark
D-AZ
Naysenate #643 · Official roll call
Kaine, Tim
D-VA
Naysenate #643 · Official roll call
Justice, James C.
R-WV
Yeasenate #643 · Official roll call
Johnson, Ron
R-WI
Yeasenate #643 · Official roll call
Hyde-Smith, Cindy
R-MS
Yeasenate #643 · Official roll call
Husted, Jon
R-OH
Yeasenate #643 · Official roll call
Hoeven, John
R-ND
Yeasenate #643 · Official roll call
Hirono, Mazie K.
D-HI
Naysenate #643 · Official roll call
Hickenlooper, John W.
D-CO
Naysenate #643 · Official roll call
Heinrich, Martin
D-NM
Naysenate #643 · Official roll call
Hawley, Josh
R-MO
Yeasenate #643 · Official roll call
Hassan, Margaret Wood
D-NH
Naysenate #643 · Official roll call
Hagerty, Bill
R-TN
Yeasenate #643 · Official roll call
Gillibrand, Kirsten E.
D-NY
Naysenate #643 · Official roll call
Gallego, Ruben
D-AZ
Naysenate #643 · Official roll call
Fischer, Deb
R-NE
Yeasenate #643 · Official roll call
Fetterman, John
D-PA
Naysenate #643 · Official roll call
Ernst, Joni
R-IA
Yeasenate #643 · Official roll call
Durbin, Richard J.
D-IL
Naysenate #643 · Official roll call
Duckworth, Tammy
D-IL
Naysenate #643 · Official roll call
Daines, Steve
R-MT
Not Votingsenate #643 · Official roll call
Curtis, John R.
R-UT
Yeasenate #643 · Official roll call
Crapo, Mike
R-ID
Yeasenate #643 · Official roll call
Cramer, Kevin
R-ND
Yeasenate #643 · Official roll call
Cotton, Tom
R-AR
Yeasenate #643 · Official roll call
Cortez Masto, Catherine
D-NV
Naysenate #643 · Official roll call
Cornyn, John
R-TX
Yeasenate #643 · Official roll call
Coons, Christopher A.
D-DE
Naysenate #643 · Official roll call
Collins, Susan M.
R-ME
Yeasenate #643 · Official roll call
Capito, Shelley Moore
R-WV
Yeasenate #643 · Official roll call
Cantwell, Maria
D-WA
Naysenate #643 · Official roll call
Budd, Ted
R-NC
Yeasenate #643 · Official roll call
Boozman, John
R-AR
Yeasenate #643 · Official roll call
Blunt Rochester, Lisa
D-DE
Naysenate #643 · Official roll call
Blumenthal, Richard
D-CT
Naysenate #643 · Official roll call
Blackburn, Marsha
R-TN
Yeasenate #643 · Official roll call
Bennet, Michael F.
D-CO
Naysenate #643 · Official roll call
Barrasso, John
R-WY
Yeasenate #643 · Official roll call
Banks, Jim
R-IN
Yeasenate #643 · Official roll call
Alsobrooks, Angela D.
D-MD
Naysenate #643 · Official roll call
Graham, Lindsey
R-SC
Yeasenate #643 · Official roll call
Moody, Ashley
R-FL
Yeasenate #643 · Official roll call