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Bill Basics
Bill Number: H.R. 6703
Full Title: Lower Health Care Premiums for All Americans Act
Primary Sponsor: Rep. Mariannette Miller-Meeks (R-IA-1)
Co-sponsors: To be determined (the bill was just introduced)
Introduction Date: December 15, 2025
Current Status: Introduced and referred to three committees:
- Committee on Energy and Commerce
- Committee on Education and Workforce
- Committee on Ways and Means
The bill is scheduled for consideration by the House Rules Committee on December 16, 2025, with House Republican leadership pushing for a floor vote before Congress recesses for the year.
Length: 111 pages
Plain-Language Summary
H.R. 6703 represents House Republicans’ alternative approach to addressing rising health insurance costs without extending the enhanced Affordable Care Act (ACA) tax credits that are set to expire on December 31, 2025. Rather than continuing subsidies that help millions of Americans afford marketplace insurance premiums, this bill focuses on what sponsors call the “root causes” of high health care costs.
The legislation tackles the problem from two main angles. First, it expands options for small businesses and self-employed individuals to band together and purchase health insurance as a group—similar to how large corporations can negotiate better rates. These are called Association Health Plans. Second, it requires companies called pharmacy benefit managers (PBMs)—the middlemen who negotiate prescription drug prices—to disclose their fees, rebates, and pricing practices to employers and government agencies.
Additionally, the bill provides funding for cost-sharing reduction payments starting in 2027. These payments help lower-income people afford deductibles and copayments under ACA plans. However, there’s a significant catch: plans that cover abortion services (except in cases of rape, incest, or to save the mother’s life) would be ineligible for these payments. This provision has drawn sharp criticism from Democrats and reproductive rights advocates, who view it as an attempt to eliminate abortion coverage from marketplace insurance plans.
Key Provisions
Title I: Improving Health Care Options for Workers
Section 101: Association Health Plans (AHPs)
What Changes: The bill expands Association Health Plans by allowing employers from different industries to join together to offer health insurance. Previously, attempts to expand AHPs were blocked in federal court during the Trump administration.
Who’s Affected:
- Small businesses with as few as one employee
- Self-employed individuals and independent contractors
- Trade associations and chambers of commerce
Requirements:
- The association must have existed for at least 2 years before offering health plans
- Must serve at least 51 employees across all member employers
- 75% of the association’s governing board must be employer members
- Cannot be owned or controlled by insurance companies
- Cannot discriminate based on health status
How It Works: Small employers join an association, which then negotiates with insurers on behalf of all members. The association can offer plans that aren’t subject to all ACA requirements that apply to individual market plans, potentially offering lower premiums but also less comprehensive coverage. The plans would still have to cover people with pre-existing conditions without charging them more, but they wouldn’t have to cover all 10 “essential health benefits” required in ACA marketplace plans.
Timeline: Would take effect upon enactment, though associations would need 2 years of existence before offering plans.
Section 102: Pharmacy Benefit Manager Transparency
What Changes: Creates extensive new reporting requirements for pharmacy benefit managers—companies that negotiate drug prices and manage prescription benefits for employers and insurers.
Who’s Affected:
- Employers with 100+ employees offering health plans
- Group health plans with 100+ participants
- Pharmacy benefit management companies
- Workers covered by employer health insurance
Reporting Requirements: PBMs must provide detailed semi-annual reports including:
- Drug acquisition costs and net prices
- Rebates received from drug manufacturers
- Administrative fees charged
- Specialty drug spending and utilization
- Top 50 drugs by spending
- Pharmacy reimbursement rates
- Formulary decisions (which drugs are covered)
Transparency for Participants: Upon request, plan participants can receive information about rebates and fees related to their specific prescriptions.
Timeline: Reporting requirements would begin 18 months after enactment, with regulations issued within that timeframe.
Title II: Funding Cost-Sharing Reduction Payments
Section 202: Cost-Sharing Reductions with Abortion Restriction
What Changes: Appropriates federal funding for cost-sharing reduction (CSR) payments starting in plan year 2027. These payments reimburse insurance companies for reducing deductibles, copayments, and coinsurance for low-income ACA enrollees (those earning 100-250% of the federal poverty level).
Background: President Trump stopped making these payments in 2017 as part of an effort to weaken the ACA. Insurers responded by raising premiums on silver-tier plans (a practice called “silver loading”), which paradoxically increased federal spending on premium subsidies but also created more generous coverage options for some enrollees.
The Abortion Restriction: No funds appropriated under this section can go to any qualified health plan that provides abortion coverage, except for abortions necessary to save the mother’s life or in cases of rape or incest.
Who’s Affected:
- Lower-income ACA marketplace enrollees (100-250% of poverty level)
- In 2025, this means individuals earning between $15,060 and $37,650 annually
- Insurance companies offering plans on ACA marketplaces
- States that require or permit abortion coverage in marketplace plans
Practical Effect: Insurance companies would face a choice: continue covering abortion and forgo federal CSR payments, or drop abortion coverage to receive the payments. This could effectively eliminate abortion coverage from most marketplace plans, even in states where abortion is legal and state law requires or permits such coverage.
Timeline: Payments would begin for plan years starting January 1, 2027 or later.
Context & Background
The Problem This Bill Aims to Address
Without congressional action, approximately 20-24 million Americans enrolled in ACA marketplace plans face dramatic premium increases in 2026. The enhanced premium tax credits enacted during the COVID-19 pandemic are set to expire on December 31, 2025. According to the Kaiser Family Foundation (KFF), premiums could more than double for many enrollees—increasing by about $1,000 per person on average. An estimated 2 million people could lose insurance coverage entirely due to unaffordable costs.
In Iowa, Rep. Miller-Meeks’s home state, more than 136,000 people purchased ACA marketplace coverage in 2025, with insurers filing 2026 rate increases ranging from 12.5% to over 25%.
Existing Law This Would Modify
The bill modifies several key pieces of legislation:
Employee Retirement Income Security Act (ERISA) of 1974: The bill amends ERISA to allow broader use of Association Health Plans by changing how “employer” is defined for purposes of group health plans.
Patient Protection and Affordable Care Act (2010): The bill appropriates funding for cost-sharing reduction payments that have been unfunded since 2017, but with new abortion restrictions.
Internal Revenue Code: Creates new reporting requirements for PBMs and enforcement mechanisms through tax penalties.
Why Now?
Multiple factors have converged to make health care costs a pressing political issue as 2025 ends:
- Subsidy Cliff: The enhanced ACA subsidies expire December 31, with no extension in place.
- Open Enrollment Uncertainty: The ACA marketplace enrollment period runs through January 15, 2026, but consumers don’t know what their actual 2026 premiums will be without congressional action.
- Political Pressure: Republicans, particularly those in competitive districts like Miller-Meeks, are facing constituent anger over rising premiums while also facing pressure from conservative groups to avoid “propping up Obamacare.”
- Legislative Gridlock: Senate Democrats and Republicans failed to reach agreement on competing health care proposals in December 2025, leaving House action as the remaining option.
- Trump Administration Position: President Trump has called for giving money directly to people rather than to insurance companies, complicating Republican consensus.
Stakeholders & Perspectives
Supporters and Their Arguments
House Republican Leadership
- Speaker Mike Johnson frames the bill as targeting “the real drivers of health care costs” rather than “writing bigger checks to insurance companies”
- Argues enhanced subsidies hide rising costs rather than addressing them
- Views the bill as fulfilling campaign promises to reform, not expand, the ACA
Rep. Mariannette Miller-Meeks (Primary Sponsor)
- As a physician, emphasizes putting “patients and their doctors over the profits of insurance companies”
- Claims the bill addresses root causes: PBM practices, lack of insurance options for small businesses, and market dysfunction
- Points to Paragon Health Institute estimates suggesting the CSR funding could reduce premiums by $900 nationally and $721 in Iowa
Small Business Advocates
- Support expanded Association Health Plans as giving small employers the same negotiating power as large corporations
- Argue current individual and small group market regulations make coverage unaffordable
PBM Reform Advocates
- Pharmacy associations, independent pharmacies, and patient advocacy groups support transparency requirements
- Organizations like AARP, American Pharmacists Association, and Crohn’s & Colitis Foundation have endorsed similar PBM reforms
- Argue PBMs manipulate pricing and create “pharmacy deserts” in rural areas
Anti-Abortion Organizations
- Susan B. Anthony Pro-Life America strongly supports the abortion restrictions
- View the cost-sharing provision as preventing taxpayer dollars from subsidizing abortion
Opposition and Their Arguments
House Democratic Leadership
- Minority Leader Hakeem Jeffries calls the proposal “toxic legislation” that “fails to extend the ACA tax credits that expire this month”
- Argues the bill doesn’t address the immediate crisis of skyrocketing 2026 premiums
- Views Republican approach as deliberately sabotaging the ACA
Democratic Congressional Campaign Committee
- Spokesperson Katie Smith accuses Miller-Meeks of “attacking Iowans’ health care”
- Claims the bill “does nothing to lower costs”
- Frames opposition as a 2026 campaign issue
Health Policy Experts
- Loren Adler (Brookings Institution): “There are very few winners from this policy”
- Concerns that Association Health Plans favor healthy people and could destabilize individual markets
- Larry Levitt (KFF): The abortion restriction would “effectively ban the procedure in Obamacare plans”
- Note that CSR funding helps only lower-income enrollees, while premium increases affect everyone
Consumer Advocates and ACA Marketplace Leaders
- Jessica Altman (Covered California): Parties feel “farther apart than they were even a few months ago”
- Consumers facing immediate decision: sign up for potentially unaffordable 2026 coverage or go uninsured
- Early enrollment data shows significant decreases in new sign-ups and increased cancellations
Reproductive Rights Organizations
- National Women’s Law Center argues the abortion restriction goes far beyond existing Hyde Amendment protections
- 25 states currently require or permit abortion coverage in ACA plans
- Concern that insurers will drop abortion coverage rather than forgo federal payments
- Note that federal funds already cannot be used for abortion services—this bill would deny payments for any costs if a plan covers abortion
Insurance Industry (Mixed)
- Some insurers support PBM transparency and CSR funding
- Concerns about abortion restriction creating complicated benefit design choices
- Pharmacy benefit management companies (through PCMA) oppose transparency requirements as costly government intrusion
Potential Impact
Practical Effects on Citizens
For ACA Marketplace Enrollees:
Higher-Income Enrollees: Without enhanced subsidy extension, those earning above 400% of poverty level (roughly $60,000+ for individuals) could see premiums increase dramatically—from under $100/month to $500+ per month in many cases.
Middle-Income Enrollees: Those earning 200-400% of poverty level could see subsidies decrease substantially, potentially making coverage unaffordable even with CSR payments that begin in 2027.
Lower-Income Enrollees (Target of CSR Payments): Beginning in 2027, could benefit from the bill if they can afford 2026 premiums. However, if their plan covers abortion, they would receive no CSR payments.
Timeline Gap: The bill provides no relief for 2026, meaning all enrollees face higher premiums for at least one year before any potential benefits materialize in 2027.
For Small Business Employees:
Potential Benefits:
- Access to more affordable insurance options through Association Health Plans
- Wider choice of providers and plan designs
- Possibility of pre-tax premium payments through CHOICE arrangements
Potential Risks:
- Plans may have less comprehensive coverage than ACA marketplace plans
- AHPs have historically had higher failure rates and fraud issues
- Age-based premium variation with no limits could make coverage very expensive for older workers
- If healthier small businesses leave traditional markets, premiums could rise for those remaining
For Self-Employed Individuals:
- Could join associations and access group insurance
- Must prove they are legitimately self-employed through verification procedures
- If verification fails, coverage could be terminated mid-year
For Workers with Employer Coverage:
- PBM transparency could lead to better drug pricing and formulary decisions by employers
- However, Congressional Budget Office analysis suggests PBM reforms have minimal impact on premiums (less than 0.1%)
- Reforms might be undermined as PBMs find new revenue sources outside disclosure requirements
For Women and People Seeking Abortion Services:
- Those in 25 states with abortion coverage requirements/permissions could lose coverage if insurers drop abortion benefits
- Could force people to pay entirely out-of-pocket for abortion (typically $600-$2,000)
- Creates pressure on states to change their laws regarding abortion coverage
Budget and Cost Implications
Cost-Sharing Reduction Payments:
- Congressional Budget Office previously estimated CSR payments at $7 billion (FY 2017), rising to $10 billion (2018) and $16 billion (2027)
- Current bill appropriates “such sums as may be necessary” starting in 2027
- Without extending enhanced premium subsidies, the CSR payments would help fewer people
- Net federal cost is uncertain—depends on how many people remain insured and which plan tiers they choose
PBM Transparency Requirements:
- Similar PBM reform bills have been scored at about $2 million implementation cost
- Congressional Budget Office has estimated such reforms would reduce premiums by less than 0.1% initially, eroding to less than 0.01% by 2034
- Estimated to shift $1.9 billion from tax-favored insurance to taxable wages over 10 years (a revenue increase)
Association Health Plans:
- Previous CBO estimates suggested similar AHP expansion could result in 300,000 more uninsured people by 2034
- Could reduce federal subsidy spending if people leave ACA marketplaces for AHPs
- Risk of market destabilization if healthier people migrate to AHPs, raising individual market premiums
No Subsidy Extension:
- Not extending enhanced subsidies would save approximately $335 billion over 10 years according to CBO estimates
- However, approximately 2 million people could lose coverage, and those remaining face much higher costs
Unintended Consequences to Watch
Market Segmentation: Association Health Plans could create a two-tiered insurance market where healthier small businesses and self-employed individuals join AHPs with lower premiums but less comprehensive coverage, while sicker individuals remain in the regulated individual market with higher premiums. This could undermine the risk-pooling that makes insurance work.
Abortion Coverage Elimination: Even in states that require abortion coverage, the financial incentive created by the bill could lead insurers to seek state law changes or drop marketplace participation entirely. This could reduce plan choices overall.
PBM Workarounds: Pharmacy benefit managers have historically responded to transparency requirements by finding new revenue sources and fee structures not covered by reporting requirements. The long-term effectiveness is questionable.
Association Stability: Historical experience with AHPs includes numerous failures, fraud cases, and insolvencies leaving members without coverage. The bill includes oversight requirements, but enforcement depends on resources and political will.
Rural Health Care: While AHPs could help rural areas by aggregating small businesses, PBM reforms might also benefit rural pharmacies facing reimbursement pressures. Net effect on rural access is unclear.
State-Federal Conflicts: The abortion provision creates tensions with state laws in 25 states, potentially leading to legal challenges and administrative complexity.
Legislative Prospects
Likelihood of Passage
House Passage: Uncertain
The bill faces significant hurdles even in the Republican-controlled House:
Within Republican Caucus:
- Some Republicans want to extend ACA subsidies to protect constituents, especially those in competitive districts
- Conservative Republicans oppose any measures seen as “strengthening Obamacare”
- President Trump’s call for health savings accounts isn’t fully addressed in this bill
- Slim Republican majority means even a few defections could sink the bill
Democratic Opposition:
- Democrats uniformly oppose the approach, calling it inadequate
- The abortion restriction is described as a “nonstarter” by Democratic leaders
- Democrats want a “clean” extension of enhanced subsidies
Senate Passage: Highly Unlikely
Even if the House passes the bill, Senate prospects are dim:
60-Vote Threshold: Senate rules require 60 votes to overcome a filibuster. With 51-49 Republican control, at least 11 Democrats would need to support the bill.
Democratic Opposition: Senate Democrats failed to advance their own 3-year subsidy extension, and have shown no interest in Republican alternatives with abortion restrictions.
Senate GOP Divisions: Some Senate Republicans (particularly those up for reelection in 2026 in swing states) face constituent pressure to extend subsidies.
Limited Time: Congress is scheduled to recess for the year by December 20, 2025, leaving minimal time for Senate consideration.
Similar Bills and Historical Precedents
Association Health Plans:
- Trump administration attempted to expand AHPs through regulation in 2018
- A federal judge struck down the rule in 2019, finding it exceeded statutory authority
- Biden administration formally rescinded the rule
- This bill attempts to accomplish through legislation what failed through regulation
- Prior AHP expansions in the 1980s-1990s resulted in numerous failures and fraud cases
PBM Transparency:
- Multiple bills addressing PBM practices have been introduced in both chambers in 2025
- Bipartisan support exists for PBM reform in principle
- S. 526 (Pharmacy Benefit Manager Transparency Act) and S. 527 passed committee markup in the 118th Congress
- Over 30 states have enacted PBM regulations
- Recent reconciliation legislation included some PBM reforms
Cost-Sharing Reduction Fights:
- Trump stopped CSR payments in 2017
- House Republicans sued the Obama administration over CSR appropriations in 2014
- The “silver loading” workaround has been in place since 2017
- This represents the first attempt to appropriate CSR funding with abortion restrictions
ACA Subsidy Extensions:
- Enhanced subsidies were created by the American Rescue Plan Act (2021)
- Extended by the Inflation Reduction Act (2022)
- Previous extensions have been partisan, with no Republican support
- Current subsidy cliff was created by Democrats’ choice to include sunset date
Bipartisan Support Level
Very Low on Overall Bill
The bill is essentially a partisan Republican alternative to Democratic proposals. Key indicators:
Co-sponsors: As of introduction, the bill had no Democratic co-sponsors (full list pending)
Committee Consideration: Referred to three committees with Republican majorities
Competing Proposals: Democrats are pursuing separate bills for subsidy extension
Specific Provisions:
- PBM transparency: Potential for bipartisan support in isolation
- Association Health Plans: Primarily Republican priority; Democrats view as ACA undermining
- CSR funding with abortion restrictions: Absolute Democratic opposition
- No subsidy extension: Absolute Democratic opposition
Timeline and Next Steps
December 16, 2025: House Rules Committee considers the bill
Week of December 16: Potential House floor vote if leadership has the votes
Before December 20: Congressional recess for year-end holidays
If Passed: Would move to Senate, where prospects are poor
More Likely Scenario: Bill serves as negotiating position for broader year-end discussions on government funding or other must-pass legislation
Alternative Paths:
- House Republicans might allow a vote on an amendment to extend subsidies
- Bipartisan discharge petitions exist to force votes on 1-year or 2-year subsidy extensions
- A compromise could emerge in negotiations, though time is extremely limited
- More likely: Subsidies lapse, and Congress addresses the issue in 2026
Political Context
This bill emerges in a fraught political environment:
2026 Midterm Elections: All House members face reelection, with control of the chamber in play. Health care costs could be a decisive issue.
Presidential Messaging: President Trump’s call for “giving money to people, not insurance companies” complicates Republican unity.
Constituent Pressure: Lawmakers from both parties report constituent concerns about rising premiums.
Ideological Fault Lines: The bill encapsulates core disagreements: Republicans want to reform the ACA and restrict abortion; Democrats want to strengthen the ACA and protect reproductive rights.
Procedural Warfare: With such slim majorities, procedural maneuvers (amendments, discharge petitions, etc.) could prove decisive.
Conclusion
H.R. 6703 represents a distinctly Republican vision for addressing health care costs: expand private market options, increase transparency, and avoid extending subsidies Republicans view as inefficient. However, it faces long odds of becoming law due to Democratic opposition to its approach (particularly the abortion restrictions), Republican divisions, Senate procedural hurdles, and severe time constraints.
The bill’s immediate impact on the 2026 premium crisis would be zero—it provides no relief for marketplace enrollees facing dramatic cost increases in just weeks. The PBM reforms and Association Health Plan expansions could have modest long-term effects, but also carry risks of market destabilization and inadequate consumer protections.
Most significantly, the bill’s attempt to deny federal cost-sharing payments to any plan covering abortion represents a major escalation in the legislative fight over reproductive rights, potentially eliminating abortion coverage from marketplace plans even in states where abortion is legal.
Whether this bill advances, dies in committee, or serves as a negotiating position in broader talks, it illustrates the deep partisan divide over health care policy as 2025 ends with millions of Americans uncertain about their insurance costs and coverage options for 2026.
This analysis is based on the bill text introduced December 15, 2025, and news reports through December 16, 2025. Legislative language and prospects may change rapidly.