The , approved by the panel on a voice vote, would allow consumers to use their tax-free flexible spending accounts or health savings accounts to pay for over-the-counter medications and women’s menstrual products.

Assuming it ultimately finds its way into law, the measure would also represent the latest piece of the Affordable Care Act’s financing to be undone.

Over-the-counter medication had been eligible for preferred tax status before the ACA. But that treatment was eliminated as part of a long list of new taxes and other provisions to generate revenue. The measures were aimed primarily at higher-income earners to pay the 10-year, roughly $1 trillion cost of the health law.

“It is paid for. It is fiscally responsible,” said President Barack Obama as he  into law in 2010.

But not so much anymore. Many of those “pay-fors,” particularly the taxes, “have been eliminated, delayed or are in jeopardy,” said Marc Goldwein of the Committee for a Responsible Federal Budget, a nonpartisan budget watchdog group. “All this stuff, it turns out, is very unpopular,” he said.

The first piece of financing to disappear happened before most of the law even took effect. Congress in 2011 repealed a requirement that any payment of more than $600 to a vendor. The idea was that if more payments were reported to taxing authorities, more taxes due would actually get paid. — loudly — that the new paperwork requirement would be excessive and Congress (and Obama) eventually agreed. The change eliminated an estimated $17 billion in ACA financing over 10 years.

In 2015, Congress delayed (for the first time) the so-called Cadillac tax, a 40% tax on the most generous employer health plans that was intended to curb excessive use of medical services. Business, labor and patient advocacy groups banded together in a coalition called , and they got Congress to delay its implementation from 2018 to 2020. In 2018, Congress delayed it again, to 2022. This past summer, the House voted overwhelmingly to eliminate the tax, which had been estimated to raise nearly $200 billion over the next decade.

Also on ice, thanks to that , are levies that were supposed to be paid by medical device makers and health insurance companies, originally worth a combined $80 billion in financing during the law’s first decade.

Yet another — albeit fairly small — source of financing for the law went away in the GOP tax bill in 2017, which zeroed out the tax penalty for failing to have health insurance. The penalty raised , the last year it was in effect.

Still, the two ACA taxes that generate the most revenue are on the books and collecting money. They are aimed at (more than $200,000 for individuals and $250,000 for couples) and were estimated to bring in more than $200 billion from 2010 to 2019. The measures, which don’t deal directly with services or provisions of the ACA, raise Medicare taxes for people at those higher incomes and increase taxes on unearned income.

The durability of these two taxes does not surprise Goldwein. Some are “unpopular to repeal,” he said, like “a tax on the rich that funds Medicare.”

What Goldwein does find surprising, though, is how durable some of the ACA’s  reductions in spending have been. The health law, somewhat controversially, reduced Medicare payments to hospitals, insurance companies and a broad array of other health providers.

“The Medicare cuts have been for the most part surprisingly sustainable politically,” he said. Even when the GOP took over the House in 2011, from the ACA. So did the 2017 GOP “repeal and replace” proposal.

On the other hand, the appointed board of experts that was to rein in future Medicare spending, the “Independent Payment Advisory Board,” never got off the ground. in 2018.

So what does this all mean? The Congressional Budget Office is no longer estimating the individual budget effect of how the ACA was paid for. But the past decade has shown that it’s been relatively easy to make hard-won tax increases go away, suggesting that interest groups, particularly health-related interest groups, still wield a lot of power on Capitol Hill.

That means that going forward, candidates’ promises about new benefits financed by new taxes should be viewed with some skepticism, said Goldwein.

Even as presidential candidates on the campaign trail are issuing financing plans, on Capitol Hill “right now everyone wants to cancel a 3% tax on the health insurance industry,” Goldwein said. That’s a reference to a major advertising campaign underway by an industry coalition of small business and insurance groups called “” The tax is one of those delayed in 2018 that will resume if Congress does not delay it again or repeal it.

Given that, he said, how likely is it that Congress — even one controlled by Democrats — would really “cancel the whole industry” by passing a “Medicare for All” bill?

HealthBent, a regular feature of Kaiser Health News, offers insight and analysis of policies and politics from KHN’s chief Washington correspondent, Julie Rovner, who has covered health care for more than 30 years.

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• The House Republican health bills would extend the reach of “health savings accounts,” which are tax-preferred vehicles for self-funding medical expenses, and repeal or delay two unpopular taxes imposed to help pay for the benefits included in the Affordable Care Act. Those taxes on health insurers and medical device makers have been delayed by Congress in the past.
• The administration’s startling about-face to continue the risk-adjustment payments to insurance companies is easing concerns about those firms participating in the ACA’s marketplaces next year. The program, which does not use federal funds, is designed to take payments from insurers who have fewer high-cost members than expected and give it to plans that see heavier costs than expected.
• Federal Medicaid officials have reopened public comments on a plan to implement work requirements for adults who gained coverage under Kentucky’s expansion program. Officials say that effort may satisfy the concerns expressed by a judge who threw out the work requirements earlier.
• The Trump administration announced that it will study some limited uses of drug imports to lower prescription costs. It is part of a promise by the president to help keep drug prices in check.

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Q: I heard that health savings account rules would be loosened under the new spending bill passed by Congress last month. Did that happen?

No. In fact, the standards have become slightly tighter this year.

In recent years, members of Congress from both parties have for health savings accounts and how the money in them can be spent, among other things. To date, though, those proposals haven’t become law.

Health savings accounts, which are linked to high-deductible health plans, continue to multiply. In 2017, there were 22 million accounts totaling in assets, an increase of 11 percent in the number of accounts over the previous year, according to Devenir, a firm that offers advice on HSA investments.

Money deposited in HSAs is tax-deductible, grows tax-free and can be used without owing tax to pay for medical expenses. Advocates promote the plans as a way to help consumers play a larger role in controlling their health spending and say that the tax advantages help people afford care.

The Internal Revenue Service that the maximum amount individuals with family coverage could contribute to their health savings accounts would actually be from their previously announced limit for 2018. The maximum contribution for people with individual coverage in 2018 remains $3,450.

The $50 family coverage contribution reduction, from $6,900 to $6,850, is pretty small change. It happened because the federal government altered the way it calculates inflation adjustments to the contribution limits.

But ignoring the new limit could create headaches for people who have already made the maximum HSA contribution for the year based on the $6,900 figure, said Roy Ramthun, president of HSA Consulting Services. If you don’t ask the bank that handles your HSA to return the $50 plus any earnings that have accrued before the next tax season, your taxable income will be off by that amount, plus you’ll be on the hook for a 6 percent penalty for exceeding the maximum contribution allowed.

That’s not going to amount to a lot of money, but there’s more than financial pain to consider, Ramthun said. “Do you really want to give the IRS a reason to come find you?”

Q: I didn’t have health insurance for one month last year, in January 2017. Do I owe a penalty for not having health insurance when I file my taxes this spring?

If you were uninsured for only one month in 2017, you won’t owe a penalty. People can be uninsured for during the year without triggering a tax penalty for not having coverage, said Tara Straw, a senior policy analyst at the Center on Budget and Policy Priorities.

This year, for the first time, the Internal Revenue Service won’t accept electronically filed tax returns unless all year, were exempt from the requirement or will pay a penalty for not having had coverage. Tax refunds that are due with paper returns that don’t have this information may be delayed, according to the IRS.

In your case, you’ll file  with your tax return to report a short-term coverage gap and claim an exemption from the coverage requirement. Your employer — or your insurer, if you purchased coverage on your own — will send a form to the IRS stating that you were covered for the other 11 months, Straw said.

Those penalties — $695 or 2.5 percent of your household income, whichever is greater — are also in force for 2018 coverage. But starting next year, you won’t owe a penalty no matter how long you may be uninsured. The tax reform law eliminated the penalty for not having health insurance in 2019.

Q: What health insurance options are available for my parents, who are seniors who worked in India and are now retired in the United States with green cards? 

Depending on their situation, people like your parents who are permanently in the United States have a number of options.

From your description, it’s unclear whether they live on their own or with you. If you claim them as dependents on your taxes, you might consider adding them to your own health insurance plan, said Shelby Gonzales, a senior policy analyst at the Center on Budget and Policy Priorities.

Assuming your parents haven’t worked for at least 10 years in the United States, they’re probably not eligible for premium-free hospitalization coverage under Medicare, the federal health insurance program for people age 65 and older, Gonzales said. If they’ve lived in the States for at least five years and their income and other resources meet state eligibility guidelines, however, they could qualify for Medicaid, the federal-state program for low-income people.

If they don’t qualify for either government health program, they could consider buying a health insurance plan on the state marketplace or through a broker.

If they buy a marketplace plan, they could be eligible for premium subsidies if their income is less than 400 percent of the (about $66,000 for a couple in 2018),Ìýsaid Gabrielle Lessard, a senior policy attorney at the National Immigration Law Center.

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The law, which took effect Jan. 1, mandates that insurers cover vasectomies without requiring patients to pay anything out-of-pocket — just as they must do for more than a dozen birth control methods for women.

But the measure may run afoul of Internal Revenue Service rules that do not include vasectomies among approved preventive services for high-deductible health plans. People with health savings accounts — which are exempt from tax liabilities — tied to those plans could no longer contribute to the savings accounts in that case.

Under the ,Ìýinsurers generally can’t charge patients a copayment or require any other cost sharing for prescription contraceptive drugs or devices approved by the Food and Drug Administration. The 2016 law is similar to what’s required under the federal Affordable Care Act, with a twist: It adds male sterilization — — to the list of services that are free for patients.

“While the ACA made important strides … it completely left men out of the equation,” said Karen Nelson, president and CEO of Planned Parenthood of Maryland, whose organization supported the bill.

Before the law took effect, a vasectomy at the organization’s Baltimore office would cost between $225 and $1,100, depending on someone’s ability to pay, said Nelson. Now the procedure will generally cost nothing for men in insured plans in Maryland.

The state law doesn’t apply to companies that are “self-funded,” meaning they pay their employees’ health care claims directly rather than buying state-regulated insurance policies.

Under IRS rules, consumers making tax-free contributions to health savings accounts (HSAs) that are linked to high-deductible health plans have to pay for all their medical care until they reach their deductible of at least in 2018. The only exception is for preventive services. The hitch for the Maryland law is that vasectomies aren’t on the IRS .

The IRS hasn’t responded to a by Maryland Insurance Commissioner Al Redmer Jr. A this year — after it failed to pass last year — that would exempt these high-deductible plans from the state mandate to cover vasectomies before the deductible is met. Such a move would preserve the tax advantages of the HSAs linked to them.

Maryland is joining a few other states, including , Vermont and, starting next year, , that have expanded contraceptive coverage without cost sharing to include male sterilization.

Vermont’s law includes language to exempt high-deductible plans with health savings accounts. While the issue has raised concerns in Maryland, in Illinois and Oregon it hasn’t appeared to generate much attention to date, legislative analysts say.

Some advocates for extending no-cost coverage to vasectomies noted that the IRS’ list of approved preventive services specifically says that it isn’t exhaustive.

But until the issue is clarified, “the safest thing to do is not make a contribution to your HSA,” said , a Maryland resident and president of HSA Consulting Services. Ramthun helped implement health savings accounts while working for the Treasury Department during the George W. Bush administration. He stressed that the uncertainty applies only to HSA contributions made after the law became effective in 2018, not to earlier contributions. The issue doesn’t affect people’s medical coverage.

Beyond the uncertainty around health savings account contributions, Maryland’s law requiring coverage of vasectomies without cost sharing addresses a gap in men’s preventive coverage.

“There are arguments to be made that male condoms and vasectomies have preventive benefits for both women and men, in terms of [sexually transmitted infection] prevention and preventing pregnancy,” said Mara Gandal-Powers, senior counsel at the National Women’s Law Center.

Seven percent of men ages 18 to 45 have had a vasectomy, according to a by researchers at Northwestern University. The prevalence increased to 16 percent among men ages 36 to 45. Men with higher incomes, higher education and a regular source of health care were more likely to have had the procedure, the study found.

The Maryland law doesn’t apply to the method of birth control that many men use: condoms. A by state Sen. John Astle, a Democrat, would expand the law to include condom coverage.

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Q: Does the GOP tax bill affect health savings accounts?

At this time, there are no changes aimed specifically at These are savings accounts linked to high-deductible plans and exempt from tax liability.

Congressional Republicans have been very interested in expanding the use of these tax-free accounts, and bills to repeal and replace the Affordable Care Act last summer included provisions to increase the maximum amount people could contribute to them or to allow people to use them to pay their health insurance premiums, among other things.  The GOP promotes the plans as a way to help consumers play a larger role in controlling their health spending and says that the tax advantages help people afford care.

The GOP tax legislation doesn’t incorporate any of those changes, said Roy Ramthun, president of HSA Consulting Services.

Some analysts say it’s still possible that HSA changes could be attached to other pieces of legislation, such as a spending bill or a bill to extend the Children’s Health Insurance Program.

“The GOP would like to get some of these HSA expansion provisions into one of these bills,” said Dorian Smith, a partner at human resources consultant Mercer.

Q: Republicans are seeking to repeal the individual mandate as part of the tax bill. Would that go into effect next year? 

Probably not. The joint bill that House and Senate negotiators have agreed to doesn’t repeal the ACA’s requirement that most people have health insurance, called the individual mandate. But it does repeal the penalty for not having coverage. That change wouldn’t take effect until 2019, however.

So, assuming the bill is enacted, most people will face a penalty if they don’t have health insurance next year of the greater of 2.5 percent of household income or $695 per adult.

Many people, however, qualify for one of to the mandate. Those include people who have suffered a hardship like eviction or bankruptcy and those whose earnings are low enough that health insurance is considered unaffordable.

In 2017, health insurance is considered unaffordable if the cheapest comprehensive coverage you can find would cost more than 8.16 percent of your household income.

“Because premiums have gone up so high in 2017 and 2018, there will be more people who qualify for the affordability exemption,” said Timothy Jost, a professor emeritus of law at Washington and Lee University in Virginia who is an expert on health law.

If you’re pondering whether to “go bare” next year, it’s worth noting that the Internal Revenue Service electronically filed returns unless you indicate whether you had coverage, an exemption or will pay the penalty.

Q: None of the marketplace plans in my area offer out-of-state coverage or any coverage for non-network providers. Why would an insurer limit what’s offered in that way?

Plans with broad provider networks have been steadily shrinking. sold on the ACA’s marketplaces in 2018 have restrictive networks, according to an analysis by the consulting firm Avalere Health. The percentage of such plans has steadily increased since 2015, when it was 54 percent, the analysis found.

Health maintenance organization (HMO) plans and exclusive provider organization (EPO) plans were categorized as restrictive because they typically have relatively fewer providers and don’t provide coverage for out-of-network care. Preferred provider organization (PPO) and point-of-service plans, on the other hand, were considered less restrictive because they generally have broader networks of providers and offer some out-of-network coverage.

The reason plans with restrictive networks are proliferating is because they help reduce costs, said Chris Sloan, a senior manager at Avalere.

“One of the ways to do that is to have a narrower network,” he said.

But there may be an upside for consumers. “It’s not just reducing costs for the sake of costs, it’s also to slow the premium growth,” he said.

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Los legisladores generalmente coinciden en cuáles son los esfuerzos que deberían realizarse para estabilizar el mercado. Arriba en la lista está garantizar los subsidios para personas de bajos ingresos, para que puedan solventar gastos de bolsillo como deducibles y copagos.

Las aseguradoras también quieren que el gobierno federal continúe exigiendo que la mayoría de los estadounidenses tengan seguro, a riesgo de pagar una multa; y que sigan los esfuerzos continuos para que las personas sin seguro se inscriban durante el próximo período de inscripción abierta, del 1 de noviembre al 15 de diciembre, para obtener cobertura.

Esos esfuerzos son esenciales, dicen las aseguradoras, para ayudar a mantener clientes saludables en sus grupos de riesgo, para poder hacer frente a los costos de los beneficiarios con necesidades médicas.

Pero ¿qué pasa con las ideas que van más allá de las que se han repetido hasta el hartazgo? Aquí hay cinco propuestas que están sonando y son controversiales.

1. Permitir que las personas ingresen al Medicare a partir de los 55 años.

Conseguir incorporar a gente levemente más joven en el Medicare, el programa federal para los estadounidenses y discapacitados de 65 años y más, es una meta demócrata de larga data. Se propuso durante el gobierno de Bill Clinton y casi se incluye en el Obamacare.

Algunos demócratas lo apoyan como un primer paso hacia un sistema de salud universal, con un pagador único, una suerte de Medicare-para-Todos. La mayoría de los republicanos se oponen por esos mismos motivos, porque no quieren una atención de salud administrada por el gobierno.

Pero los defensores argumentan que ayudaría al actual mercado individual a excluir a las personas mayores, reduciendo así la edad promedio del grupo de riesgo. Dado que los pacientes mayores, en promedio, son más costosos de asegurar, el cambio podría reducir las primas para todos los que quedan en el Obamacare.

Esta es la meta de un proyecto de ley introducido a principios de agosto por la Senadora Debbie Stabenow (demócrata de Michigan) y otros siete senadores demócratas. Ese proyecto de ley permitiría a los clientes del mercado del Obamacare de 55 a 64 años comprar la cobertura de Medicare en vez de un plan de salud regular, pero también podrían usar créditos tributarios de ACA si fueran elegibles. Los costos de estos planes todavía no se han calculado.

“La forma en que lo hemos estructurado realmente ayuda al Medicare a tener personas más jóvenes en ese grupo y ayuda a los seguros privados a sacar a personas de alto costo de sus grupos de riesgo”, dijo Stabenow a The Detroit News.

Sin embargo, la idea no les convence a los analistas de salud conservadores. “Esta es sólo una manera de decir que vamos a sacar a estas personas de los mercados de seguros y ponerlos donde hay subsidios más grandes”, dijo Joseph Antos, del American Enterprise Institute (AEI).

1. Permitir a las personas “comprar” seguro del Medicaid.

Ya hay personas que compran seguro del Medicaid, el programa de salud federal, gerenciado por los estados, para personas de bajos ingresos. En 2005, el Congreso aprobó el Family Opportunity Act, que permite a ciertas familias de bajos ingresos comprar cobertura del Medicaid para niños discapacitados que no sean elegibles. Tradicionalmente, el Medicaid ha proporcionado a las personas con discapacidades beneficios más robustos que los seguros de salud privados.

A principios de este año, el gobernador republicano de Nevada, Brian Sandoval, vetó un proyecto de ley que habría permitido a los residentes del estado comprar cobertura del Medicaid a través del mercado de seguros de salud estatal.

Ahora, el senador Brian Schatz (demócrata de Hawaii) está impulsando un plan de salud federal del Medicaid, que describió para Vox.com. Este plan daría a los estados la opción de permitir que las personas con ingresos por encima de los umbrales de elegibilidad actuales del Medicaid paguen una prima para unirse al programa. Al igual que con la opción de comprar un plan del Medicare, permitiría a aquellos que califican para créditos tributarios federales utilizarlos para pagar las primas.

La propuesta también aumentaría los pagos del Medicaid a médicos, hospitales y otros proveedores de atención médica al mismo nivel que se paga por los pacientes del Medicare. Tradicionalmente, los bajos pagos del Medicaid han hecho que muchos médicos no ingresaran al programa.

Los analistas conservadores también reaccionan mal a esta opción. “Es completamente imposible”, dijo a Vox Avik Roy, de la Foundation for Research on Equal Opportunity. Roy predijo que aumentaría el gasto del Medicaid en $2 mil millones en 10 años.

1. Sacar a los adultos jóvenes del seguro de sus padres y volver a ponerlos en el mercado individual.

Permitir que los jóvenes de hasta 26 años permanezcan en los planes de salud de sus padres es, sin duda, una de las disposiciones más populares de ACA. Los demócratas la han promocionado con orgullo mientras los republicanos no se atreven a tocarla en casi ninguna de sus propuestas de revisión.

Sin embargo, lo que ha sido una bendición para 3 millones de adultos jóvenes (y un alivio para sus padres) significó un costo para el mercado individual en sí: en 2016, sólo el 28% de los compradores de planes de salud en los mercados tenían entre 18 y 34 años, muy por debajo del 40% que la mayoría de los analistas dijeron que era necesario tener para mantener al mercado estable.

1. Exigir a las aseguradoras que participan en otros programas gubernamentales que ofrezcan cobertura en el mercado.

Una deficiencia clara del mercado individual es la falta de competencia de las aseguradoras, particularmente en las zonas rurales. Si bien parece que no hay condados que se hayan quedado sin ninguna compañía que ofrezca cobertura para el próximo año, el porcentaje de los condados con una sola aseguradora parece que va a subir a partir un 33% para finales de 2017.

En un esfuerzo por alentar más fuertemente a las empresas privadas a que ofrezcan cobertura, varios analistas han sugerido que se establezca la participación en los mercados de ACA como un requisito para participar en otros programas gubernamentales.

1. Permitir que las personas usen contribuciones de cuentas de ahorro de salud (HSA) para pagar las primas del seguro médico.

Una disposición que no llamó mucho la atención en una de las versiones de la ley de salud del Senado que no se aprobó en julio habría permitido a la gente usar el dinero de las cuentas de ahorro de salud para pagar sus primas de seguro.

Las HSA están vinculadas a planes de salud con deducibles altos, y los consumidores usan el dinero en la cuenta para pagar sus gastos de bolsillo. Este dinero es libre de impuestos.

Con pocas excepciones, a las personas con HSA no se les ha permitido usar esos fondos para pagar primas mensuales. Pero el cambio sería una forma de aliviar a las personas que compran su propio seguro, ganan demasiado para obtener subsidios federales de primas y no pueden deducir las primas de sus impuestos porque no son técnicamente independientes.

Estas personas, aunque probablemente pequeñas en número, se han visto afectadas de manera desproporcionada por el aumento de las primas en el mercado individual desde que la ACA tomó pleno efecto.

Sin embargo, el cambio implicaría algunas compensaciones.

Roy Ramthun, quien ayudó a diseñar las HSA como staff del Senado a principios de los años 2000 y ayudó a implementarlas cuando estaba en el Departamento del Tesoro durante el gobierno de George W. Bush, dijo que, en general, “los republicanos han preferido subvencionar las primas a través de deducciones fiscales y créditos y dejar la HSA para los gastos de su propio bolsillo. “Permitir que las primas se paguen con fondos de la HSA, dijo,” podría comerse todo el saldo de la cuenta y no dejar nada para los gastos de bolsillo”. Hay límites a cuánto dinero se puede poner en una HSA. Para 2017, el máximo es $3,400 para un individuo y $ 6,750 para una familia.

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The Senate Health, Education, Labor and Pensions Committee the week Congress returns in September on “stabilizing premiums in the individual insurance market” that will feature state governors and insurance commissioners. A bipartisan group is also working to come up with compromise proposals.

Both before and after implementation of the federal health law, this market — serving people who don’t get coverage through work or the government — has proved problematic. Before the law, many people with preexisting health conditions could not get insurance at any price. Now, consumers in the individual market often face higher out-of-pocket costs and fewer choices of health care providers and insurers than in past years. More than 12 million people buy that insurance through the ACA’s marketplaces, while another 5 million .

Lowering the age for Medicare eligibility (whether by allowing people to purchase coverage early or letting them join on the same terms as those aged 65) is controversial. Some Democrats support it as a first step toward a single-payer, Medicare-for-All system. Most Republicans oppose it on those same grounds — as a step toward government-run health care.

But proponents argue it would help the current individual market by excluding the oldest people, thereby lowering the average age of the risk pool. Since older patients, on average, cost more to insure, the change could lower premiums for everyone left in the ACA market. That’s the stated goal of a introduced earlier this month by Sen. Debbie Stabenow (D-Mich.) and seven other Democratic senators. That bill would allow Obamacare market customers ages 55-64 to purchase Medicare coverage instead, but would also let them use ACA tax credits if they are eligible for those. The cost of such policies, however, has not been worked out.

“The way we’ve structured it actually both helps Medicare by having younger people in that pool, and it helps private insurance by taking higher-cost individuals out of their pool,” Stabenow told The .

Conservative health analysts don’t buy that, though. “This is just a way of saying we’re going to take these people out of the exchanges and put them where there are bigger subsidies,” said Joseph Antos at the conservative-leaning American Enterprise Institute (AEI).

2. Allow people to ‘buy in’ to Medicaid.

An alternative to letting people buy in to Medicare is letting them buy in to Medicaid, the joint federal-state program for those with low incomes.

Medicaid buy-ins already exist — for example, in 2005 Congress passed the , which allows families earning up to three times the poverty level to purchase Medicaid coverage for their disabled children who aren’t otherwise eligible. Medicaid has typically provided richer benefits for those with disabilities than private health insurance.

Earlier this year, Gov. Brian Sandoval (R-Nev.) that would have allowed Nevada residents to buy Medicaid coverage through the state’s insurance exchange.

Now Sen. Brian Schatz (D-Hawaii) is pushing a federal Medicaid buy-in plan, which he described to last week. It would give states the option to allow people with incomes over current Medicaid eligibility thresholds to pay a premium to join the program. Like the Medicare buy-in bill, it would allow those who qualify for federal tax credits to use them to pay the premiums.

The proposal would also raise the amounts Medicaid pays to doctors, hospitals and other health care providers to the same level as it pays for Medicare patients. Traditionally, low Medicaid payment rates have kept many doctors, particularly specialists, from taking Medicaid.

As with the Medicare expansion, the idea of a further Medicaid expansion does not sit well with conservative policy analysts. “It’s completely unworkable,” Avik Roy of the Foundation for Research on Equal Opportunity, told . He predicted it would raise Medicaid spending by $2 trillion over 10 years.

3. Get younger adults off their parents’ insurance and back into the individual market.

Allowing young adults up to age 26 to stay on their parents’ health plans is unquestionably one of the most popular ACA provisions. Democrats have touted it proudly while Republicans have dared not touch it in almost any of their overhaul proposals.

Yet what has been a boon to 3 million young adults (and a relief to their parents) has come at a cost to the individual marketplace itself, where only an estimated 28 percent of those buying coverage in state exchanges were ages 18-34 in 2016. That is well below the 40 percent most analysts said was necessary to keep the market stable.

“Frankly, it was really stupid,” to keep those young people out of the individual market, said Antos of AEI. The result has been a lack of people in the risk pool who are “young, healthy and whose parents will pay their premiums.”

But rolling back that piece of the law might be nearly impossible, said Antos, because “this is a middle-class giveaway.”

4. Require insurers who participate in other government programs to offer marketplace coverage.

One clear shortcoming of the individual marketplace is a lack of insurer competition, particularly in rural areas. While there appear to be no counties left with for the coming year, the percentage of counties with only one insurer seems certain to rise from .

In an effort to more strongly encourage private companies to step up and offer coverage, several analysts have suggested tying access to participation in other government programs to a willingness to offer individual ACA policies as well.

For example, insurers be required to provide policies in the marketplaces as a condition of being able to offer coverage to federal workers. Others have suggested that private insurers who offer profitable Medicare Advantage plans could also be required to offer individual exchange coverage, although the same rural areas with a lack of private individual market insurers also tend to coverage.

5. Let people use HSA contributions to pay health insurance premiums.

A little-noticed provision in one of the versions of the that failed to pass in July would have allowed people to use money from tax-preferred (HSAs) to pay their insurance premiums. A from a group of ideologically diverse health care experts included a similar idea.

HSAs are linked to high-deductible insurance plans, and consumers use the money in the account to pay their out-of-pocket expenses. The money put into the account and the earnings are not taxable.

With a few exceptions, people with HSAs have not been allowed to use those funds to pay monthly premiums. But the change would be one way to provide relief to people who buy their own insurance, earn too much to get federal premium subsidies and cannot deduct premiums from their taxes because they are not technically self-employed. Such people, though likely small in number, have been disproportionately hurt by rising premiums in the individual market since the ACA took full effect.

Still, the change would involve some trade-offs.

Roy Ramthun, who helped design HSAs as a Senate staffer in the early 2000s and helped implement them while at the Treasury Department during the George W. Bush administration, said that, generally, “Republicans have preferred to subsidize insurance premiums through tax deductions and credits and leave the HSA for out-of-pocket expenses.” Allowing premiums to be paid from HSA funds, he said, “could eat up the entire balance of the account and leave nothing for out-of-pocket expenses.” There are limits to how much money can be put into an HSA. For 2017, is $3,400 for an individual and $6,750 for a family.

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Corbelli’s insurance is linked to a health savings account so that she and her husband can put aside money tax-free to help cover their family’s drug and medical expenses. But there’s a hitch: Plans like theirs can’t cover any care for chronic conditions until the deductible is satisfied.

Those out-of-pocket expenses could shrink under a Trump administration  that would change Internal Revenue Service rules about what care can be covered before the deductible is met in plans linked to health savings accounts, or HSAs.

“It would save us a lot of money,” said Corbelli, 41, who lives in Orlando with her husband and their two children, ages 3 and 5.

KHN contributing columnist Michelle Andrews writes the series , which explores health care coverage and costs.

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Health plans with deductibles of thousands of dollars have become increasingly commonplace. Plans often cover services like generic drugs or doctor visits before consumers have satisfied their deductibles, typically requiring a copayment or coinsurance rather than demanding that consumers pony up the entire amount.

But plans that link to health savings accounts have more restrictions than other high-deductible plans. In addition to minimum deductibles and maximum HSA contribution limits, the plans can’t pay for anything but preventive care before consumers meet a deductible. Under current IRS rules, such preventive care is such as cancer screenings and immunizations that prevent a disease or condition, called “primary prevention.” With HSA-eligible plans, medical services or medications that prevent an existing chronic condition from getting worse or prevent complications from occurring — called “secondary prevention” — can’t be covered before the deductible is paid.

The Trump administration’s draft executive order, which was first obtained last month by and has yet to be issued, would allow such secondary preventive services to be covered.

Under the Affordable Care Act, most health plans, including HSA-eligible plans, are required to cover services recommended by the U.S. Preventive Services Task Force without charging consumers anything for them. That requirement is generally limited to primary prevention.

“We know health savings accounts are here to stay and we’d like to make them better,” said Dr. A. Mark Fendrick, an internist who is director of the University of Michigan’s Center for Value-Based Insurance Design and who has advocated for the change.

If people have diabetes, for example, they need regular eye and foot exams to prevent complications such as blindness and amputations down the road. But HSA plans can’t pay anything toward that care until people satisfy their deductible. “The executive order gives plans the flexibility to do that,” he said.

Similarly, it’s critical to remove obstacles to treatment for people like Corbelli with high blood pressure or heart disease, said Sue Nelson, vice president for federal advocacy at the American Heart Association.

“For people with cardiovascular disease, affordability is their No. 1 concern,” Nelson said.

The draft executive order is short on details, and administration officials would have to determine which new preventive services should be covered pre-deductible. Guidelines from medical specialty boards and quality metrics that many physicians are already being measured against could be used, said Roy Ramthun, president and founder of HSA Consulting Services who led the Treasury Department’s implementation of the HSA program in the early 2000s.

Back then, they took a conservative approach. “We said we can be more flexible later, but we can’t put the genie back in the bottle,” said Ramthun, who supports expanding preventive services coverage.

Many if the list of services that could be covered pre-deductible were expanded, said Tracy Watts, a senior partner at human resources consultant Mercer. Fifty-three percent of employers with 500 or more workers offer HSA-eligible plans, according to Mercer survey data. Three-quarters of employers put money into their employees’ HSA accounts, she said.

Erin Corbelli’s husband’s employer contributes up to $1,500 every year to their health savings account, which can help cover their pre-deductible costs.

Not everyone is so fortunate. “You’re kind of at the mercy of what your employer can offer and what your disposable income is,” she said.

Republicans for the expanded use of health savings accounts as a tax-advantaged way for consumers to get more financial “skin in the game.”

Consumer advocates have been much less enthusiastic, noting that the accounts typically benefit higher-income consumers who have cash to spare.

Still, given the reality of the growing prevalence of high-deductible plans, with or without health savings accounts, it’s a sensible proposal, many say.

“This is not a silver bullet or a solution to the problems that high-deductible plans can pose,” said Lydia Mitts, associate director of affordability initiatives at Families USA, an advocacy group. “But this is a good step in thinking about how we offer access to treatment people need in a timely and affordable way.”

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Investors are betting on it, bidding up shares of HSA provider HealthEquity by about 35 percent since the November election. It’s one of the best performing stocks on Wall Street since Donald Trump won the White House.

Another big beneficiary might be Optum Bank, the industry leader, with more than 3 million of these accounts and about $7 billion in assets it manages for consumers. It’s owned by the nation’s largest health insurer, UnitedHealth Group.

For years, these companies and others have been lobbying lawmakers for changes that could become reality with a Republican-controlled Congress and Trump administration.

The GOP  introduced Monday in the House reflects the party’s broad consensus for giving more Americans access to HSAs, which allow people to put aside money tax-free for medical expenses.

“There is an excitement in the business now,” Dr. Steve Neeleman, founder of Utah-based HealthEquity and a former trauma surgeon. “There are definitely things Washington can do to make HSAs more enticing to a broader market.”

were introduced in 2003 in legislation championed by President George W. Bush. Enrollment has grown steadily to nearly 21 million accounts with $41 billion in assets, according to , a research and consulting firm that tracks the industry.

Still, that number is a small fraction of the 178 million people who have health insurance through their jobs or purchase it on their own.

Industry officials are eager to reach new markets, including baby boomers in Medicare and enrollees in the military’s Tricare system, for whom — under current law — HSAs are off-limits. They also want to manage larger accounts that generate more revenue. Republican proposals in Congress could help accomplish both.

Proponents say consumers with HSAs may be more judicious in using services and seeking lower prices because their own money is at stake. Backers also like the tax breaks: There’s no tax on the funds’ investment gains or on withdrawals if spent on medical care. But critics note this treatment favors the wealthy as those with lower incomes often struggle to afford health care and have little to set aside in savings accounts.

A found that high-income households were considerably more likely than low-income to contribute to HSAs. The highest-income tax filers were also substantially more likely to fund their accounts fully.

The House Republican plan proposes to nearly double the HSA contribution limits to $6,550 for individuals and $13,100 for families beginning in 2018. Meanwhile, in the Senate, other proposals — including by Sen. Rand Paul (R-Ky.) and advanced by Sens. Bill Cassidy (R-La.) and Susan Collins (R-Maine) — lay out slightly different yet favorable treatment of HSAs.

The over-65 market in Medicare is a prime target for expansion.

“That is a great population that has the potential to save and really take more control over their health care,” said Eric Remjeske, president of the Devenir Group, the research and consulting firm.

Neeleman agreed and said it’s wrong to shut out thousands of baby boomers who are retiring every day. “It’s just not fair,” he said. Backers note that, even though Medicare is not a high-deductible health plan, there is cost sharing in Medicare, which leads many in Congress to think the prohibition should be abandoned.

The companies overseeing these accounts rake in money from a variety of fees, much like banks do.

Often consumers pay service fees that range from $2 to $5 per month for each account. The companies also earn interest on the customers’ money they manage in what’s known as “custodial” revenue. And HSA administrators collect fees from merchants when consumers use company-issued debit cards to pay for medical expenses out of their accounts.

At HealthEquity, the second-largest HSA provider, about half of its revenue comes from service fees and the rest derives from custodial revenue or debit fees, according to its annual report. Companies can also earn fees from mutual funds offered to customers as investment options. In the workplace, some employers cover some or all of the fees for workers.

Neeleman said that HealthEquity and other firms provide an important service and that they’re upfront about the fees they collect.

In addition to well-heeled retirees on Medicare, companies running these accounts also see opportunity among lower-income households.

Several states have experimented with adding savings accounts in Medicaid, the state-federal insurance program for the poor. Vice President while he was governor of Indiana. Medicaid members in Indiana can get additional benefits such as vision and dental coverage if they make small monthly contributions to accounts similar to HSAs. However, debate continues as to how effective the approach will be for this population.

Industry officials doubt they will get everything on their wish list from Congress. For instance, unlimited contributions to tax-free accounts could cost the federal government too much in revenue and invite more criticism that HSAs are a tax shelter for the rich.

Kevin Robertson, a senior vice president and director of sales for HSA Bank, the industry’s third-largest company, said some proposals are “more likely wishful thinking” but the overall direction is unmistakable as the GOP pushes a market-driven approach to health care.

“The political and economic winds are favorable and most definitely pushing HSAs,” he said.

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