Fund patients, not insurance companies: progress report

I'm old enough to remember the hesitation I felt as an employee in choosing the new HSA benefit over traditional health insurance.

It felt at once more independent and beneficial over time; and yet scary, as though I were losing security. In hindsight, it was the best benefit decision I ever made. 

From Insurance Business Magazine, ICHRA appears to be at approximately that phase of implementation.

Short glossary:

ICHRA = individual coverage health reimbursement arrangement = CHOICE Arrangement = custom health option and individual care expense.

https://www.insurancebusinessmag.com/us/news/benefits/half-of-brokers-still-havent-sold-an-ichra-and-the-gap-is-showing-589620.aspx

Half of brokers still haven't sold an ICHRA and the gap is showing

TASC's 2026 survey reveals implementation barriers are reshaping how benefits advisers recommend the product

GROUP BENEFITS

Mark Rosanes    |    Sep 14, 2026

More than half of benefits brokers have never sold an individual coverage health reimbursement arrangement, and after a year of watching more employers try the model, fewer of them expect adoption to grow.

The TASC 2026 Broker ICHRA Survey, commissioned by Total Administrative Services Corporation, which sells ICHRA administration services, found 54% of broker respondents have still never sold an ICHRA, up from 47% in 2025. Brokers who have sold the product are reporting back on the experience: employee education and enrollment taking longer than expected, administration more labor-intensive than projected, individual-market network limitations, and cases where expected savings did not materialize. Employee confusion was the most frequently cited concern, flagged by 85% of respondents, up from 82% a year earlier.

Broker expectations for adoption growth fell 15 percentage points year over year, from 65% in 2025 to 50% in 2026. The share of brokers who fully support ICHRAs dropped from 48% to 29%. Outright opposition remained a minority position at 17%, up from 9% in 2025, but the largest shift was toward conditional support: brokers saying ICHRAs can work, but only in the right circumstances.

A separate July 2026 study by the Employee Benefit Research Institute (EBRI) and Morgan Health, a division of JPMorganChase, corroborates the pattern from the employer side. More than 80% of companies told EBRI researchers they were concerned that individual market out-of-pocket costs could be too high for some of their workers. The same study found that about three-quarters of employers said they would be more likely to adopt an ICHRA if their broker, benefits consultant, or a peer business recommended it. The EBRI-Morgan Health survey covered nearly 1,000 benefits decision-makers.

A widening gap in a growing market
That execution friction is accumulating even as the model gains federal momentum. On September 3, the Centers for Medicare and Medicaid Services (CMS) and the Small Business Administration (SBA) formally rebranded ICHRAs as CHOICE Arrangements, short for custom health option and individual care expense, at a joint event in Indiana. The underlying structure, tax treatment, and compliance requirements are unchanged. The rebrand signals a federal commitment to expanding uptake, particularly among small employers.

The HRA Council's 2025-2026 annual data report found more than 20,000 US businesses now offer an ICHRA, a 53% increase from 2025, with covered lives surpassing 500,000. But those figures measure employer adoption, rather than broker confidence, and both surveys suggest the two are diverging.

The cost-effectiveness argument has held up better than overall sentiment. Sixty-four percent of brokers in the TASC survey still describe ICHRAs as more cost-effective than traditional group coverage, down from approximately 70% in 2025, but cost advantage alone is no longer enough to move a recommendation forward when implementation concerns remain unresolved.

An SBA and CMS joint initiative puts CHOICE Arrangements in front of small business owners who have not previously considered the model. Those employers will ask their advisers whether the product is worth exploring, and the survey data describes a broker community that has become more selective about the answer.

Christian Rosenstock, TASC's chief service offering officer, said the findings show brokers are moving past the theoretical question of whether ICHRAs work. "Brokers are looking beyond whether ICHRA works in theory," he said. "They want confidence that the right partner can make it work in practice, from implementation and enrollment to compliance, education and ongoing administration."

The TASC survey found growing broker emphasis on administrator quality as a decision factor in 2026, with enrollment support, compliance competence, and ease of administration ranking higher than in 2025. The administrator choice determines what the client experience looks like in practice - enrollment, payments, compliance handling, and the workload that lands back on the broker when things go wrong.

Am I the only one who thinks this sounds heavy on admin, light on patients using their own money for healthcare shopping?

Nearly 1 in 3 in Michigan are on Medicaid. A program change to cash to patients to would have huge impact on the healthcare market.

For querying minds: Medicaid numbers are easily verified. However, be aware the high total is disguised by the State of Michigan, which reports expanded Medicaid "Healthy Michigan" separately.

One way to transition Medicaid to patients controlling the cash would be the HSA.

https://mihealthfreedom.org/medicaid-hsa/

Replace Medicaid Middlemen with an HSA: all of Michigan would benefit

Abigail Nobel | Jan 29, 2026

Everyone on Medicaid either is a responsible adult, or has a responsible adult to make their healthcare decisions. So why are we paying thousands of middlemen to complicate their care?

Medicaid Middlemen
MDHHS case managers, contracted managed care insurance plans, and other bureaucratic gatekeepers absorb billions of tax dollars that could pay directly for care. Michigan Medicaid is arguably the most out-of-control, expensive part of the state budget.

In addition, it imposes an incalculable burden of time and suffering on patients and clinicians with its byzantine billing and records system.

Michigan should convert Medicaid and Healthy Michigan plans to expanded HSAs based on need.

Updated Health Savings Accounts
Health Savings Accounts (HSAs) are better than ever for individual care, now that they can pay Direct Primary Care (DPC) memberships.

Michigan physicians are bailing out of corporate healthcare to become independent. I hear there’s a new DPC conversion in Traverse City, and a multi-practice group is spreading across the Mitten.

Cash is the universal medium to access services. Such simplicity is mind-boggling, especially compared to our complicated Medicaid.

Process basics to consider

Obtain a federal Medicaid HSA waiver.

• Approval for a traditional waiver like Indiana’s would be relatively simple. However, I’d aim higher: an expanded HSA to allow no-cap deposits. Since this empowers individuals with greater independence, and streamlines the state role, I suspect CMS would be agreeable.
• Verify participant qualifications to maximize funds for the truly needy.
  This is an existing MDHHS function. It shouldn’t be difficult since COVID exemptions have been repealed.
• Fund HSAs for all qualified Medicaid participants.

Several methods come to mind. I’m sure others can think of more features.

• Plan at least two funding levels: chronic disability and temporary need.
  It may seem necessary to gauge need from prior medical records, but that will get complicated very rapidly.
• Pre-fund with installments monthly or bi-annually.
• Match all patient contributions.
• Plan for the recipient to have full ownership of the account.

Once the basics are in place, transition insurance to back-up catastrophic care only. No managed care, no prior authorization, no access to patient records except for catastrophic claims.

Redundant state employees may retire early or enter the private sector workforce.

Objections

There will be fraud!
Banks and the IRS provide tight guardrails for HSAs.

And let’s not forget that today’s Medicaid is rife with waste, fraud and abuse. This move is a much-needed reset.

Until now, middleman billing covered a multitude of sins. With middlemen gone, and an HSA bank card paying for service, transparency is a breeze.

The Medicaid population can’t handle HSAs!

Let’s be nice, here, shall we? New HSA card-holders will have a learning curve. Especially, perhaps, generational Medicaid families. And that’s OK.

People new to HSAs will network their communities and social media, ask their doctors, ask the bank holding the HSA.

Forging new bonds outside the official welfare system is healthy. Shopping is an innate human urge. Local, sustainable connections help grow personal independence and responsibility.

And the churn population will take to an HSA like a duck to water. Families of disabled children, especially, know what they need and often where to find it. Until the HSA, their primary difficulty was finding an appointment and getting permission for Medicaid to pay for it.

We have to help them!
I predict lobbies will want to encumber a transition to Medicaid HSA with navigators, care managers, and others to hand-hold and collect data. (MDHHS in the lead, here.)

I’d recommend limiting transition to an information brochure, and no more from the state.

This is less harsh than it sounds. Letting people shop for their own care will release their economic voice and a wave of pride at their budding self-preservation skills.

Imagine the boost to human dignity when, instead of trying to make an appointment with Medicaid, someone can say, “I have an HSA.”

Federal law controls Medicaid through CMS, which calls the shots thanks to controlling federal dollars.

States like Indiana run Medicaid "sort-of-like-HSAs" through a CMS 1115 waiver. View Indiana’s Healthy Indiana Plan POWER Account page at https://in.gov/fssa/hip/2590.htm

CMS’s Section 1115 demonstrations page: https://www.medicaid.gov/medicaid/section-1115-demonstrations/about-section-1115-demonstrations

The state-by-state list of demonstrations is linked from that page at https://www.medicaid.gov/medicaid/section-1115-demonstrations/demonstration-and-waiver-list

Michigan's 1115 waiver is history.

The MI Health Account (also called MIHA) was the HSA-like cost-sharing feature of Michigan’s Healthy Michigan Plan (the state’s Medicaid expansion). It tracked co-pays and, for enrollees above 100% of the federal poverty level, monthly contributions (capped at 2% of income). It was not a tax-advantaged IRC §223 HSA.

It was discontinued effective January 1, 2024. Michigan’s official Healthy Michigan Plan page states that the account went away, the last payments were due January 15, 2024, and unpaid amounts are no longer collected from tax refunds or lottery winnings. Coverage itself continued under the Medicaid State Plan after the Section 1115 demonstration expired at the end of 2023.

The MDHHS operational protocol describes how the account worked while active. 
https://www.michigan.gov/-/media/Project/Websites/mdhhs/Folder3/Folder65/Folder2/Folder165/Folder1/Folder265/Attachment_C_-_MI_Health_Account_Protocol_-_Clean.pdf

The state law that ended MIHA accounts was Public Act 98 of 2023 (House Bill 4495). It amended the Social Welfare Act to remove the requirement that the MI Health Account be used for Healthy Michigan Plan cost-sharing, and shifted authority for the plan’s cost-sharing rules. 
Summary and status: https://www.legislature.mi.gov/Bills/Bill?ObjectName=2023-HB-4495

The account operated under the Healthy Michigan Plan Section 1115 demonstration approved through 2023. Michigan’s evaluation documents note the discontinuation and the move to State Plan authority on January 1, 2024. 
MDHHS stores a 400+ page summary of the whole exercise.
https://www.michigan.gov/-/media/Project/Websites/mdhhs/Folder2/Folder78/Folder1/Folder178/Healthy_Michigan_Plan_1115_Demonstration_Approval.pdf

However, 1115 waivers have their limits for states promoting patient shopping.

Lanhee Joseph Chen is an American political scientist, lawyer, legal scholar, and academic who serves as the David and Diane Steffy Fellow in American Public Policy Studies and Co-Chair of the Health Care Policy Working Group at the Hoover Institution. He is also director of domestic policy studies and a lecturer in public policy at Stanford University.

His 2023 open access article on JAMA Health Forum explains 1115 waiver shortcomings.

https://jamanetwork.com/journals/jama-health-forum/fullarticle/2805043

The aim of the Healthy Indiana Plan was to create incentives for participants to think about their own health care consumption, as well as to promote saving and personal ownership of the accounts. Nevertheless, the Healthy Indiana Plan includes many complex rules that restrict the use of the savings accounts. Participants never fully own their account balance. And only their contributions (and not money from the state) can be returned to them if they leave the program in good standing. These policies reduce incentives to be price conscious and fail to give recipients more control over their health care.

Pairing HSAs with Medicaid would maintain health coverage, but unlike standard Medicaid, would give beneficiaries an asset that offers value beyond traditional Medicaid coverage. The accounts would offer them more choice in the health care they consume and the potential for greater financial security in the long run.

Currently, federal rules force most Medicaid recipients into coverage without major options. This contrasts with the expansion of private coverage options, particularly after the pandemic. Recent expansions in Direct Primary Care and consumer-directed health arrangements, for example, have given those with job-based coverage more choices. Changes to existing waiver rules would allow innovations from private coverage to potentially extend to Medicaid beneficiaries as well.

Medicaid recipients should have more of the same choices that individuals in private coverage have, and states are well positioned to offer it.

He points out, interestingly, that ACA Section 1332 waivers may offer a better path out of Medicaid dependency.

https://www.cms.gov/marketplace/states/section-1332-state-innovation-waivers

... section 1332 of the ACA includes potentially expansive waiver authority that holds tremendous promise for new and innovative state-based systems of coverage and care delivery. With these waivers, states can use federal dollars (from Medicaid and beyond) to provide coverage to their residents that is at least as affordable, widespread, and comprehensive as that in the ACA. Although a few states have discussed the use of section 1332 waivers for more dramatic reforms that would affect participants in the individual and small group markets, their use has remained relatively limited because of the measure of control that presidential administrations have to approve applications. Congress should consider legislation that would simplify the waiver application process, clarify and streamline the standards that states must meet to receive a waiver, and create a fast-track process for states that have already received a waiver and want to renew or modify it.

State lawmakers do not have to look far for good ideas to deploy through section 1332 waivers. Over the last 2 decades, demand-side health care reforms have given consumers more control over their health care future. Health savings accounts (HSAs) embody this idea. Although they are not for everyone and are still saddled with restrictions that prevent broader adoption, HSAs are popular with users who willingly forego high-premium plans for an opportunity to save dollars tax-free. The result is a better incentive structure; studies show HSAs have reduced health care use among participants.5

States could use section 1332 waiver authority to adopt similar saving vehicles for Medicaid recipients. This would help not only to promote saving and ownership among beneficiaries, but also encourage smarter consumption of health benefits. States could give Medicaid participants HSA access in conjunction with their coverage and fund those accounts to help offset costs, including co-pays at the point of service. Depending on state budget constraints, these cost-sharing requirements could feature annual out-of-pocket maximums that match the annual contribution to the recipient’s savings vehicle. This would ensure recipients would not be made worse off.

Rules would be needed to prevent withdrawals for nonqualified spending for a certain amount of time. Importantly, like traditional HSAs, participants could spend their accounts on any qualified medical spending, regardless of whether a service is currently covered by Medicaid. For example, Medicaid recipients could use a portion of their contributions to pay for nontraditional coverage options or services that may not be covered, such as dental benefits. In addition, when they leave Medicaid, recipients should be able to retain their HSA balances and use them in conjunction with employer-sponsored or other private plans (subject to existing federal rules governing HSAs).

Dr. Chen has more published articles in the free market healthcare space.
https://jamanetwork.com/searchresults?author=Lanhee+J.+Chen&q=Lanhee+J.+Chen

A congressional proposal claims to make good on the Trump promise to fund patients, not insurance companies.

Bill text here: https://www.rickscott.senate.gov/services/files/A825A3CA-ADE1-4E2D-8F5D-7E98D65BA27A

Two of the sponsors co-write a Washington Examiner op-ed describing the proposal.
https://www.washingtonexaminer.com/restoring-america/faith-freedom-self-reliance/3916505/healthcare-crisis-congress-more-affordable-care-act/

The article, clipped here for length, points out that people -

... cannot compare prices between providers before making decisions about their own health. They have fewer hospital and physician choices, and they watch helplessly as subsidies flow to insurance companies while their out-of-pocket costs keep rising. These aren’t partisan complaints. This is the experience of millions of Americans across the political spectrum.

Our approach is straightforward: stop treating families like statistics and start treating them like the capable decision-makers they are. Instead of funneling billions of taxpayer dollars through layers of bureaucracy to large insurance companies, redirect those resources into Trump Health Freedom Accounts, where individuals have control over their healthcare dollars. Families can use these funds to pay premiums or other healthcare expenses, while also having the flexibility to shop for insurance across state lines to compare multiple plans and choose coverage that truly meets their needs.

The difference is profound. Rather than being forced to accept whatever narrow physician and hospital network Washington or an insurance company offers, families will have real, affordable options. They can seek out the specialist three states over who has the best track record treating their condition. They can weigh whether a high-deductible plan with lower premiums makes more sense for their situation. They make informed choices that reflect the realities of their lives, not the preferences of distant policymakers. It’s no accident that this solution comes from leaders representing Texas and Florida, two states that have consistently shown that less government interference and more market freedom deliver better results for families.

Our bill maintains all protections for Americans with preexisting conditions, a commitment we make without caveat or exception. It also gives states the flexibility to expand narrow markets by waiving certain federal mandates that have restricted competition and driven up costs.

Perhaps the most transformative element is transparency. Right now, American healthcare operates in a pricing black box. Families receive more information about the cost of a used car than a CT scan. We change that by requiring hospitals to disclose actual prices — not estimates, not ranges, but the real costs patients will face. Additionally, this legislation mandates public reporting of outcomes data so Americans can compare not just prices, but quality and success rates across providers.

Imagine seeing upfront what a procedure will cost, then comparing that price and the provider’s track record with other hospitals in your region or across the country. This is standard practice in virtually every other consumer market. There is no reason healthcare should remain the exception.

And now is the time to act. Republicans control both chambers of Congress and the White House. If meaningful reform cannot happen now, with a unified government and clear public demand for change, when can it? The people didn’t grant us this majority to conduct more studies. They expect solutions to problems that have festered for more than a decade.

ASSOCIATION HEALTH PLANS CAN FIX THE SMALL BUSINESS HEALTHCARE CRISIS

Our proposal provides the people with solutions to the core complaints Americans have about their healthcare: costs, choice, and transparency. It is a proposal that maintains the exchanges, protects coverage for preexisting conditions, and supports working people. At the same time, it radically transfers power away from Washington and into the hands of patients by allowing you to keep the money you earn, shop for the care that fits your needs, and know the true cost of the treatments you’re considering. This isn’t ideological warfare; it’s common sense.

It’s time for Congress to stop talking about addressing the failures within our healthcare system and start voting on it. The More Affordable Care Act is on the table. The people are watching. It’s time for us to act.

August Pfluger represents Texas’s 11th Congressional District in the U.S. House of Representatives. Rick Scott is the senior U.S. senator from Florida.

You'll find faster results in the private sector, of course. Independent innovators don't wait for Big Health consensus or government approvals.

Speedy, low-cost options include meds, labs, radiology, primary care, coverage alternatives, and surgery.

Did I miss anything?

Citizens Council for Health Freedom hot-links cash pay healthcare sites in its two-page graphic download.

https://www.cchfreedom.org/wp-content/uploads/2026/09/CASH-PAY-RESOURCES-FINAL.pdf

Direct Primary Care connects you to the low-cost world.

Accept no substitutes - MHF did the deep dive for you.

Find hotlinks in the original post.

https://mihealthfreedom.org/direct-primary-care/

What is Direct Primary Care?

Abigail Nobel   |   Feb 23, 2022  Updated Oct 15, 2024

Direct Primary Care (DPC) is an affordable model of self-pay care that increasingly appeals to both patients and physicians. DPC fits well with health sharing membership and good medication shopping skills to provide maximum healthcare savings.

By definition, DPC should exclude insurance and associated headaches. This model achieves an outstanding array of healthcare freedom benefits for both the patient and the physician. True DPC will:

• return relationship and autonomy to the center of care
• eliminate cookie-cutter protocols, mandates, and formularies
• save money
• reduce complexity
• prioritize more time for care
• offer more office services
• eliminate reimbursement incentives
• individualize care
• no third party billing, coding, prior auth, or copays

Direct Primary Care works like a membership

Patients save time, money, and frustration. They sign up for monthly payments in the $50-$85 range, or pay a reduced annual rate. Most can expect to get into the office within a day or two. Visits are about care, not payment. Often included in the price: common labs, medications, minor procedures, and text or video access. Some add family members at a reduced rate.

On the other hand, physicians retake control of their professional autonomy and their schedule. A major benefit is getting to spend evenings with family instead of clicking boxes on electronic records.

Primary care practices are the most common DPC adopters, but Urology, Dermatology, Podiatry, and other specialties also enjoy the freedom of this model.

How do I find a DPC Practice in Michigan?

DPC maps are the Wild West, with all sorts of innovators trying to capture the market. Both of these free market leaders are worth checking out: The Wedge of Health Freedom, and the DPC Frontier Mapper.

In addition, new practices are constantly starting up. To be sure you don’t miss out, search your nearest city + Direct Primary Care and DPC.

Share this article and grow the conversation. Ask around for DPC recommendations, and give your own. What does DPC quality mean to you and your doctor?

Final tips:

DPC is attracting major employers, cities, counties, and other government units. Their DPC-like arrangements will save costs for employee healthcare benefits.

However, be alert: in the end, third party involvement always costs patients and physicians in lost autonomy.

Direct Primary Care practices are unique and vary widely. Shop well, and don’t be afraid to ask offices for all the information you need to find the best fit!