The "Health Care Fairness for All Act" aims to enhance health care fairness and affordability by overhauling federal health law. A primary objective is the elimination of individual and employer mandates imposed by the Affordable Care Act (ACA), along with related tax requirements and reporting obligations. This includes repealing the individual health insurance mandate (Section 5000A of the IRC) and the employer health insurance mandate (Section 4980H of the IRC). The bill also clarifies that employer reimbursement arrangements for individual health insurance premiums do not constitute a group health plan under various federal laws.

While repealing many ACA provisions, the bill retains essential consumer protections such as no lifetime or annual limits, dependent coverage through age 26, guaranteed availability and renewability of coverage, and prohibitions on pre-existing condition exclusions and discrimination based on health status. However, it introduces a late enrollment penalty for individuals without continuous creditable coverage, with states having waiver authority. States are granted significant flexibility in regulating their health insurance markets, including the ability to limit open enrollment periods, permit age-based premium variations (up to 5:1), and waive certain ACA Exchange provisions. The federal mandate for essential health benefits is removed, allowing states to determine their own requirements. States may also establish "default health insurance coverage" for uninsured residents, which includes high-deductible plans with limited prescription drug coverage, from which individuals can opt out.

A new universal health insurance tax credit (Section 36C) is introduced, providing a credit amount for qualified residents based on individual and family coverage, and the number of qualifying children. The credit is designed to coordinate with employer-provided health insurance, with an "employer-provided health insurance tax subsidy" mechanism. Advance payments of this credit can be made directly to Health Savings Accounts (HSAs) or health insurance issuers. States can apply for grants funded by a portion of unused federal tax credits to provide health services to indigent individuals.

The bill transitions to "Roth HSAs," which are non-deductible accounts allowing tax-free withdrawals for qualified medical expenses. Contributions to traditional, deductible HSAs will be limited after December 31, 2025, with exceptions for rollovers and employer-provided insurance. Roth HSA contribution limits are increased, and the bill clarifies that direct patient care arrangements (e.g., direct primary care) are considered qualified medical expenses for HSAs and are not treated as health insurance coverage.

Medicare reforms include repealing restrictions on physician-owned hospitals, prohibiting the use of an "inpatient-only list" for outpatient services, and promoting site-neutral payments by removing certain exceptions for off-campus outpatient departments. It also allows Medicare Advantage plans to contribute to Roth HSAs for chronically ill enrollees and makes telehealth flexibilities permanent. For Medicaid, the bill establishes a reformed payment system based on aggregate beneficiary-based amounts per state and category, replacing the current federal matching system. This new system includes a chronic care quality bonus for states meeting performance targets and offers states an option to receive Medicare payments for full-benefit dual-eligible individuals. Finally, the legislation codifies existing hospital price transparency rules, ensuring their force and effect of law.