How MAHA Could Grow Its Reach Through Health Savings Accounts

As “Make America Healthy Again” advocates rise to the upper echelons of health policymaking, their ability to legitimize and implement their philosophy from inside federal agencies has grown.

Now, an administration flirting openly with pseudoscientific approaches to health care could expand the market for MAHA-backed products, using federal agencies’ sway over what qualifies as health savings account, or HSA, spending.

“They’re doing what most purportedly anti-regulatory people have always done, which is to fix the regulatory system in their favor,” Peter Lurie, the president of the Center for Science in the Public Interest, said about the MAHA officials at the Department of Health and Human Services. “The idea that these HSAs could be expanding into areas that have no evidence base is something that worries us deeply, and ultimately, I don’t think it’s in the interest of the taxpayer.”

It is unclear to what, if any, extent MAHA’s influence has seeped into HSA regulation. HHS, the Internal Revenue Service, the Department of the Treasury and the White House all declined to provide specifics about how HHS would be involved in developing HSA policy.

“HHS works with federal partners to ensure that policies affecting Health Savings Accounts are informed by gold-standard, evidence-based science and implemented consistent with the law,” an HHS spokesperson, Andrew Nixon, wrote in a statement to NOTUS.

But it’s not uncommon for administrations to achieve policy goals through agencies’ interpretations and rule-making. In practice, if the Trump administration wanted to align tax policy with specific priorities, like health and wellness, much of that could take place through interdepartmental direction.

“If HHS has a priority, like getting people healthy and getting people to eat organic foods, HHS … will effectively say to the Treasury Department, ‘Hey, we think it would be smart for you to add gym memberships and organic food into the definition of medical care, to which there’s preferred tax treatment associated with,’” Chris Condeluci, a tax and employee benefits lawyer at CC Law & Policy, said.

Some of the top officials at HHS have shown an especially open mind around expanding HSA use.

Before Calley Means, a senior adviser at the Department of Health and Human Services, entered government, he was talking openly about his views on how HSAs should be used, along with his belief that relevant tax codes should be interpreted more broadly.

“We’ve actually been educating members of Congress about this,” Means, a close confidant of Kennedy and now a senior adviser to him at HHS, said on Joe Rogan’s podcast in October 2024. “The definition of medicine in the IRS tax code is not a synthetic pill made by a large pharmaceutical industry. The definition of medicine is something that’s recommended by a medical practitioner for the prevention or reversal, cure or mitigation of a condition.”

“The problem is that they’ve co-opted what medicine is in our brains,” Means continued.

Means founded Truemed, a company that helps businesses seeking to make their products HSA eligible and, in return, takes a cut of the profits, though Means has since divested.

Kennedy also argued in his confirmation hearing before the Senate Finance Committee in January that HSA expansion “ensures Americans have more choices when it comes to accessing high-quality care.”

HSAs have become a key part of Republicans’ health care agenda — some congressional Republicans tout HSAs as an alternative to Affordable Care Act premium subsidies — and were expanded to more insurance plans by the most recent reconciliation package.

What qualifies under HSAs is often spelled out in legislation. Any gray area beyond that is left up to the Internal Revenue Service and the Treasury Department for interpretation.

A Treasury spokesperson told NOTUS via email that “Treasury is focused on working with federal partners to ensure that policies affecting Health Savings Accounts are implemented consistent with the law and in a way that supports access to high-quality, evidence-based health care.”

The Treasury Department and the IRS, however, often rely on others for guidance.

Thomas Buchmueller, a professor at the University of Michigan who worked at HHS during the Biden administration, said that while he thinks of HSA regulation as being primarily under the IRS’s jurisdiction, he would expect HHS to be involved in the IRS’s development of guidance related to the reconciliation bill’s HSA expansion.

“There are definitely cases where an agency has questions about, ‘How exactly should we write this? How should we interpret this?’ They’re asking sincerely for guidance from subject matter experts,” Buchmueller said.

Health experts who spoke with NOTUS expressed concerns that the approach to funding health care through HSAs incentivizes misleading marketing, since it’s up to consumers what to direct those tax-advantaged funds toward.

“While on the surface it would appear that we have more choices as a consumer, the reality would be, the deluge of misinformation that’s coming in from the manufacturers and poor-quality products, then we end up spending our monies on inferior products that do not work,” Pieter Cohen, a professor at Harvard Medical School, said.

And because the IRS has long been underresourced, it often relies on HHS input to determine health-related policies, like what qualifies as medical expenses under HSA plans.

In response to questions about how the IRS coordinates its guidance with other agencies, including HHS, the IRS declined to provide specifics. It directed NOTUS to a draft version of its HSA guidance for taxpayers that was updated to reflect the reconciliation bill’s HSA expansion.

But even in the first Trump administration, there was close consultation between HHS and the IRS to determine what qualified under HSAs, such as in 2019 when the IRS expanded its list of “preventive care” measures that could be covered by HSAs.

William Fischer, a former IRS employee who worked on the 2019 guidance and now advises companies on health insurance tax policy at Groom Law Group, said that for that expansion, HHS provided the scientific studies used to determine what counted as preventive care, and for which diagnoses.

“HHS certainly had input on that list, and that list was developed in conjunction with HHS,” Fischer said, adding that he didn’t think the HSA-expansion advocates at HHS would be very successful because “at the end of the day, Treasury and IRS have final say over the HSA rules, and any expansion would have to be code-based.”

The 2019 guidance stipulates that the IRS, in consultation with HHS, will “periodically review the list of preventive care services and items listed” to determine whether more services should be added “approximately every five to ten years.”

But lawmakers who have advanced pro-HSA legislation say the system is working exactly as intended.

Sen. Bill Cassidy, who was one of the Republicans who introduced legislation earlier this month that would expand HSAs, told NOTUS he wasn’t concerned about the potential for agency influence over the policy because the policy has already been decided by legislators before it hits the IRS’s desk.

“Sometimes people want gym memberships, coverage for this, coverage for that,” Cassidy said. “But we usually do that through a transparent process.”