[Congressional Bills 118th Congress]
[From the U.S. Government Publishing Office]
[S. 4817 Introduced in Senate (IS)]
<DOC>
118th CONGRESS
2d Session
S. 4817
To amend title I of the Patient Protection and Affordable Care Act to
authorize the establishment of, and provide support for, State-based
universal health care systems that provide comprehensive health
benefits to State residents, and for other purposes.
_______________________________________________________________________
IN THE SENATE OF THE UNITED STATES
July 25, 2024
Mr. Markey (for himself, Ms. Warren, and Mr. Merkley) introduced the
following bill; which was read twice and referred to the Committee on
Finance
_______________________________________________________________________
A BILL
To amend title I of the Patient Protection and Affordable Care Act to
authorize the establishment of, and provide support for, State-based
universal health care systems that provide comprehensive health
benefits to State residents, and for other purposes.
Be it enacted by the Senate and House of Representatives of the
United States of America in Congress assembled,
SECTION 1. SHORT TITLE; PURPOSE.
(a) Short Title.--This Act may be cited as the ``State-Based
Universal Health Care Act of 2024''.
(b) Purpose.--The purpose of this Act is to establish a flexible
framework under which States can provide comprehensive universal health
coverage to their residents.
SEC. 2. WAIVER FOR STATE UNIVERSAL HEALTH CARE.
(a) In General.--Part 4 of subtitle D of title I of the Patient
Protection and Affordable Care Act (42 U.S.C. 18021 et seq.) is amended
by adding at the end the following:
``SEC. 1335. WAIVER FOR STATE UNIVERSAL HEALTH CARE.
``(a) Application.--
``(1) In general.--Subject to paragraph (6), a State may
apply to the Secretary (as defined in subsection (i)(3)) for
the waiver of so much of the requirements described in
paragraph (2) with respect to health benefits coverage within
the State for plan years beginning on or after January 1, 2025,
as is necessary to implement a comprehensive State universal
health care plan in the State under this section. Such
application shall--
``(A) be filed at such time and in such manner as
the Secretary may require;
``(B) contain such information as the Secretary may
require, including--
``(i) a comprehensive description of the
State legislation, or other State legal
authority as applicable, and program to
implement a plan meeting the requirements for a
waiver under this section;
``(ii) a plan for how the State will
achieve in 5 years health coverage for at least
95 percent of residents of the State; and
``(iii) a 10-fiscal-year budget plan for
such plan that is budget neutral for the
Federal Government; and
``(C) provide an assurance that the State has legal
authority to implement such plan or has enacted the law
described in subsection (b)(2).
``(2) Requirements.--The requirements described in this
paragraph with respect to health benefits coverage within the
State for plan years beginning on or after January 1, 2025, are
as follows:
``(A) Sections 1301 through 1324.
``(B) Section 1402.
``(C) Sections 36B and 4980H of the Internal
Revenue Code of 1986.
``(D) Title XI of the Social Security Act.
``(E) Title XVIII of the Social Security Act.
``(F) Title XIX of the Social Security Act.
``(G) Title XXI of the Social Security Act.
``(H) Chapter 89 of title 5, United States Code.
``(I) Chapter 55 of title 10, United States Code,
including coverage under the TRICARE program.
``(J) Section 514 of the Employee Retirement Income
Security Act of 1974.
``(3) Passthrough of funding.--With respect to a State
waiver under paragraph (1), under which the State assumes
responsibility for health coverage under one or more of the
specified Federal health programs, including under each of the
Federal health care or subsidy programs specified in
subparagraphs (A), (B), (C), (E), (F), (G), (H), and (I) of
paragraph (2), the Secretary shall not spend Federal health or
related administrative funds that would otherwise have been
spent for such a program, as applicable, for the time periods
covered under the waiver and shall provide for an alternative
means by which the aggregate amount of such funds (determined
by the Secretary in coordination with the State), including
caseload growth, adjusted for inflation in health care costs
within the State, shall be paid to the State for purposes of
implementing the State plan under the waiver. Any savings in
health care spending, including administrative savings, shall
be available to the State for reinvestment in health care
services under the State plan. Such amount shall be determined
annually by the Secretary, taking into account the amount that
would otherwise have been spent under each such Federal health
program, including for administrative activities and caseload
growth, with respect to residents of such State, for those time
periods covered under the waiver, adjusted for inflation in
health care costs, if such waiver did not apply. Such amount
shall include funds equal to the aggregate amount of premium
tax credits, cost-sharing reductions, or small-business
credits, to the extent applicable to an approved waiver, under
sections 36B and 45R of the Internal Revenue Code of 1986 or
under section 1402 that would have been available to
individuals and businesses in the State for those time periods
covered under the waiver, including caseload growth, adjusted
for inflation in health care costs, if such waiver did not
apply.
``(4) Waiver consideration and transparency.--
``(A) In general.--An application for a waiver
under this section shall be considered by the
Secretary, after taking into account recommendations of
the Panel under subsection (g), in accordance with the
regulations described in subparagraph (B).
``(B) Regulations.--Not later than 180 days after
the date of the enactment of the State-Based Universal
Health Care Act of 2024, the Secretary shall promulgate
regulations relating to waivers under this section that
provide--
``(i) a process for public notice and
comment in accordance with the public notice
and comment requirements applicable under
regulations used for Medicaid waivers pursuant
to section 1115 of the Social Security Act;
``(ii) a process for the submission of an
application that ensures the disclosure of--
``(I) the provisions of law that
the State involved seeks to waive; and
``(II) the specific plans of the
State to ensure that the waiver will be
in compliance with subsection (b);
``(iii) a process for providing public
notice and comment after the application is
received by the Secretary that is sufficient to
ensure a meaningful level of public input and
that does not impose requirements that are in
addition to, or duplicative of, requirements
imposed under chapter 5 of title 5, United
States Code (commonly referred to as the
Administrative Procedure Act), or requirements
that are unreasonable or unnecessarily
burdensome with respect to State compliance;
``(iv) a process for the submission to the
Secretary of periodic reports by the State
concerning the implementation of the program
under the waiver;
``(v) a process for the periodic evaluation
by the Secretary with respect to waivers
granted under this section; and
``(vi) a process for providing technical
assistance on--
``(I) how to develop an application
to any State seeking to submit an
application for a waiver relating to
developing a program of providing
health care for all residents for such
State; and
``(II) how to improve such a
program for purposes of a State seeking
assistance pursuant to subsection
(e)(2).
``(C) Report.--The Secretary shall annually report
to Congress concerning actions taken by the Secretary
with respect to applications for waivers under this
section and programs conducted pursuant to such waivers
that are approved.
``(5) Regional waiver request and plan.--Nothing in this
section shall be construed to prevent 2 or more States in a
region from submitting a single application under this section
for a waiver that establishes a plan that is applicable to all
of the States included in such application. In the case of such
an application and plan, the requirements of this section shall
continue to be applicable with respect to each State included
in such application.
``(6) Coordination with 1332 waivers.--A State may not
apply for a waiver under this section with respect to a plan
year if such State has in effect, with respect to such plan
year, a waiver under section 1332.
``(7) Authorization of appropriations.--There is authorized
to be appropriated such sums as may be necessary for providing
funds to States with a waiver under this section for purposes
of carrying out activities described in subsection (b)(1)(E).
``(b) Granting of Waivers.--
``(1) In general.--The Secretary shall grant a request for
a waiver under subsection (a)(1) if the Secretary determines
that the State plan--
``(A) will provide, in accordance with subparagraph
(B), health benefits coverage to applicable State
residents that is at least as comprehensive as the
health benefits coverage that such residents would have
received under one or more of the specified Federal
health programs (as defined in subsection (i)(4)), as
applicable, for which such residents would have been
eligible, absent such waiver;
``(B) will provide, in the case of such a waiver
under subsection (a)(1) for the State to waive any of
the requirements described in subsection (a)(2)(F), as
applicable, health benefits coverage to applicable
State residents who would have otherwise received
health benefits coverage in the form of medical
assistance under the State Federal health program
described in subsection (i)(4)(B) (regardless of
whether the State provides for such assistance through
a State Medicaid plan under title XIX of the Social
Security Act or a waiver of such State Medicaid plan)
that includes at least the mandatory benefits under
title XIX of the Social Security Act that are required
of a State without a waiver of a State Medicaid plan
under such title, including benefits for early and
periodic screening, diagnostic, and treatment, benefits
for non-emergency transportation, and retroactive
coverage;
``(C) will provide coverage and cost-sharing
protections against excessive out-of-pocket spending to
State residents that are at least as affordable as the
coverage and cost-sharing protections under the
specified Federal health program (as defined in
subsection (i)(4)) for which such residents would have
been eligible, absent such waiver;
``(D) will provide coverage to all residents of the
State, including those otherwise covered under one or
more of the Federal health care or subsidy programs
specified in subparagraphs (B), (C), (E), (F), (G), and
(H) of subsection (a)(2), except individuals who are
eligible for benefits through the Indian Health Service
or for benefits and services under title 38, United
States Code;
``(E) will provide for public education activities
to raise awareness of the availability of such coverage
and the facilitation of enrollment in such coverage,
and to raise awareness regarding restrictions on the
sale of duplicative or supplemental private insurance
(and, if the State chooses to continue to offer
qualified health plans through an Exchange, public
education activities will raise awareness of the
availability of and the facilitation of enrollment in
such plans in a manner similar to an entity that serves
as a navigator under a grant under section 1311(i));
``(F) will be publicly administered by an agency or
multiple agencies of the State, or an independent
public entity within the government of the State;
``(G) will not preclude the purchase of insurance
that offers coverage for benefits that are not offered
under the State plan;
``(H) will provide systems for complaints, appeals,
independent review, and other procedures for accessing
and maintaining benefits that are at least as
accessible to applicable State residents as those of
one or more of the specified Federal health programs
(as defined in subsection (i)(4)) for which such
residents would have otherwise been eligible without
application of such waiver under subsection (a)(1); and
``(I) will provide coverage for reproductive health
care services, including abortion, contraception, and
gender-affirming care.
Subparagraph (D) shall not be construed as limiting a State
from contracting with one or more private entities to
administer the State plan.
``(2) Requirement to enact a law.--
``(A) In general.--A law described in this
paragraph is a State law (including an executive order
by a State governor) that provides for State actions
under a waiver under this section, including the
implementation of the State plan under subsection
(a)(1)(B).
``(B) Termination of opt out.--A State may repeal a
law described in subparagraph (A) and terminate the
authority provided under the waiver with respect to the
State.
``(c) Scope of Waiver.--
``(1) In general.--The Secretary shall determine the scope
of a waiver of a requirement described in subsection (a)(2)
granted to a State under subsection (a)(1).
``(2) Limitation.--Under this section, the Secretary may
not waive any Federal law or requirement that is not listed in
subsection (a)(2).
``(d) Determinations by Secretary.--
``(1) Time for determination.--The Secretary shall, with
respect to an application from a State under this section and
after taking into account recommendations of the Panel under
subsection (g) for such application, make a determination under
subsection (a)(1) not later than 90 days after the receipt of
such recommendations.
``(2) Effect of determination.--
``(A) Granting of waivers.--If the Secretary
determines to grant a waiver under subsection (a)(1),
the Secretary shall notify the State involved of such
determination and the terms and effectiveness of such
waiver.
``(B) Denial of waiver.--If the Secretary
determines a waiver should not be granted under
subsection (a)(1), the Secretary shall notify the State
involved and the appropriate committees of Congress of
such determination and the reasons therefor.
``(e) Required Reports; 5-Year Review.--
``(1) In general.--As a condition of receipt of a waiver
under this section, after each 5-year period of such waiver, a
State shall submit to the Secretary a report that is carried
out by an independent, non-partisan entity, with respect to
such 5-year period and after a process for public notice and
comment at the State level, including public hearings,
sufficient to ensure a meaningful level of public input, on the
following:
``(A) How waiver funds have been spent by the
State.
``(B) The number of residents of the State without
health insurance and a description of how the State
plans to provide health insurance coverage within the
subsequent 5 years to residents of the State without
health insurance.
``(C) How affordability in the State for health
care has changed over the period.
``(D) Whether the State has achieved health
coverage for at least 95 percent of the residents of
the State.
``(E) Measurable changes in quality and access.
``(F) Any additional information specified by the
Secretary for purposes of determining the successes and
challenges of the waiver.
``(2) 5-year review.--In the case a State, based on the
report submitted under paragraph (1) for a 5-year period--
``(A) has been determined by the Secretary to have
not achieved health coverage for at least 95 percent of
the residents of the State--
``(i) the State shall have access to
technical assistance described in subsection
(a)(4)(B)(vii) to improve the health insurance
program of the State implemented through the
waiver under this section;
``(ii) the State shall have a grace period
of 12 months after such determination to
achieve health coverage for at least 95 percent
of residents of the State; and
``(iii) if after such 12 months, the State
has not achieved such health coverage, the
waiver under this section may be terminated at
the discretion of the Secretary; and
``(B) has been determined by the Secretary to have
achieved health coverage for at least 95 percent of
residents of the State, the State, as a condition of
continuing such waiver, shall submit to the Secretary a
plan for achieving health coverage for the remainder of
the residents of the State.
``(f) Assuring Coordination.--
``(1) In general.--Not later than 180 days after the date
of the enactment of the State-Based Universal Health Care Act
of 2024, the Secretary of Health and Human Services, the
Secretary of the Treasury, the Secretary of Defense, the
Secretary of Labor, and the Director of the Office of Personnel
Management, shall, through the execution of an interagency
memorandum of understanding among such Secretaries and
Director--
``(A) develop a process for coordinating and
consolidating the State waiver processes applicable
under the provisions of this section, and the existing
waiver processes applicable under--
``(i) titles XI, XVIII, XIX, and XXI of the
Social Security Act; and
``(ii) any other Federal law relating to
the provision of health care items or services;
and
``(B) ensure that--
``(i) regulations (including regulations
required under subsection (a)(4)(B)), rulings,
and interpretations issued by such Secretaries
and Director relating to the same matter over
which two or more such Secretaries or Director
have responsibility under this section are
administered so as to have the same effect at
all times; and
``(ii) coordination of policies relating to
the granting, implementation, and continuation
of waivers through such Secretaries and
Director in order to have a coordinated
strategy that avoids duplication of effort by
the States or Secretaries and Director and
ensures clarity about waiver application status
and approval.
``(2) Single application.--The process under paragraph
(1)(A) shall permit a State to submit a single application for
a waiver under all of the provisions of this section and the
provisions of law listed under clauses (i) and (ii) of such
paragraph.
``(3) Submission of conforming amendments.--The Secretary
of Health and Human Services, in coordination with the other
Secretaries listed in paragraph (1) (including the Director of
the Office of Personnel Management), shall submit to Congress
such recommendations for such technical and conforming
amendments to law as may be appropriate to assist in the
implementation of this section.
``(g) Independent Assessment Panel for Comprehensive Health Care.--
``(1) Establishment.--There is established a committee to
be known as the `Independent Assessment Panel for Comprehensive
Health Care' (in this section referred to as the `Panel').
``(2) Consideration of submissions.--The Secretary shall
forward a copy of each waiver application submitted under this
section to the Panel for consideration under this subsection.
``(3) Duties.--The Panel shall--
``(A) review any waiver application by a State
forwarded under paragraph (2) and any report submitted
under paragraph (1) of subsection (e) for purposes of
the review under paragraph (2) of such subsection;
``(B) not later than 90 days after submission of
such application (or report) by the State, provide to
the State and to the Secretary the recommendations of
the Panel regarding the approval or disapproval of such
waiver application (or regarding the status of the
waiver for continuation pursuant to subsection (e)(2))
and, if applicable, possible improvements to such
application (or for purposes of subsection (e)(2)); and
``(C) submit to Congress an annual report on waiver
applications (and waiver reports under subsection (e))
reviewed by the Panel during the applicable year,
including the number of applications (and reports)
received and the number of applications recommended for
approval (and of reports with respect to which
recommendations for continuation were provided).
``(4) Membership.--
``(A) Number and appointment.--The Panel shall
consist of 11 members appointed by the Secretary of
Health and Human Services, of whom--
``(i) 1 shall be appointed on the
recommendation of the Speaker of the House of
Representatives;
``(ii) 1 shall be appointed on the
recommendation of the minority leader of the
House of Representatives;
``(iii) 1 shall be appointed on the
recommendation of the majority leader of the
Senate;
``(iv) 1 shall be appointed on the
recommendation of the minority leader of the
Senate;
``(v) 1 shall be appointed on the
recommendation of the Republican Governors
Association;
``(vi) 1 shall be appointed on the
recommendation of the Democratic Governors
Association;
``(vii) 1 shall be a representative from
the patient advocacy community;
``(viii) 2 shall be representatives of a
labor organization representing health care
professionals who provide direct patient care,
including at least one labor organization that
primarily represents registered nurses;
``(ix) 1 shall be a representative of
primary care physicians; and
``(x) 1 shall be a representative of health
care professionals practicing in rural or
underserved areas.
``(B) Term of service.--
``(i) In general.--Each member of the Panel
shall serve a 3-year term. A member may serve
after the expiration of that member's term
until a successor has been appointed pursuant
to subparagraph (A).
``(ii) Vacancy.--Any member appointed to
fill a vacancy occurring before the expiration
of the term for which the member's predecessor
was appointed shall be appointed only for the
remainder of that term. A vacancy in the
Commission shall be filled in the manner in
which the original appointment was made.
``(C) Pay.--Members of the Panel shall serve
without pay.
``(D) Chairperson; vice chairperson.--
``(i) Chairperson.--The Secretary of Health
and Human Services, or a designee of the
Secretary, shall serve on the Panel as the
Chairperson of the Panel.
``(ii) Vice chairperson.--The Administrator
of the Federal Emergency Management Agency, or
a designee of the Administrator, shall serve on
the Panel as the Vice Chairperson of the Panel.
``(5) Staff, experts, and consultants.--The Panel may--
``(A) appoint such staff as the Panel considers to
be appropriate, without regard to the provisions of
title 5, United States Code, governing appointments in
the competitive service;
``(B) fix the pay of such staff, without regard to
the provisions of chapter 51 and subchapter III of
chapter 53 of such title relating to classification and
General Schedule pay rates; and
``(C) procure the services of experts and
consultants in accordance with the provisions of
section 3109(b) of such title.
``(6) Detail of federal personnel.--Upon request of the
Panel, the head of any Federal agency may detail, on a
reimbursable basis, any of the personnel of the agency to the
Panel to assist it in carrying out the duties under paragraph
(3).
``(7) Federal advisory committee act.--The Federal Advisory
Committee Act (5 U.S.C. App.) shall apply to the Panel.
``(8) Authorization of appropriations.--There is authorized
to be appropriated such sums as may be necessary to the Panel
for carrying out the duties of the panel for each of fiscal
years 2025 through 2030.
``(h) Guidance Relating to American Indians and Alaska Natives.--
``(1) In general.--The Secretary shall issue guidance with
respect to applying the provisions of this section in a manner
consistent with the following:
``(A) To further the goal that Federal health
services to maintain and improve the health of Indians
are consonant with and required by the Federal
Government's historical and unique legal relationship
with, and resulting responsibility to, Indians.
``(B) No enrollment fee, premium, or similar
charge, and no deduction, copayment, cost sharing, or
similar charge, is to be imposed against an Indian who
is furnished an item or service through a waiver under
this section. All costs incurred in waiving such
charges shall be borne by the Federal Government in
fulfillment of the trust responsibility.
``(C) A State may not require the enrollment of an
individual who is an Indian in health insurance offered
through a waiver under this section.
``(D) Health insurance issuers offering coverage
pursuant to a waiver under this section must make good
faith efforts to contract with Indian health care
providers operating within the area served by the
issuers.
``(E) Health insurance issuers offering coverage
pursuant to a waiver under this section shall pay
Indian health care providers, whether such providers
are participating or nonparticipating providers with
respect to the coverage, for covered services provided
to those Indian enrollees who are eligible to receive
services from such providers at a rate equal to the
rate negotiated between such entity and the provider
involved or, if such a rate has not been negotiated, at
a rate that is not less than the level and amount of
payment which the entity would make for the services if
the services were furnished by a participating provider
which is not an Indian health care provider.
``(F) Health insurance issuers offering coverage
pursuant to a waiver under this section will include a
standard contract addendum when contracting with Indian
health care providers. The contract addendum will be
developed in consultation with Tribes and in conference
with urban Indian health programs operating within the
service area of the State.
``(G) The treatment of Indians under this section
does not constitute invidious racial discrimination in
violation of the due process clause of the Fifth or
Fourteenth Amendments, but is reasonable and rationally
designed to further the health of Indians.
``(H) In the case of any State in which 1 or more
Indian health care programs furnishes health care
services, the State will provide for a process under
which the State seeks advice on a regular, ongoing
basis from designees of such Indian health care
programs and urban Indian organizations on matters
relating to the application of a waiver under this
section that are likely to have a direct effect on such
Indian health programs and that--
``(i) shall include solicitation of advice
prior to submission of any plan amendments,
waiver requests, and proposals for
demonstration projects likely to have a direct
effect on Indians or Indian health care
programs; and
``(ii) may include appointment of an
advisory committee and of a designee of such
Indian health care programs to the medical care
advisory committee advising the State on its
waiver under this section.
``(2) Definitions.--For purposes of this subsection:
``(A) The term `Indian' has the meaning given such
term in section 447.50 of title 42, Code of Federal
Regulations (as in effect on July 1, 2010).
``(B) The term `Indian health care provider' has
the meaning given such term in section 438.14(a) of
title 42, Code of Federal Regulations.
``(i) Definitions.--In this section:
``(1) Health benefits coverage.--The term `health benefits
coverage'--
``(A) means--
``(i) health insurance coverage, as such
term is defined in section 2791(b) of the
Public Health Service Act (42 U.S.C. 300gg-
(b)); and
``(ii) coverage under a group health plan,
as such term is defined in section 2791(a) of
the Public Health Service Act (42 U.S.C. 300gg-
(a)); and
``(B) includes any medical coverage or health
benefits provided under one or more of the specified
Federal health program described in subparagraphs (A)
through (E) of paragraph (4), as applicable to a waiver
under subsection (a)(1).
``(2) Resident.--With respect to a State, the term
`resident' means an individual--
``(A) who is--
``(i) a citizen or national of the United
States; or
``(ii) an alien lawfully residing in the
State (including an alien who is granted
deferred action or who is otherwise authorized
to remain in the United States); and
``(B) whose primary residence (as defined by the
State) is located in the State.
``(3) Secretary.--The term `Secretary' means--
``(A) the Secretary of Health and Human Services
with respect to waivers relating to the provisions
described in subparagraphs (A), (B), and (D) through
(G) of paragraph (2) of subsection (a);
``(B) the Secretary of the Treasury with respect to
waivers relating to the provisions described in
subparagraph (C) of such paragraph;
``(C) the Director of the Office of Personnel
Management with respect to waivers relating to the
provisions described in subparagraph (H) of such
paragraph;
``(D) the Secretary of Defense with respect to
waivers relating to the provisions described in
subparagraph (I) of such paragraph; and
``(E) the Secretary of Labor with respect to
waivers relating to the provisions described in
subparagraph (J) of such paragraph.
``(4) Specified federal health program.--The term
`specified Federal health program' means one or more of the
following programs, as applicable to a waiver under subsection
(a)(1):
``(A) The Medicare program under title XVIII of the
Social Security Act.
``(B) The Medicaid program under title XIX of the
Social Security Act.
``(C) The Children's Health Insurance Program under
title XXI of the Social Security Act.
``(D) The Federal Employees Health Benefits Plan
under chapter 89 of title 5, United States Code.
``(E) Medical coverage under chapter 55 of title
10, United States Code, including coverage under the
TRICARE program.
``(F) An Exchange established under this subtitle.
``(G) Subsidies under section 1402.
``(H) Tax credits under sections 36B and 45R of the
Internal Revenue Code of 1986.''.
(b) Clerical Amendment.--The table of contents in section 1(b) of
the Patient Protection and Affordable Care Act (42 U.S.C. 18001 note)
is amended by inserting after the item relating to section 1334 the
following new item:
``1335. Waiver for State universal health care.''.
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