II 

118TH CONGRESS 

2D SESSION S. 4682 

To amend the Patient Protection and Affordable Care Act to establish a 

public health insurance option, and for other purposes. 

IN THE SENATE OF THE UNITED STATES 

JULY 11 (legislative day, JULY 10), 2024 

Mr. WHITEHOUSE (for himself and Mr. BROWN) introduced the following bill; 

which was read twice and referred to the Committee on Health, Education, Labor, and Pensions 

A BILL 

To amend the Patient Protection and Affordable Care Act 

to establish a public health insurance option, and for 

other purposes. 

1 Be it enacted by the Senate and House of Representa2 tives of the United States of America in Congress assembled, 

3 SECTION 1. SHORT TITLE. 

4 This Act may be cited as the ‘‘Consumer Health Op5 tions and Insurance Competition Enhancement Act’’ or 

6 the ‘‘CHOICE Act’’. 

7 SEC. 2. PUBLIC HEALTH INSURANCE OPTION. 

8 (a) IN GENERAL.—Part 2 of subtitle D of title I of 

9 the Patient Protection and Affordable Care Act (42 


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1 U.S.C. 18031 et seq.) is amended by adding at the end 

2 the following: 

3 ‘‘SEC. 1314. PUBLIC HEALTH INSURANCE OPTION. 

4 ‘‘(a) ESTABLISHMENT.— 

5 ‘‘(1) IN GENERAL.—For plans years beginning 

6 on or after January 1, 2026, the Secretary shall es7 tablish, and provide for the offering through the Ex8 changes of, a qualified health plan (in this section 

9 referred to as the ‘public health insurance option’) 

10 that provides value, choice, competition, and stability 

11 of affordable, high-quality coverage throughout the 

12 United States in accordance with this section. 

13 ‘‘(2) PRIMARY RESPONSIBILITY.—In designing 

14 the public health insurance option, the primary re15 sponsibility of the Secretary shall be to create an af16 fordable health plan without compromising quality 

17 or access to care. 

18 ‘‘(b) ADMINISTRATING THE PUBLIC HEALTH INSUR19 ANCE OPTION.— 

20 ‘‘(1) OFFERED THROUGH EXCHANGES.— 

21 ‘‘(A) EXCLUSIVE TO EXCHANGES.—The 

22 public health insurance option shall be offered 

23 exclusively by the Secretary through the Ex24 changes and not by a health insurance issuer. 


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1 ‘‘(B) ENSURING A LEVEL PLAYING

2 FIELD.—Except as otherwise provided under 

3 this section, the public health insurance option 

4 shall comply with requirements under this title, 

5 and title XXVII of the Public Health Service 

6 Act, that are applicable to health plans offered 

7 through the Exchanges, including requirements 

8 related to benefits, benefit levels, provider net9 works, notices, consumer protections, and cost10 sharing. 

11 ‘‘(C) PROVISION OF BENEFIT LEVELS.— 

12 The public health insurance option shall offer 

13 bronze, silver, and gold plans. 

14 ‘‘(2) ADMINISTRATIVE CONTRACTING.— 

15 ‘‘(A) AUTHORITIES.—The Secretary may 

16 enter into contracts for the purpose of per17 forming administrative functions (including 

18 functions described in subsection (a)(4) of sec19 tion 1874A of the Social Security Act) with re20 spect to the public health insurance option in 

21 the same manner as the Secretary may enter 

22 into contracts under subsection (a)(1) of such 

23 section. The Secretary shall have the same au24 thority with respect to the public health insur25 ance option as the Secretary has under such 


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1 subsection (a)(1) and subsection (b) of section 

2 1874A of the Social Security Act with respect 

3 to title XVIII of such Act. 

4 ‘‘(B) TRANSFER OF INSURANCE RISK.— 

5 Any contract under this paragraph shall not in6 volve the transfer of insurance risk from the 

7 Secretary to the entity entering into such con8 tract with the Secretary. 

9 ‘‘(3) STATE ADVISORY COUNCIL.— 

10 ‘‘(A) ESTABLISHMENT.—A State may es11 tablish a public or nonprofit entity to serve as 

12 the State Advisory Council to provide rec13 ommendations to the Secretary on the oper14 ations and policies of the public health insur15 ance option offered through the Exchange oper16 ating in the State. 

17 ‘‘(B) RECOMMENDATIONS.—A State Advi18 sory Council established under subparagraph 

19 (A) shall provide recommendations on at least 

20 the following: 

21 ‘‘(i) Policies and procedures to inte22 grate quality improvement and cost con23 tainment mechanisms into the health care 

24 delivery system. 


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1 ‘‘(ii) Mechanisms to facilitate public 

2 awareness of the availability of the public 

3 health insurance option. 

4 ‘‘(iii) Alternative payment models and 

5 value-based insurance design under the 

6 public health insurance option that encour7 age quality improvement and cost control. 

8 ‘‘(C) MEMBERS.—The members of any 

9 State Advisory Council shall be representatives 

10 of the public and include health care consumers 

11 and health care providers. 

12 ‘‘(D) APPLICABILITY OF RECOMMENDA13 TIONS.—The Secretary may apply the rec14 ommendations of a State Advisory Council to 

15 the public health insurance option in that State, 

16 in any other State, or in all States. 

17 ‘‘(4) DATA COLLECTION.—The Secretary shall 

18 collect such data as may be required— 

19 ‘‘(A) to establish rates for premiums and 

20 health care provider reimbursement under sub21 section (c); and 

22 ‘‘(B) for other purposes under this section, 

23 including to improve quality, and reduce racial, 

24 ethnic, and other disparities, in health and 

25 health care. 


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1 ‘‘(c) FINANCING THE PUBLIC HEALTH INSURANCE

2 OPTION.— 

3 ‘‘(1) PREMIUMS.— 

4 ‘‘(A) ESTABLISHMENT.—The Secretary 

5 shall establish geographically adjusted premium 

6 rates for the public health insurance option— 

7 ‘‘(i) in a manner that complies with 

8 the requirement for premium rates under 

9 subparagraph (C) and considers the data 

10 collected under subsection (b)(4); and 

11 ‘‘(ii) at a level sufficient to fully fi12 nance— 

13 ‘‘(I) the costs of health benefits 

14 provided by the public health insur15 ance option; and 

16 ‘‘(II) administrative costs related 

17 to operating the public health insur18 ance option. 

19 ‘‘(B) CONTINGENCY MARGIN.—In estab20 lishing premium rates under subparagraph (A), 

21 the Secretary shall include an appropriate 

22 amount for a contingency margin. 

23 ‘‘(C) VARIATIONS IN PREMIUM RATES.— 

24 The premium rate charged for the public health 

25 insurance option may not vary except as proVerDate Sep 11 2014 00:48 Aug 15, 2024 Jkt 049200 PO 00000 Frm 00006 Fmt 6652 Sfmt 6201 E:\BILLS\S4682.IS S4682

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1 vided under section 2701 of the Public Health 

2 Service Act. 

3 ‘‘(2) HEALTH CARE PROVIDER PAYMENT RATES

4 FOR ITEMS AND SERVICES.— 

5 ‘‘(A) IN GENERAL.— 

6 ‘‘(i) RATES NEGOTIATED BY THE SEC7 RETARY.—Not later than January 1, 2025, 

8 and except as provided in clause (ii), the 

9 Secretary shall, through a negotiated 

10 agreement with health care providers, es11 tablish rates for reimbursing health care 

12 providers for providing the benefits covered 

13 by the public health insurance option. 

14 ‘‘(ii) MEDICARE REIMBURSEMENT

15 RATES.—If the Secretary and health care 

16 providers are unable to reach a negotiated 

17 agreement on a reimbursement rate, the 

18 Secretary shall reimburse providers at 

19 rates determined for equivalent items and 

20 services under the original medicare fee21 for-service program under parts A and B 

22 of title XVIII of the Social Security Act. 

23 ‘‘(iii) FOR NEW SERVICES.—The Sec24 retary shall modify reimbursement rates 

25 described in clause (ii) in order to accomVerDate Sep 11 2014 00:48 Aug 15, 2024 Jkt 049200 PO 00000 Frm 00007 Fmt 6652 Sfmt 6201 E:\BILLS\S4682.IS S4682

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1 modate payments for services, such as 

2 well-child visits, that are not otherwise cov3 ered under the original medicare fee-for4 service program. 

5 ‘‘(B) PRESCRIPTION DRUGS.—Any pay6 ment rate under this subsection for a prescrip7 tion drug shall be at a rate negotiated by the 

8 Secretary. If the Secretary is unable to reach a 

9 negotiated agreement on such a reimbursement 

10 rate, the Secretary shall use rates determined 

11 for equivalent drugs paid for under the original 

12 medicare fee-for-service program. The Secretary 

13 shall modify such rates in order to accommo14 date payments for drugs that are not otherwise 

15 covered under the original medicare fee-for16 service program. 

17 ‘‘(3) ACCOUNT.— 

18 ‘‘(A) ESTABLISHMENT.—There is estab19 lished in the Treasury of the United States an 

20 account for the receipts and disbursements at21 tributable to the operation of the public health 

22 insurance option, including the start-up funding 

23 under subparagraph (C) and appropriations au24 thorized under subparagraph (D). 


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1 ‘‘(B) PROHIBITION OF STATE IMPOSITION

2 OF TAXES.—Section 1854(g) of the Social Se3 curity Act shall apply to receipts and disburse4 ments described in subparagraph (A) in the 

5 same manner as such section applies to pay6 ments or premiums described in such section. 

7 ‘‘(C) START-UP FUNDING.— 

8 ‘‘(i) AUTHORIZATION OF FUNDING.— 

9 There are authorized to be appropriated 

10 such sums as may be necessary to estab11 lish the public health insurance option and 

12 cover 90 days of claims reserves based on 

13 projected enrollment. 

14 ‘‘(ii) AMORTIZATION OF START-UP

15 FUNDING.—The Secretary shall provide for 

16 the repayment of the startup funding pro17 vided under clause (i) to the Treasury in 

18 an amortized manner over the 10-year pe19 riod beginning on January 1, 2026. 

20 ‘‘(D) ADDITIONAL AUTHORIZATION OF AP21 PROPRIATIONS.—To carry out paragraph (2) of 

22 subsection (b), there are authorized to be ap23 propriated such sums as may be necessary. 

24 ‘‘(d) HEALTH CARE PROVIDER PARTICIPATION.— 

25 ‘‘(1) PROVIDER PARTICIPATION.— 


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1 ‘‘(A) IN GENERAL.—The Secretary shall 

2 establish conditions of participation for health 

3 care providers under the public health insurance 

4 option. 

5 ‘‘(B) LICENSURE OR CERTIFICATION.— 

6 The Secretary shall not allow a health care pro7 vider to participate in the public health insur8 ance option unless such provider is appro9 priately licensed or certified under State law. 

10 ‘‘(2) ESTABLISHMENT OF A PROVIDER NET11 WORK.— 

12 ‘‘(A) MEDICARE AND MEDICAID PARTICI13 PATING PROVIDERS.—A health care provider 

14 that is a participating provider of services or 

15 supplier under the Medicare program under 

16 title XVIII of the Social Security Act or under 

17 a State Medicaid plan under title XIX of such 

18 Act is a participating provider in the public 

19 health insurance option unless the health care 

20 provider opts out of participating in the public 

21 health insurance option through a process es22 tablished by the Secretary. 

23 ‘‘(B) ADDITIONAL PROVIDERS.—The Sec24 retary shall establish a process to allow health 

25 care providers not described in subparagraph 


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1 (A) to become participating providers in the 

2 public health insurance option.’’. 

3 (b) CONFORMING AMENDMENTS.— 

4 (1) TREATMENT AS A QUALIFIED HEALTH

5 PLAN.—Section 1301(a) of the Patient Protection 

6 and Affordable Care Act (42 U.S.C. 18021(a)) is 

7 amended— 

8 (A) in paragraph (1)(C), by inserting ‘‘ex9 cept in the case of the public health insurance 

10 option established under section 1314,’’ before 

11 ‘‘is offered by’’; 

12 (B) in paragraph (2)— 

13 (i) in the paragraph heading, by in14 serting ‘‘, THE PUBLIC HEALTH INSUR15 ANCE OPTION,’’ before ‘‘AND’’; and 

16 (ii) by inserting ‘‘the public health in17 surance option under section 1314,’’ before 

18 ‘‘and a multi-State plan’’; and 

19 (C) by adding at the end the following: 

20 ‘‘(5) PUBLIC HEALTH INSURANCE OPTION.— 

21 The term ‘qualified health plan’ shall include the 

22 public health insurance option established under sec23 tion 1314.’’. 

24 (2) LEVEL PLAYING FIELD.—Section 1324(a) 

25 of the Patient Protection and Affordable Care Act 


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1 (42 U.S.C. 18044(a)) is amended by inserting ‘‘the 

2 public health insurance option under section 1314,’’ 

3 before ‘‘or a multi-State qualified health plan’’. 

Æ 


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