I 

114TH CONGRESS 

1ST SESSION H. R. 3241 

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 HOUSE OF REPRESENTATIVES 

JULY 28, 2015 

Mr. MCDERMOTT introduced the following bill; which was referred to the 

Committee on Energy and Commerce, and in addition to the Committees 

on Ways and Means, Oversight and Government Reform, Armed Services, 

and Education and the Workforce, for a period to be subsequently determined by the Speaker, in each case for consideration of such provisions 

as fall within the jurisdiction of the committee concerned 

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. 

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; PURPOSE. 

4 (a) SHORT TITLE.—This Act may be cited as the 

5 ‘‘State-Based Universal Health Care Act of 2015’’. 


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1 (b) PURPOSE.—The purpose of this Act is to estab2 lish a flexible framework under which each State can pro3 vide comprehensive universal health coverage to all of its 

4 residents. 

5 SEC. 2. WAIVER FOR STATE UNIVERSAL HEALTH CARE. 

6 (a) IN GENERAL.—Subtitle D of title I of the Patient 

7 Protection and Affordable Care Act (Public Law 111– 

8 148) is amended by inserting after section 1332 (42 

9 U.S.C. 18052) the following new section: 

10 ‘‘SEC. 1332A. WAIVER FOR STATE UNIVERSAL HEALTH 

11 CARE. 

12 ‘‘(a) APPLICATION.— 

13 ‘‘(1) IN GENERAL.—A State may apply to the 

14 Secretary (as defined in subsection (g)(3)) for the 

15 waiver of so much of the requirements described in 

16 paragraph (2) with respect to health benefits cov17 erage within that State for plan years beginning on 

18 or after January 1, 2016, as is necessary to imple19 ment a comprehensive State universal health care 

20 plan in the State under this section. Such applica21 tion shall— 

22 ‘‘(A) be filed at such time and in such 

23 manner as the Secretary may require; 

24 ‘‘(B) contain such information as the Sec25 retary may require, including— 


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1 ‘‘(i) a comprehensive description of 

2 the State legislation and program to imple3 ment a plan meeting the requirements for 

4 a waiver under this section; and 

5 ‘‘(ii) a 10-fiscal-year budget plan for 

6 such plan that is budget neutral for the 

7 Federal Government; and 

8 ‘‘(C) provide an assurance that the State 

9 has enacted the law described in subsection 

10 (b)(2). 

11 ‘‘(2) REQUIREMENTS.—The requirements de12 scribed in this paragraph with respect to health ben13 efits coverage within the State for plan years begin14 ning on or after January 1, 2016, are as follows: 

15 ‘‘(A) Parts I, II, and III of subtitle D. 

16 ‘‘(B) Section 1402. 

17 ‘‘(C) Sections 36B, 4980H, and 5000A of 

18 the Internal Revenue Code of 1986. 

19 ‘‘(D) Title XI of the Social Security Act. 

20 ‘‘(E) Title XVIII of the Social Security 

21 Act. 

22 ‘‘(F) Title XIX of the Social Security Act. 

23 ‘‘(G) Title XXI of the Social Security Act. 

24 ‘‘(H) Chapter 89 of title 5 of the United 

25 States Code. 


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1 ‘‘(I) Chapter 55 of title 10, United States 

2 Code, including coverage under the TRICARE 

3 program. 

4 ‘‘(J) Section 514 of the Employee Retire5 ment Income Security Act of 1974. 

6 ‘‘(3) PASS THROUGH OF FUNDING.—With re7 spect to a State waiver under paragraph (1), under 

8 which the State assumes responsibility for health 

9 coverage under a specified Federal health program, 

10 including under each of the Federal health care or 

11 subsidy programs specified in subparagraphs (B), 

12 (C), (E), (F), (G), and (H) of paragraph (2), the 

13 Secretary shall not spend Federal health funds that 

14 would otherwise have been spent for such program 

15 and shall provide for an alternative means by which 

16 the aggregate amount of such funds shall be paid to 

17 the State for purposes of implementing the State 

18 plan under the waiver. Such amount shall be deter19 mined annually by the Secretary, taking into ac20 count the amount that would otherwise have been 

21 spent under such Federal health program with re22 spect to residents of such State, if such waiver did 

23 not apply. Such amount shall include funds equal to 

24 the amount of premium tax credits, cost-sharing re25 ductions, or small-business credits under sections 


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1 36B and 45R of the Internal Revenue Code of 1986 

2 or under section 1402 that would have been avail3 able to individuals and businesses in the State if 

4 such waiver did not apply. 

5 ‘‘(4) WAIVER CONSIDERATION AND TRANS6 PARENCY.— 

7 ‘‘(A) IN GENERAL.—An application for a 

8 waiver under this section shall be considered by 

9 the Secretary in accordance with the regula10 tions described in subparagraph (B). 

11 ‘‘(B) REGULATIONS.—Not later than 180 

12 days after the date of enactment of the State13 Based Universal Health Care Act of 2015, the 

14 Secretary shall promulgate regulations relating 

15 to waivers under this section that provide— 

16 ‘‘(i) a process for public notice and 

17 comment at the State level, including pub18 lic hearings, sufficient to ensure a mean19 ingful level of public input; 

20 ‘‘(ii) a process for the submission of 

21 an application that ensures the disclosure 

22 of— 

23 ‘‘(I) the provisions of law that 

24 the State involved seeks to waive; and 


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1 ‘‘(II) the specific plans of the 

2 State to ensure that the waiver will be 

3 in compliance with subsection (b); 

4 ‘‘(iii) a process for providing public 

5 notice and comment after the application is 

6 received by the Secretary, that is sufficient 

7 to ensure a meaningful level of public 

8 input and that does not impose require9 ments that are in addition to, or duplica10 tive of, requirements imposed under the 

11 Administrative Procedure Act, or require12 ments that are unreasonable or unneces13 sarily burdensome with respect to State 

14 compliance; 

15 ‘‘(iv) a process for the submission to 

16 the Secretary of periodic reports by the 

17 State concerning the implementation of the 

18 program under the waiver; and 

19 ‘‘(v) a process for the periodic evalua20 tion by the Secretary with respect to waiv21 ers granted under this section. 

22 ‘‘(C) REPORT.—The Secretary shall annu23 ally report to Congress concerning actions 

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1 tions for waivers, and programs conducted 

2 through waivers granted, under this section. 

3 ‘‘(b) GRANTING OF WAIVERS.— 

4 ‘‘(1) IN GENERAL.—The Secretary may grant a 

5 request for a waiver under subsection (a)(1) only if 

6 the Secretary determines that the State plan— 

7 ‘‘(A) will provide health benefits coverage 

8 to State residents that is at least as comprehen9 sive as the health benefits coverage that such 

10 residents would have received under the speci11 fied Federal health program for which such 

12 residents would have been eligible, absent such 

13 waiver; 

14 ‘‘(B) will provide coverage and cost sharing 

15 protections against excessive out-of-pocket 

16 spending to State residents that are at least as 

17 affordable as the coverage and cost sharing pro18 tections under the specified Federal health pro19 gram for which such residents would have been 

20 eligible, absent such waiver; 

21 ‘‘(C) will provide coverage to substantially 

22 all residents of the State, including substan23 tially all those otherwise covered under the Fed24 eral health care or subsidy programs specified 

25 in subparagraphs (B), (C), (E), (F), (G), and 


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1 (H) of subsection (a)(2), except individuals who 

2 are eligible for benefits through the Indian 

3 Health Service or for benefits and services 

4 under title 38, United States Code; 

5 ‘‘(D) will be publicly administered by an 

6 agency of the State; and 

7 ‘‘(E) will not increase the Federal deficit. 

8 Subparagraph (D) shall not be construed as limiting 

9 a State from contracting with one or more private 

10 entities to administer the plan. 

11 ‘‘(2) REQUIREMENT TO ENACT A LAW.— 

12 ‘‘(A) IN GENERAL.—A law described in 

13 this paragraph is a State law that provides for 

14 State actions under a waiver under this section, 

15 including the implementation of the State plan 

16 under subsection (a)(1)(B). 

17 ‘‘(B) TERMINATION OF OPT OUT.—A State 

18 may repeal a law described in subparagraph (A) 

19 and terminate the authority provided under the 

20 waiver with respect to the State. 

21 ‘‘(c) SCOPE OF WAIVER.— 

22 ‘‘(1) IN GENERAL.—The Secretary shall deter23 mine the scope of a waiver of a requirement de24 scribed in subsection (a)(2) granted to a State under 

25 subsection (a)(1). 


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1 ‘‘(2) LIMITATION.—Under this section, the Sec2 retary may not waive any Federal law or require3 ment that is not listed in subsection (a)(2). 

4 ‘‘(d) DETERMINATIONS BY SECRETARY.— 

5 ‘‘(1) TIME FOR DETERMINATION.—The Sec6 retary shall make a determination under subsection 

7 (a)(1) not later than 180 days after the receipt of 

8 an application from a State under such subsection. 

9 ‘‘(2) EFFECT OF DETERMINATION.— 

10 ‘‘(A) GRANTING OF WAIVERS.—If the Sec11 retary determines to grant a waiver under sub12 section (a)(1), the Secretary shall notify the 

13 State involved of such determination and the 

14 terms and effectiveness of such waiver. 

15 ‘‘(B) DENIAL OF WAIVER.—If the Sec16 retary determines a waiver should not be grant17 ed under subsection (a)(1), the Secretary shall 

18 notify the State involved and the appropriate 

19 committees of Congress of such determination 

20 and the reasons therefor. 

21 ‘‘(e) TERM OF WAIVER.—No waiver under this sec22 tion may extend over a period of longer than 5 years un23 less the State requests continuation of such waiver, and 

24 such request shall be deemed granted unless the Secretary, 

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1 retary, either denies such request in writing or informs 

2 the State in writing with respect to any additional infor3 mation which is needed in order to make a final deter4 mination with respect to the request. 

5 ‘‘(f) ASSURING COORDINATION.— 

6 ‘‘(1) IN GENERAL.—Not later than 180 days 

7 after the enactment of the State-Based Universal 

8 Health Care Act of 2015, the Secretary of Health 

9 and Human Services, the Secretary of the Treasury, 

10 the Director of the Office of Personnel Management, 

11 the Secretary of Defense, and the Secretary of 

12 Labor shall, through the execution of an interagency 

13 memorandum of understanding among such Secre14 taries and the Director— 

15 ‘‘(A) develop a process for coordinating 

16 and consolidating the State waiver processes 

17 applicable under the provisions of this section, 

18 and the existing waiver processes applicable 

19 under— 

20 ‘‘(i) titles XI, XVIII, XIX, and XXI 

21 of the Social Security Act; and 

22 ‘‘(ii) any other Federal law relating to 

23 the provision of health care items or serv24 ices; and 

25 ‘‘(B) ensure that— 


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1 ‘‘(i) regulations (including regulations 

2 required under subsection (a)(4)(B)), rul3 ings, and interpretations issued by such 

4 Secretaries and the Director relating to the 

5 same matter over which two or more such 

6 Secretaries or Director have responsibility 

7 under this section are administered so as 

8 to have the same effect at all times; and 

9 ‘‘(ii) coordination of policies relating 

10 to the granting, implementation, and con11 tinuation of waivers through such Secre12 taries and Director in order to have a co13 ordinated strategy that avoids duplication 

14 of effort by the States or Secretaries and 

15 Director and ensures clarity about waiver 

16 application status and approval. 

17 ‘‘(2) SINGLE APPLICATION.—The process under 

18 paragraph (1)(A) shall permit a State to submit a 

19 single application for a waiver under all of the provi20 sions of this section and the provisions of law listed 

21 under clauses (i) and (ii) of such paragraph. 

22 ‘‘(3) SUBMISSION OF CONFORMING AMEND23 MENTS.—The Secretary of Health and Human Serv24 ices, in coordination with the other Secretaries (in25 cluding the Director of the Office of Personnel ManVerDate Sep 11 2014 07:23 Jul 29, 2015 Jkt 049200 PO 00000 Frm 00011 Fmt 6652 Sfmt 6201 E:\BILLS\H3241.IH H3241

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1 agement), shall submit to Congress such rec2 ommendations for such technical and conforming 

3 amendments to law as may be appropriate to assist 

4 in the implementation of this section. 

5 ‘‘(g) DEFINITIONS.—In this section: 

6 ‘‘(1) HEALTH BENEFITS COVERAGE.—The term 

7 ‘health benefits coverage’— 

8 ‘‘(A) means— 

9 ‘‘(i) health insurance coverage, as 

10 such term is defined in section 2791(b) of 

11 the Public Health Service Act (42 U.S.C. 

12 300gg–91(b)); and 

13 ‘‘(ii) coverage under a group health 

14 plan, as such term is defined in section 

15 2791(a) of the Public Health Service Act 

16 (42 U.S.C. 300gg–91(a)); and 

17 ‘‘(B) includes any medical coverage or 

18 health benefits provided under any specified 

19 Federal health program described in subpara20 graphs (A) through (E) of paragraph (4). 

21 ‘‘(2) RESIDENT.—With respect to a State, the 

22 term ‘resident’ means an individual who is a citizen 

23 or national of the United States or an alien lawfully 

24 residing in the State, and whose primary residence 

25 (as defined by the State) is located in the State. 


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1 ‘‘(3) SECRETARY.—The term ‘Secretary’ 

2 means— 

3 ‘‘(A) the Secretary of Health and Human 

4 Services with respect to waivers relating to the 

5 provisions described in subparagraphs (A), (B), 

6 and (D) through (G) of paragraph (2) of sub7 section (a); 

8 ‘‘(B) the Secretary of the Treasury with 

9 respect to waivers relating to the provisions de10 scribed in subparagraph (C) of such paragraph; 

11 ‘‘(C) the Director of the Office of Per12 sonnel Management with respect to waivers re13 lating to the provisions described in subpara14 graph (H) of such paragraph; 

15 ‘‘(D) the Secretary of Defense with respect 

16 to waivers relating to the provisions described 

17 in subparagraph (I) of such paragraph; and 

18 ‘‘(E) the Secretary of Labor with respect 

19 to waivers relating to the provisions described 

20 in subparagraph (J) of such paragraph. 

21 ‘‘(4) SPECIFIED FEDERAL HEALTH PROGRAM.— 

22 The term ‘specified Federal health program’ means 

23 all of the following programs: 

24 ‘‘(A) The Medicare program under title 

25 XVIII of the Social Security Act. 


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1 ‘‘(B) The Medicaid program under title 

2 XIX of the Social Security Act. 

3 ‘‘(C) The Children’s Health Insurance Pro4 gram under title XXI of the Social Security 

5 Act. 

6 ‘‘(D) The Federal Employees Health Bene7 fits Plan under chapter 89 of title 5 of the 

8 United States Code. 

9 ‘‘(E) Medical coverage under chapter 55 of 

10 title 10, United States Code, including coverage 

11 under the TRICARE program. 

12 ‘‘(F) An Exchange established under this 

13 subtitle. 

14 ‘‘(G) Subsidies under section 1402. 

15 ‘‘(H) Tax credits under sections 36B and 

16 45R of the Internal Revenue Code of 1986.’’. 

17 (b) CLERICAL AMENDMENT.—The table of contents 

18 in section 1(b) of such Act is amended by inserting after 

19 the item relating to section 1332 the following new item: 

‘‘Sec. 1332A. Waiver for State universal health care.’’. 

Æ 


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