I 
115TH CONGRESS 
2D SESSION 
H. R. 6097 
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 
JUNE 13, 2018 
Ms. JAYAPAL (for herself, Ms. SCHAKOWSKY, and Mr. POCAN) introduced the 
following bill; which was referred to the Committee on Energy and Com-
merce, and in addition to the Committees on Ways and Means, Oversight 
and Government Reform, Armed Services, and Education and the Work-
force, 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 resi-
dents, and for other purposes. 
Be it enacted by the Senate and House of Representa-
tives 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 2018’’. 
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(b) PURPOSE.—The purpose of this Act is to estab-
lish a flexible framework under which States can provide 
comprehensive universal health coverage to all of their 
residents. 
SEC. 2. WAIVER FOR STATE UNIVERSAL HEALTH CARE. 
(a) IN GENERAL.—Title I of the Patient Protection 
and Affordable Care Act (Public Law 111–148) is amend-
ed by striking section 1332 (42 U.S.C. 18052) and insert-
ing the following new section: 
‘‘SEC. 1332. WAIVER FOR STATE UNIVERSAL HEALTH CARE. 
‘‘(a) APPLICATION.— 
‘‘(1) IN GENERAL.—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 cov-
erage within that State for plan years beginning on 
or after January 1, 2019, as is necessary to imple-
ment a comprehensive State universal health care 
plan in the State under this section. Such applica-
tion shall— 
‘‘(A) be filed at such time and in such 
manner as the Secretary may require; 
‘‘(B) contain such information as the Sec-
retary may require, including— 
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‘‘(i) a comprehensive description of 
the State legislation and program to imple-
ment 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 the population of the 
State, with five percent of the population 
of the State not spending more than 10 
percent of their adjusted gross income on 
health; 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 enacted, or will be enacting before the cur-
rent State legislative session adjourns, the law 
described in subsection (b)(2). 
‘‘(2) REQUIREMENTS.—The requirements de-
scribed in this paragraph with respect to health ben-
efits coverage within the State for plan years begin-
ning on or after January 1, 2019, are as follows: 
‘‘(A) Parts I, II, and III of this subtitle. 
‘‘(B) Section 1402. 
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‘‘(C) Sections 36B and 4980H of the In-
ternal 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 of the United 
States Code. 
‘‘(I) Chapter 55 of title 10, United States 
Code, including coverage under the TRICARE 
program. 
‘‘(J) Section 514 of the Employee Retire-
ment Income Security Act of 1974. 
‘‘(3) PASS THROUGH OF FUNDING.—With re-
spect to a State waiver under paragraph (1), under 
which the State assumes responsibility for health 
coverage under a specified Federal health program, 
including under each of the Federal health care or 
subsidy programs specified in subparagraphs (B), 
(C), (E), (F), (G), and (H) of paragraph (2), the 
Secretary shall not spend Federal health funds that 
would otherwise have been spent for such program 
and shall provide for an alternative means by which 
the aggregate amount of such funds shall be paid to 
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the State for purposes of implementing the State 
plan under the waiver. Such amount shall be deter-
mined annually by the Secretary, taking into ac-
count the amount that would otherwise have been 
spent under such Federal health program with re-
spect to residents of such State, if such waiver did 
not apply. Such amount shall include funds equal to 
the amount of premium tax credits, cost-sharing re-
ductions, or small-business credits under sections 
36B and 45R of the Internal Revenue Code of 1986 
or under section 1402 that would have been avail-
able to individuals and businesses in the State if 
such waiver did not apply. 
‘‘(4) WAIVER
CONSIDERATION
AND
TRANS-
PARENCY.— 
‘‘(A) IN GENERAL.—An application for a 
waiver under this section shall be considered by 
the Secretary, after taking into account rec-
ommendations of the Panel under subsection 
(g), in accordance with the regulations de-
scribed in subparagraph (B). 
‘‘(B) REGULATIONS.—Not later than 180 
days after the date of enactment of the State- 
Based Universal Health Care Act of 2017, the 
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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 no-
tice and comment requirements applicable 
under regulations used for Medicaid waiv-
ers 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 require-
ments that are in addition to, or duplica-
tive of, requirements imposed under the 
Administrative Procedure Act, or require-
ments that are unreasonable or unneces-
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sarily burdensome with respect to State 
compliance; 
‘‘(iv) a process for the Panel under 
subsection (g) to consider the applications 
for waivers so submitted and provide rec-
ommendations with respect to such appli-
cations; 
‘‘(v) a process for the submission to 
the Secretary of periodic reports by the 
State concerning the implementation of the 
program under the waiver; 
‘‘(vi) a process for the periodic evalua-
tion by the Secretary with respect to waiv-
ers granted under this section; and 
‘‘(vii) a process for providing technical 
assistance on— 
‘‘(I) how to develop an applica-
tion to any State seeking to submit an 
application for a waiver relating to de-
veloping a program of providing 
health care for all residents for such 
State; and 
‘‘(II) how to improve such a pro-
gram for purposes of a State seeking 
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assistance pursuant to subsection 
(e)(2). 
‘‘(C) REPORT.—The Secretary shall annu-
ally report to Congress concerning actions 
taken by the Secretary with respect to applica-
tions for waivers, and programs conducted 
through waivers granted, under this section. 
Each such report shall include, with respect to 
any action by the Secretary so taken, with re-
spect to an application, that was not consistent 
with the recommendations of the Panel under 
subsection (g), with respect to such application, 
the reasons such action was taken. 
‘‘(5) REGIONAL WAIVER REQUEST AND PLAN.— 
Nothing in this section shall be construed to prevent 
two 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 re-
spect to each State included in such application. 
‘‘(6) AUTHORIZATION
OF
APPROPRIATIONS.— 
There is authorized to be appropriated such sums as 
may be necessary for providing funds to States with 
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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 may grant a 
request for a waiver under subsection (a)(1) only if 
the Secretary determines that the State plan— 
‘‘(A) will provide, in accordance with sub-
paragraph (B), health benefits coverage to 
State residents that is at least as comprehen-
sive as the health benefits coverage that such 
residents would have received under the speci-
fied Federal health program (as defined in sub-
section (i)(4)) 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 sub-
section (a)(2)(F), health benefits coverage to 
State residents who would have otherwise re-
ceived 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 pro-
vides for such assistance through a State plan 
under title XIX of the Social Security Act or a 
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waiver of such plan) that includes at least the 
mandatory benefits under title XIX of the So-
cial Security Act that are required of a State 
without a waiver of a State plan under such 
title, including at least 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 pro-
tections under the specified Federal health pro-
gram (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 all those otherwise cov-
ered under the Federal health care or subsidy 
programs specified in subparagraphs (B), (C), 
(E), (F), (G), and (H) of subsection (a)(2), ex-
cept individuals who are eligible for benefits 
through the Indian Health Service or for bene-
fits and services under title 38, United States 
Code; 
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‘‘(E) will provide for public education ac-
tivities to raise awareness of the availability of 
qualified health plans and the facilitation of en-
rollment in such coverage 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 of the State; 
‘‘(G) will not preclude the purchase of sup-
plemental insurance; 
‘‘(H) will provide systems for complaints, 
appeals, independent review, and other proce-
dures for accessing and maintaining benefits 
that are at least as accessible to State residents 
as those of the specified Federal health pro-
grams (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 not increase the Federal deficit. 
Subparagraph (D) shall not be construed as limiting 
a State from contracting with one or more private 
entities to administer the plan. 
‘‘(2) REQUIREMENT TO ENACT A LAW.— 
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‘‘(A) IN
GENERAL.—A law described in 
this paragraph is a State law 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 deter-
mine the scope of a waiver of a requirement de-
scribed in subsection (a)(2) granted to a State under 
subsection (a)(1). 
‘‘(2) LIMITATION.—Under this section, the Sec-
retary may not waive any Federal law or require-
ment that is not listed in subsection (a)(2). 
‘‘(d) DETERMINATIONS BY SECRETARY.— 
‘‘(1) TIME
FOR
DETERMINATION.—The Sec-
retary shall, with respect to an application from a 
State under this subsection and after taking into ac-
count recommendations of the Panel under sub-
section (g) for such application, make a determina-
tion under subsection (a)(1) not later than 90 days 
after the receipt of such recommendations. 
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‘‘(2) EFFECT OF DETERMINATION.— 
‘‘(A) GRANTING OF WAIVERS.—If the Sec-
retary determines to grant a waiver under sub-
section (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 Sec-
retary determines a waiver should not be grant-
ed 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, suffi-
cient to ensure a meaningful level of public input, on 
the following: 
‘‘(A) How waiver funds have been spent by 
the State. 
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ance program of the State implemented 
through the waiver under this section; 
‘‘(ii) the State shall have a grace pe-
riod of 6 months after such determination 
to achieve health coverage for at least 95 
percent of such population; and 
‘‘(iii) if after such 6 months, the State 
has not achieved such health coverage, the 
waiver under this section shall be termi-
nated; and 
‘‘(B) has been determined by the Sec-
retary, after taking into account recommenda-
tions of the Panel under subsection (g), to have 
achieved health coverage for at least 95 percent 
of the population of the State, the State, as a 
condition of continuing such waiver, shall sub-
mit to the Secretary a plan for achieving health 
coverage for the remainder of the population of 
the State. 
‘‘(f) ASSURING COORDINATION.— 
‘‘(1) IN GENERAL.—Not later than 180 days 
after the enactment of the State-Based Universal 
Health Care Act of 2018, the Secretary of Health 
and Human Services, the Secretary of the Treasury, 
the Director of the Office of Personnel Management, 
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the Secretary of Defense, and the Secretary of 
Labor shall, through the execution of an interagency 
memorandum of understanding among such Secre-
taries and the 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 serv-
ices; and 
‘‘(B) ensure that— 
‘‘(i) regulations (including regulations 
required under subsection (a)(4)(B)), rul-
ings, and interpretations issued by such 
Secretaries and the 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 con-
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tinuation of waivers through such Secre-
taries and Director in order to have a co-
ordinated 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 provi-
sions of this section and the provisions of law listed 
under clauses (i) and (ii) of such paragraph. 
‘‘(3) SUBMISSION
OF
CONFORMING
AMEND-
MENTS.—The Secretary of Health and Human Serv-
ices, in coordination with the other Secretaries (in-
cluding the Director of the Office of Personnel Man-
agement), shall submit to Congress such rec-
ommendations 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 COM-
PREHENSIVE HEALTH CARE.— 
‘‘(1) ESTABLISHMENT.—There is established a 
committee to be known as the ‘Independent Assess-
ment Panel for Comprehensive Health Care’ (in this 
section referred to as the ‘Panel’). 
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‘‘(2) CONSIDERATION
OF
SUBMISSIONS.—The 
Secretary shall forward a copy of each waiver appli-
cation 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 sub-
section (e) for purposes of the review under 
paragraph (2) of such subsection; 
‘‘(B) not later than 90 days after submis-
sion 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 ap-
plication (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 num-
ber of applications (and reports) received and 
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the number of applications recommended for 
approval (and of reports with respect to which 
recommendations for continuation were pro-
vided). 
‘‘(4) MEMBERSHIP.— 
‘‘(A) NUMBER
AND
APPOINTMENT.—The 
Panel shall consist of seven members appointed 
by the Secretary of Health and Human Serv-
ices, of whom— 
‘‘(i) one shall be appointed on the rec-
ommendation of the Speaker of the House 
of Representatives; 
‘‘(ii) one shall be appointed on the 
recommendation of the minority leader of 
the House of Representatives; 
‘‘(iii) one shall be appointed on the 
recommendation of the majority leader of 
the Senate; 
‘‘(iv) one shall be appointed on the 
recommendation of the minority leader of 
the Senate; 
‘‘(v) one shall be appointed from the 
Republican Governors Association; 
‘‘(vi) one shall be appointed from the 
Democratic Governors Association; and 
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‘‘(vii) one shall be a representative 
from the consumer advocacy community. 
‘‘(B) TERM OF SERVICE.— 
‘‘(i) IN GENERAL.—Each member of 
the Panel shall serve a three-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 ap-
pointed 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 origi-
nal appointment was made. 
‘‘(C) PAY.—Members of the Panel shall 
serve without pay. 
‘‘(D) 
CHAIRPERSON; 
VICE
CHAIR-
PERSON.— 
‘‘(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. 
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‘‘(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 sub-
section (a); 
‘‘(B) the Secretary of the Treasury with 
respect to waivers relating to the provisions de-
scribed in subparagraph (C) of such paragraph; 
‘‘(C) the Director of the Office of Per-
sonnel Management with respect to waivers re-
lating to the provisions described in subpara-
graph (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 
all of the following programs: 
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