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 deter-
mined 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 2015’’. 
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(b) PURPOSE.—The purpose of this Act is to estab-
lish a flexible framework under which each State can pro-
vide comprehensive universal health coverage to all of its 
residents. 
SEC. 2. WAIVER FOR STATE UNIVERSAL HEALTH CARE. 
(a) IN GENERAL.—Subtitle D of title I of the Patient 
Protection and Affordable Care Act (Public Law 111– 
148) is amended by inserting after section 1332 (42 
U.S.C. 18052) the following new section: 
‘‘SEC. 1332A. WAIVER FOR STATE UNIVERSAL HEALTH 
CARE. 
‘‘(a) APPLICATION.— 
‘‘(1) IN GENERAL.—A State may apply to the 
Secretary (as defined in subsection (g)(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, 2016, 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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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 in accordance with the regula-
tions described in subparagraph (B). 
‘‘(B) REGULATIONS.—Not later than 180 
days after the date of enactment of the State- 
Based Universal Health Care Act of 2015, the 
Secretary shall promulgate regulations relating 
to waivers under this section that provide— 
‘‘(i) a process for public notice and 
comment at the State level, including pub-
lic hearings, sufficient to ensure a mean-
ingful level of public input; 
‘‘(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 
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‘‘(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-
sarily 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; and 
‘‘(v) a process for the periodic evalua-
tion by the Secretary with respect to waiv-
ers granted under this section. 
‘‘(C) REPORT.—The Secretary shall annu-
ally report to Congress concerning actions 
taken by the Secretary with respect to applica-
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tions for waivers, and programs conducted 
through waivers granted, under this section. 
‘‘(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 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 for which such 
residents would have been eligible, absent such 
waiver; 
‘‘(B) 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 for which such residents would have been 
eligible, absent such waiver; 
‘‘(C) will provide coverage to substantially 
all residents of the State, including substan-
tially all those otherwise covered under the Fed-
eral health care or subsidy programs specified 
in subparagraphs (B), (C), (E), (F), (G), and 
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(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; 
‘‘(D) will be publicly administered by an 
agency of the State; and 
‘‘(E) 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.— 
‘‘(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). 
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‘‘(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 make a determination under subsection 
(a)(1) not later than 180 days after the receipt of 
an application from a State under such subsection. 
‘‘(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) TERM OF WAIVER.—No waiver under this sec-
tion may extend over a period of longer than 5 years un-
less the State requests continuation of such waiver, and 
such request shall be deemed granted unless the Secretary, 
within 90 days after the date of its submission to the Sec-
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retary, either denies such request in writing or informs 
the State in writing with respect to any additional infor-
mation which is needed in order to make a final deter-
mination with respect to the request. 
‘‘(f) ASSURING COORDINATION.— 
‘‘(1) IN GENERAL.—Not later than 180 days 
after the enactment of the State-Based Universal 
Health Care Act of 2015, the Secretary of Health 
and Human Services, the Secretary of the Treasury, 
the Director of the Office of Personnel Management, 
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— 
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