I 
118TH CONGRESS 
1ST SESSION H. R. 6270 
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 
NOVEMBER 7, 2023 
Mr. KHANNA (for himself, Ms. BALINT, Mr. BLUMENAUER, Ms. BONAMICI, 
Mr. BOWMAN, Ms. BUSH, Mr. GARCI´A of Illinois, Mr. GRIJALVA, Ms. 
HOYLE of Oregon, Mr. HUFFMAN, Ms. JAYAPAL, Ms. LEE of California, 
Mr. NEGUSE, Ms. NORTON, Ms. OMAR, Mr. PHILLIPS, Mr. POCAN, Ms. 
PRESSLEY, Ms. SALINAS, Ms. SCHAKOWSKY, Mr. SCHIFF, Mr. SMITH of 
Washington, Mr. THANEDAR, Mrs. WATSON COLEMAN, Ms. TLAIB, Mrs. 
RAMIREZ, and Mr. MCGOVERN) introduced the following bill; which was 
referred to the Committee on Energy and Commerce, and in addition to 
the Committees on Ways and Means, Armed Services, Oversight and Ac-
countability, and Education and the Workforce, for a period to be subse-
quently 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, 
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SECTION 1. SHORT TITLE; PURPOSE. 
(a) SHORT TITLE.—This Act may be cited as the 
‘‘State-Based Universal Health Care Act of 2023’’. 
(b) PURPOSE.—The purpose of this Act is to estab-
lish 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.—Subtitle D of title I of the Patient 
Protection and Affordable Care Act (42 U.S.C. 18021 et 
seq.) is amended by inserting after section 1334 the fol-
lowing new section: 
‘‘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 sub-
section (i)(3)) for the waiver of so much of the re-
quirements described in paragraph (2) with respect 
to health benefits coverage within the State for plan 
years beginning on or after January 1, 2024, as is 
necessary to implement a comprehensive State uni-
versal health care plan in the State under this sec-
tion. Such application 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, or other State legal 
authority as applicable, and program to 
implement a plan meeting the require-
ments 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 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, 2024, are as follows: 
‘‘(A) Sections 1301 through 1324. 
‘‘(B) Section 1402. 
‘‘(C) Sections 36B and 4980H of the In-
ternal Revenue Code of 1986. 
‘‘(D) Title XI of the Social Security Act. 
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‘‘(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 Retire-
ment Income Security Act of 1974. 
‘‘(3) PASSTHROUGH
OF
FUNDING.—With re-
spect 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 Fed-
eral 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 pro-
gram, 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 
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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 sav-
ings, shall be available to the State for reinvestment 
in health care services under the State plan. Such 
amount shall be determined annually by the Sec-
retary, taking into account the amount that would 
otherwise have been spent under each such Federal 
health program, including for administrative activi-
ties 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. 
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‘‘(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 the enactment of the 
State-Based Universal Health Care Act of 
2023, the Secretary shall promulgate regula-
tions 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 
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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 chap-
ter 5 of title 5, United States Code (com-
monly 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 evalua-
tion by the Secretary with respect to waiv-
ers granted under this section; and 
‘‘(vi) a process for providing technical 
assistance on— 
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‘‘(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 
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 under this section and pro-
grams conducted pursuant to such waivers that 
are approved. 
‘‘(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. 
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‘‘(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 ef-
fect, 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 sub-
paragraph (B), health benefits coverage to ap-
plicable State residents that is at least as com-
prehensive 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 eligi-
ble, absent such waiver; 
‘‘(B) will provide, in the case of such a 
waiver under subsection (a)(1) for the State to 
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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 ac-
tivities to raise awareness of the availability of 
such coverage and the facilitation of enrollment 
in such coverage, and to raise awareness re-
garding 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 edu-
cation 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)); 
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‘‘(F) will be publicly administered by an 
agency or multiple agencies of the State, or an 
independent public entity within the govern-
ment of the State; 
‘‘(G) will not preclude the purchase of in-
surance that offers coverage for benefits that 
are not offered under the State plan; 
‘‘(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 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 ap-
plication of such waiver under subsection 
(a)(1); and 
‘‘(I) will provide coverage for reproductive 
health care services, including abortion, contra-
ception, 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.— 
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‘‘(A) IN
GENERAL.—A law described in 
this paragraph is a State law (including an ex-
ecutive order by a State governor) that provides 
for State actions under a waiver under this sec-
tion, 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 section and after taking into ac-
count recommendations of the Panel under sub-
section (g) for such application, make a determina-
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tion 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 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: 
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‘‘(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 resi-
dents 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 
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(a)(4)(B)(vii) to improve the health insur-
ance program of the State implemented 
through the waiver under this section; 
‘‘(ii) the State shall have a grace pe-
riod 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 cov-
erage, the waiver under this section may be 
terminated at the discretion of the Sec-
retary; 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 sub-
mit 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 2023, the Secretary of 
Health and Human Services, the Secretary of the 
Treasury, the Secretary of Defense, the Secretary of 
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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 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 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 listed 
in paragraph (1) (including the Director of the Of-
fice of Personnel Management), shall submit to Con-
gress such recommendations for such technical and 
conforming amendments to law as may be appro-
priate 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 11 members appointed by 
the Secretary of Health and Human Services, 
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 on the rec-
ommendation of the Republican Governors 
Association; 
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‘‘(vi) one shall be appointed on the 
recommendation of the Democratic Gov-
ernors Association; 
‘‘(vii) one shall be a representative 
from the patient advocacy community; 
‘‘(viii) two shall be representatives of 
a labor organization representing health 
care professionals who provide direct pa-
tient care, including at least one labor or-
ganization that primarily represents reg-
istered nurses; 
‘‘(ix) one shall be a representative of 
primary care physicians; and 
‘‘(x) one 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 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 
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‘‘(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 
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 Pro-
gram under title XXI of the Social Security 
Act. 
‘‘(D) The Federal Employees Health Bene-
fits Plan under chapter 89 of title 5, United 
States Code. 
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‘‘(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.’’. 
Æ 
VerDate Sep 11 2014 
02:36 Nov 15, 2023
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