I 114th CONGRESS 1st Session H. R. 3241 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. Short title; purpose (a) Short title This Act may be cited as the State-Based Universal Health Care Act of 2015 . (b) Purpose The purpose of this Act is to establish a flexible framework under which each State can provide comprehensive universal health coverage to all of its residents. 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: 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 coverage within that State for plan years beginning on or after January 1, 2016, as is necessary to implement a comprehensive State universal health care plan in the State under this section. Such application shall— (A) be filed at such time and in such manner as the Secretary may require; (B) contain such information as the Secretary may require, including— (i) a comprehensive description of the State legislation and program to implement a plan meeting the requirements for a waiver under this section; and (ii) 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 the law described in subsection (b)(2). (2) Requirements The requirements described in this paragraph with respect to health benefits coverage within the State for plan years beginning on or after January 1, 2016, are as follows: (A) Parts I, II, and III of subtitle D. (B) Section 1402. (C) Sections 36B, 4980H, and 5000A of the Internal 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 Retirement Income Security Act of 1974. (3) Pass through of funding With respect 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 the State for purposes of implementing the State plan under the waiver. Such amount shall be determined annually by the Secretary, taking into account the amount that would otherwise have been spent under such Federal health program with respect 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 reductions, or small-business credits 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 if such waiver did not apply. (4) Waiver consideration and transparency (A) In general An application for a waiver under this section shall be considered by the Secretary in accordance with the regulations 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 public hearings, sufficient to ensure a meaningful 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 (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 requirements that are in addition to, or duplicative of, requirements imposed under 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; and (v) a process for the periodic evaluation by the Secretary with respect to waivers granted under this section. (C) Report The Secretary shall annually report to Congress concerning actions taken by the Secretary with respect to applications 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 comprehensive as the health benefits coverage that such residents would have received under the specified 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 protections under the specified Federal health program for which such residents would have been eligible, absent such waiver; (C) will provide coverage to substantially all residents of the State, including substantially all those otherwise covered under 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; (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 determine the scope of a waiver of a requirement described in subsection (a)(2) granted to a State under subsection (a)(1). (2) Limitation Under this section, the Secretary may not waive any Federal law or requirement that is not listed in subsection (a)(2). (d) Determinations by Secretary (1) Time for determination The Secretary 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 Secretary determines to grant a waiver under subsection (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 Secretary determines a waiver should not be granted 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 section may extend over a period of longer than 5 years unless 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 Secretary, either denies such request in writing or informs the State in writing with respect to any additional information which is needed in order to make a final determination 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 Secretaries 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 services; and (B) ensure that— (i) regulations (including regulations required under subsection (a)(4)(B)), rulings, 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 continuation of waivers through such Secretaries and Director in order to have a coordinated 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 provisions of this section and the provisions of law listed under clauses (i) and (ii) of such paragraph. (3) Submission of conforming amendments The Secretary of Health and Human Services, in coordination with the other Secretaries (including the Director of the Office of Personnel Management), shall submit to Congress such recommendations for such technical and conforming amendments to law as may be appropriate to assist in the implementation of this section. (g) Definitions In this section: (1) Health benefits coverage The term health benefits coverage — (A) means— (i) health insurance coverage, as such term is defined in section 2791(b) of the Public Health Service Act ( 42 U.S.C. 300gg–91(b) ); and (ii) coverage under a group health plan, as such term is defined in section 2791(a) of the Public Health Service Act ( 42 U.S.C. 300gg–91(a) ); and (B) includes any medical coverage or health benefits provided under any specified Federal health program described in subparagraphs (A) through (E) of paragraph (4). (2) Resident With respect to a State, the term resident means an individual who is a citizen or national of the United States or an alien lawfully residing in the State, and 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 subsection (a); (B) the Secretary of the Treasury with respect to waivers relating to the provisions described in subparagraph (C) of such paragraph; (C) the Director of the Office of Personnel Management with respect to waivers relating to the provisions described in subparagraph (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: (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 Program under title XXI of the Social Security Act. (D) The Federal Employees Health Benefits Plan under chapter 89 of title 5 of the United States Code. (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 such Act is amended by inserting after the item relating to section 1332 the following new item: Sec. 1332A. Waiver for State universal health care. .