[Congressional Bills 118th Congress]
[From the U.S. Government Publishing Office]
[S. 4817 Introduced in Senate (IS)]
<DOC>
118th CONGRESS
2d Session
S. 4817
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 SENATE OF THE UNITED STATES
July 25, 2024
Mr. Markey (for himself, Ms. Warren, and Mr. Merkley) introduced the
following bill; which was read twice and referred to the Committee on
Finance
_______________________________________________________________________
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.
Be it enacted by the Senate and House of Representatives 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 2024''.
(b) Purpose.--The purpose of this Act is to establish 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.--Part 4 of subtitle D of title I of the Patient
Protection and Affordable Care Act (42 U.S.C. 18021 et seq.) is amended
by adding at the end the following:
``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 subsection (i)(3)) for
the waiver of so much of the requirements described in
paragraph (2) with respect to health benefits coverage within
the State for plan years beginning on or after January 1, 2025,
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, or other State legal
authority as applicable, and program to
implement 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 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 described in this
paragraph with respect to health benefits coverage within the
State for plan years beginning on or after January 1, 2025, are
as follows:
``(A) Sections 1301 through 1324.
``(B) Section 1402.
``(C) Sections 36B and 4980H 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, 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) Passthrough of funding.--With respect 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
Federal 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 program, 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 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 savings, shall
be available to the State for reinvestment in health care
services under the State plan. Such amount shall be determined
annually by the Secretary, taking into account the amount that
would otherwise have been spent under each such Federal health
program, including for administrative activities 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.
``(4) Waiver consideration and transparency.--
``(A) In general.--An application for a waiver
under this section shall be considered by the
Secretary, after taking into account recommendations of
the Panel under subsection (g), in accordance with the
regulations described 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 2024, the 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 notice
and comment requirements applicable under
regulations used for Medicaid waivers 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 requirements that are in
addition to, or duplicative of, requirements
imposed under chapter 5 of title 5, United
States Code (commonly 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 evaluation
by the Secretary with respect to waivers
granted under this section; and
``(vi) a process for providing technical
assistance on--
``(I) how to develop an application
to any State seeking to submit an
application for a waiver relating to
developing a program of providing
health care for all residents for such
State; and
``(II) how to improve such a
program for purposes of a State seeking
assistance pursuant to subsection
(e)(2).
``(C) Report.--The Secretary shall annually report
to Congress concerning actions taken by the Secretary
with respect to applications for waivers under this
section and programs conducted pursuant to such waivers
that are approved.
``(5) Regional waiver request and plan.--Nothing in this
section shall be construed to prevent 2 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 respect to each State included
in such application.
``(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 effect, 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 subparagraph
(B), health benefits coverage to applicable State
residents that is at least as comprehensive 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
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 subsection (a)(2)(F), as
applicable, health benefits coverage to applicable
State residents who would have otherwise received
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 provides for such assistance through
a State Medicaid plan under title XIX of the Social
Security Act or a waiver of such State Medicaid plan)
that includes at least the mandatory benefits under
title XIX of the Social Security Act that are required
of a State without a waiver of a State Medicaid plan
under such title, including 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 protections under the
specified Federal health program (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 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 activities
to raise awareness of the availability of such coverage
and the facilitation of enrollment in such coverage,
and to raise awareness regarding 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
education 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));
``(F) will be publicly administered by an agency or
multiple agencies of the State, or an independent
public entity within the government of the State;
``(G) will not preclude the purchase of insurance
that offers coverage for benefits that are not offered
under the State plan;
``(H) will provide systems for complaints, appeals,
independent review, and other procedures 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
application of such waiver under subsection (a)(1); and
``(I) will provide coverage for reproductive health
care services, including abortion, contraception, 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.--
``(A) In general.--A law described in this
paragraph is a State law (including an executive order
by a State governor) 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, with
respect to an application from a State under this section and
after taking into account recommendations of the Panel under
subsection (g) for such application, make a determination 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 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) 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,
sufficient to ensure a meaningful level of public input, on the
following:
``(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 residents of the State without
health insurance.
``(C) How affordability in the State for health
care has changed over the period.
``(D)