HR4406-119

What This Bill Does

The State-Based Universal Health Care Act creates a new ACA section 1335 waiver pathway for state universal health care. Beginning with plan years on or after January 1, 2026, a state may apply to waive enough federal health-coverage requirements to implement a comprehensive state universal health care plan. The waiver can reach ACA market rules and subsidies, tax provisions, Social Security Act titles XI, XVIII, XIX, and XXI, FEHB, TRICARE, and ERISA preemption. A state application must describe the state legal authority and program, show how the state will reach at least 95 percent resident coverage within five years, provide a 10-fiscal-year federal budget-neutral plan, and assure state authority to implement the plan. Federal agencies must coordinate through an interagency memorandum of understanding within 180 days, allow a single state application, avoid duplicative waiver work, and issue consistent regulations and interpretations. States missing the 95 percent coverage threshold get technical assistance and a 12-month grace period before possible waiver termination, and states reaching 95 percent must plan for covering remaining residents. The bill also creates an 11-member Independent Assessment Panel for Comprehensive Health Care to review waiver applications and continuation reports within 90 days and report annually to Congress.

Who Benefits and How

States seeking universal health care benefit from a single federal waiver pathway that can consolidate ACA, Medicare, Medicaid, CHIP, FEHB, TRICARE, and ERISA rules. State residents without stable coverage benefit if an approved plan reaches at least 95 percent resident coverage within five years. Patient advocates benefit from representation on the Independent Assessment Panel reviewing state waiver applications. State health agencies benefit from technical assistance and a single coordinated application process across federal programs.

Who Bears the Burden and How

HHS, Treasury, Defense, Labor, and OPM must coordinate waiver processes, regulations, interpretations, and single-application procedures. States must enact or identify legal authority, prove federal budget neutrality over 10 fiscal years, and maintain 95 percent coverage progress. The Independent Assessment Panel must review applications and reports within 90 days and report annually to Congress. Federal program administrators must redirect or coordinate funding from existing health programs into approved state universal plans.

Key Provisions

• Creates a state universal health care waiver for plan years beginning on or after January 1, 2026.
• Allows waiver of ACA, Medicare, Medicaid, CHIP, FEHB, TRICARE, ERISA, and related federal health financing requirements.
• Requires applications to show state legal authority, 95 percent resident coverage within five years, and 10-fiscal-year federal budget neutrality.
• Requires a 180-day interagency MOU, single state waiver application, coordinated federal policy, technical assistance, and possible termination after a 12-month grace period.
• Establishes an 11-member Independent Assessment Panel for Comprehensive Health Care with 90-day review and annual congressional reporting duties.