State-Based Universal Health Care Act of 2025

Bill Number

H.R. 4406

Origin Chamber

House

Congress

119th Congress, Session 1

Policy Area

Health

Status

Introduced

Latest Action

2025-07-15: Referred to the Committee on Energy and Commerce, and in addition to the Committees on Armed Services, Ways and Means, Oversight and Government Reform, and Education and 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.

Last Updated

2026-07-03T08:06:22Z

AI-Generated Summary

Purpose of the Legislation

The State-Based Universal Health Care Act of 2025 aims to create a flexible framework allowing states to design and implement their own universal health care systems. It amends the Patient Protection and Affordable Care Act (ACA) to let states provide comprehensive health benefits to all residents, while ensuring federal funding support and maintaining key protections.

Key Provisions

• Waiver Application Process: States can apply to the Secretary of Health and Human Services (and other relevant federal officials) for waivers starting January 1, 2026, to bypass requirements of major federal health programs. Applications must include state legislation or authority, a 5-year plan to cover at least 95% of residents, and a 10-year budget that is neutral for the federal government (meaning no net increase in federal spending).
• Federal Funding Passthrough: For approved waivers, the federal government redirects funds from programs like Medicare, Medicaid, CHIP (Children's Health Insurance Program), ACA subsidies, and others to the state. This includes adjustments for inflation, population growth, and any savings, which states can reinvest in their programs.
• Waiver Approval Criteria: Waivers are granted if the state plan:
• Provides coverage at least as comprehensive and affordable as federal programs, including mandatory Medicaid benefits like screenings, non-emergency transport, and retroactive coverage.
• Covers all state residents (defined as U.S. citizens, nationals, or lawfully residing aliens with primary residence in the state), excluding those eligible only for Indian Health Service or Veterans Affairs benefits.
• Includes public education on enrollment, restrictions on duplicative private insurance, and systems for complaints, appeals, and reviews.
• Ensures coverage for reproductive health services, including abortion, contraception, and gender-affirming care.
• Is administered publicly by state agencies or entities, though private contractors can be used.
• Transparency and Oversight: The Secretary must issue regulations within 180 days for public notice, comment, and reporting. States submit 5-year independent reports on coverage, affordability, quality, and access. Waivers can be terminated if 95% coverage isn't met after a grace period, with technical assistance available.
• Independent Assessment Panel: A new 11-member panel (appointed by the Secretary with input from congressional leaders, governors' associations, and health stakeholders) reviews applications and reports, providing recommendations within 90 days. It includes representatives from patients, labor (e.g., nurses), primary care, and rural providers.
• Interagency Coordination: Federal agencies (HHS, Treasury, Defense, Labor, OPM) must create a unified process for waivers, including a single application option, to avoid duplication.
• Special Protections for American Indians and Alaska Natives: Guidance ensures no fees or cost-sharing for Indians; states must consult tribal programs; insurers must contract fairly with Indian health providers at negotiated rates.
• Regional Options and Limitations: Multiple states can apply jointly; waivers cannot overlap with existing ACA section 1332 waivers; states can repeal their enabling laws to end participation.
• Funding Authorization: Appropriations for technical assistance, panel operations (2026–2031), and related activities.

Significant Changes to Existing Law

• New Waiver Authority: Adds section 1335 to the ACA, expanding beyond current section 1332 waivers (which focus on insurance markets) to allow waivers of broad federal programs like Medicare, Medicaid, CHIP, TRICARE (military health), federal employee benefits, and ERISA (Employee Retirement Income Security Act) rules on employer plans. This is a major shift, enabling states to fully replace these with a single universal system.
• Budget Neutrality Requirement: Introduces a strict federal budget-neutrality standard for state plans, unlike some prior waivers that allowed flexibility in federal costs.
• Coverage Mandates: Requires near-universal coverage (95% goal) and specific benefits (e.g., reproductive care), which goes further than the ACA's individual mandate (repealed in 2017) by tying it to state-level implementation.
• Panel and Review Mechanisms: Establishes a new independent panel and mandatory 5-year reviews, adding oversight not present in prior waiver processes.

Potential Impacts

• On Citizens: Participating states could achieve broader health coverage for residents, reducing uninsured rates and out-of-pocket costs, with improved access to comprehensive benefits. However, non-participating states' residents remain under existing federal programs, potentially creating coverage disparities across state lines.
• On Government Agencies: Federal agencies like HHS shift administrative burdens to states, with passthrough funding simplifying federal spending but requiring new coordination (e.g., via interagency memos). States gain flexibility but must handle public administration, reporting, and 95% coverage goals, possibly increasing state budgets or taxes.
• On International Relations: No direct impacts, as the bill focuses on domestic health policy.
• Broader Effects: Could lead to innovation in state health systems, cost savings from efficiencies, or challenges if states struggle with implementation, affecting national health spending trends.

Main Stakeholders Affected

• State Governments and Residents: Primary beneficiaries/enactors; states design and fund systems, while residents gain potential universal access.
• Federal Agencies: HHS, Treasury, Defense, Labor, and OPM handle approvals, funding, and coordination; the new panel involves diverse appointees.
• Health Care Providers and Insurers: Providers (e.g., primary care, rural, Indian health) must adapt to state plans; private insurers face limits on duplicative coverage but can offer supplemental or non-covered benefits.
• Vulnerable Groups: American Indians/Alaska Natives receive tailored protections; low-income, children, military families, and federal employees see integrated coverage under state systems.
• Labor and Advocacy Groups: Nurses, physicians, and patient advocates influence via the panel; businesses may see changes in employer mandates.

Notable Legal, Constitutional, or Political Implications

• Legal Implications: Broadens waiver powers under the ACA, potentially inviting lawsuits over waiver scope (e.g., if seen as exceeding congressional intent for programs like Medicare). Requires states to enact enabling laws, providing a clear legal pathway but allowing easy repeal.
• Constitutional Implications: Relies on federalism principles, empowering states under the Spending Clause (Congress's power to attach conditions to funds). Ensures no discrimination against Indians, affirming federal trust responsibilities; could raise interstate commerce questions if state plans affect cross-border care.
• Political Implications: Promotes state experimentation with universal health care, appealing to progressive goals without a national mandate. Bipartisan panel appointments and public input processes aim for balance, but approval depends on the administration, potentially polarizing debates on federal vs. state roles in health policy. Annual congressional reports enhance oversight.

This summary was generated by AI and may contain inaccuracies. Refer to the official source document for the authoritative text.

Sponsor

Rep. Khanna, Ro [D-CA-17]

Cosponsors (35)

Rep. Cherfilus-McCormick, Sheila [D-FL-20], Rep. Cohen, Steve [D-TN-9], Rep. McGovern, James P. [D-MA-2], Del. Norton, Eleanor Holmes [D-DC-At Large], Rep. Neguse, Joe [D-CO-2], Rep. Omar, Ilhan [D-MN-5], Rep. Pingree, Chellie [D-ME-1], Rep. Salinas, Andrea [D-OR-6], Rep. Smith, Adam [D-WA-9], Rep. Thanedar, Shri [D-MI-13], Rep. Huffman, Jared [D-CA-2], Rep. Tlaib, Rashida [D-MI-12], Rep. Watson Coleman, Bonnie [D-NJ-12], Rep. Jayapal, Pramila [D-WA-7], Rep. Lee, Summer L. [D-PA-12], Rep. Thompson, Bennie G. [D-MS-2], Rep. Ansari, Yassamin [D-AZ-3], Rep. Bonamici, Suzanne [D-OR-1], Rep. Nadler, Jerrold [D-NY-12], Rep. Ramirez, Delia C. [D-IL-3], Rep. Dexter, Maxine [D-OR-3], Rep. Velázquez, Nydia M. [D-NY-7], Rep. Schakowsky, Janice D. [D-IL-9], Rep. Frost, Maxwell [D-FL-10], Rep. Pocan, Mark [D-WI-2], Rep. Stansbury, Melanie A. [D-NM-1], Rep. Hoyle, Val T. [D-OR-4], Rep. Clarke, Yvette D. [D-NY-9], Rep. Pressley, Ayanna [D-MA-7], Rep. Olszewski, Johnny [D-MD-2], Rep. Bynum, Janelle S. [D-OR-5], Rep. Deluzio, Christopher R. [D-PA-17], Rep. Mfume, Kweisi [D-MD-7], Rep. Randall, Emily [D-WA-6], Rep. Balint, Becca [D-VT-At Large]

Recent Actions

• 2025-07-15: Referred to the Committee on Energy and Commerce, and in addition to the Committees on Armed Services, Ways and Means, Oversight and Government Reform, and Education and 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.
• 2025-07-15: Referred to the Committee on Energy and Commerce, and in addition to the Committees on Armed Services, Ways and Means, Oversight and Government Reform, and Education and 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.
• 2025-07-15: Referred to the Committee on Energy and Commerce, and in addition to the Committees on Armed Services, Ways and Means, Oversight and Government Reform, and Education and 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.
• 2025-07-15: Referred to the Committee on Energy and Commerce, and in addition to the Committees on Armed Services, Ways and Means, Oversight and Government Reform, and Education and 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.
• 2025-07-15: Referred to the Committee on Energy and Commerce, and in addition to the Committees on Armed Services, Ways and Means, Oversight and Government Reform, and Education and 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.
• 2025-07-15: Introduced in House
• 2025-07-15: Introduced in House

Bill Versions

• State-Based Universal Health Care Act of 2025 — issued 2025-07-15 — PDF (30 pages)

Related Bills

• S. 2286 (119th Congress)