119-hr4406

[Congressional Bills 119th Congress]
[From the U.S. Government Publishing Office]
[H.R. 4406 Introduced in House

    (IH) ]

<DOC>

119th CONGRESS
 1st Session
 H. R. 4406

 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

 July 15, 2025

 Mr. Khanna (for himself, Mrs. Cherfilus-McCormick, Mr. Cohen, Mr. 
 McGovern, Ms. Norton, Mr. Neguse, Ms. Omar, Ms. Pingree, Ms. Salinas, 
 Mr. Smith of Washington, Mr. Thanedar, Mr. Huffman, Ms. Tlaib, Mrs. 
 Watson Coleman, Ms. Jayapal, Ms. Lee of Pennsylvania, Mr. Thompson of 
 Mississippi, Ms. Ansari, Ms. Bonamici, Mr. Nadler, Mrs. Ramirez, Ms. 
 Dexter, and Ms. Velazquez) introduced the following bill; which was 
 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

_______________________________________________________________________

 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 2025''.

    (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.--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 following 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 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, 2026, 
 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, 2026, 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 2025, 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 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 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) 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

    (a)

    (4)
        (B)
            (vii) to improve the health insurance 
 program of the State implemented through the 
 waiver under this section;
 ``
            (ii) the State shall have a grace period 
 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 coverage, the 
 waiver under this section may be terminated at 
 the discretion of the Secretary; 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 submit 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 2025, the Secretary of Health and Human Services, the 
 Secretary of the Treasury, the Secretary of Defense, the 
 Secretary of 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 services; 
 and
 ``
        (B) ensure that--
 ``
            (i) regulations (including regulations 
 required under subsection

    (a)

    (4)
        (B) ), rulings, 
 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 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 listed in paragraph

    (1) (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) Independent Assessment Panel for Comprehensive Health Care.--
 ``

    (1) Establishment.--There is established a committee to 
 be known as the `Independent Assessment Panel for Comprehensive 
 Health Care' (in this section referred to as the `Panel').
 ``

    (2) Consideration of submissions.--The Secretary shall 
 forward a copy of each waiver application 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 subsection

    (e) for purposes of 
 the review under paragraph

    (2) of such subsection;
 ``
        (B) not later than 90 days after submission 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 application (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 number of applications (and reports) 
 received and the number of applications recommended for 
 approval (and of reports with respect to which 
 recommendations for continuation were provided).
 ``

    (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 
 recommendation 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 
 recommendation of the Republican Governors 
 Association;
 ``
            (vi) one shall be appointed on the 
 recommendation of the Democratic Governors 
 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 patient care, 
 including at least one labor organization that 
 primarily represents registered 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 appointed to 
 fill a vacancy occurring before the expiration 
 of the term for which the member's predecessor 
 was appointed shall be appointed only for the 
 remainder of that term. A vacancy in the 
 Commission shall be filled in the manner in 
 which the original appointment was made.
 ``
            (C) Pay.--Members of the Panel shall serve 
 without pay.
 ``
            (D) Chairperson; vice chairperson.--
 ``
            (i) Chairperson.--The Secretary of Health 
 and Human Services, or a designee of the 
 Secretary, shall serve on the Panel as the 
 Chairperson of the Panel.
 ``
            (ii) Vice chairperson.--The Administrator 
 of the Federal Emergency Management Agency, or 
 a designee of the Administrator, shall serve on 
 the Panel as the Vice Chairperson of the Panel.
 ``

    (5) Staff, experts, and consultants.--The Panel may--
 ``
        (A) appoint such staff as the Panel considers to 
 be appropriate, without regard to the provisions of 
 title 5, United States Code, governing appointments in 
 the competitive service;
 ``
        (B) fix the pay of such staff, without regard to 
 the provisions of chapter 51 and subchapter III of 
 chapter 53 of such title relating to classification and 
 General Schedule pay rates; and
 ``
            (C) procure the services of experts and 
 consultants in accordance with the provisions of 
 

section 3109

    (b) of such title.
 ``

    (6) Detail of federal personnel.--Upon request of the 
 Panel, the head of any Federal agency may detail, on a 
 reimbursable basis, any of the personnel of the agency to the 
 Panel to assist it in carrying out the duties under paragraph

    (3) .
 ``

    (7) Federal advisory committee act.--The Federal Advisory 
 Committee Act (5 U.S.C. App.) shall apply to the Panel.
 ``

    (8) Authorization of appropriations.--There is authorized 
 to be appropriated such sums as may be necessary to the Panel 
 for carrying out the duties of the panel for each of fiscal 
 years 2026 through 2031.
 ``

    (h) Guidance Relating to American Indians and Alaska Natives.--
 ``

    (1) In general.--The Secretary shall issue guidance with 
 respect to applying the provisions of this section in a manner 
 consistent with the following:
 ``
        (A) To further the goal that Federal health 
 services to maintain and improve the health of Indians 
 are consonant with and required by the Federal 
 Government's historical and unique legal relationship 
 with, and resulting responsibility to, Indians.
 ``
        (B) No enrollment fee, premium, or similar 
 charge, and no deduction, copayment, cost sharing, or 
 similar charge, is to be imposed against an Indian who 
 is furnished an item or service through a waiver under 
 this section. All costs incurred in waiving such 
 charges shall be borne by the Federal Government in 
 fulfillment of the trust responsibility.
 ``
            (C) A State may not require the enrollment of an 
 individual who is an Indian in health insurance offered 
 through a waiver under this section.
 ``
            (D) Health insurance issuers offering coverage 
 pursuant to a waiver under this section must make good 
 faith efforts to contract with Indian health care 
 providers operating within the area served by the 
 issuers.
 ``
        (E) Health insurance issuers offering coverage 
 pursuant to a waiver under this section shall pay 
 Indian health care providers, whether such providers 
 are participating or nonparticipating providers with 
 respect to the coverage, for covered services provided 
 to those Indian enrollees who are eligible to receive 
 services from such providers at a rate equal to the 
 rate negotiated between such entity and the provider 
 involved or, if such a rate has not been negotiated, at 
 a rate that is not less than the level and amount of 
 payment which the entity would make for the services if 
 the services were furnished by a participating provider 
 which is not an Indian health care provider.
 ``
        (F) Health insurance issuers offering coverage 
 pursuant to a waiver under this section will include a 
 standard contract addendum when contracting with Indian 
 health care providers. The contract addendum will be 
 developed in consultation with Tribes and in conference 
 with urban Indian health programs operating within the 
 service area of the State.
 ``
        (G) The treatment of Indians under this section 
 does not constitute invidious racial discrimination in 
 violation of the due process clause of the Fifth or 
 Fourteenth Amendments, but is reasonable and rationally 
 designed to further the health of Indians.
 ``
        (H) In the case of any State in which 1 or more 
 Indian health care programs furnishes health care 
 services, the State will provide for a process under 
 which the State seeks advice on a regular, ongoing 
 basis from designees of such Indian health care 
 programs and urban Indian organizations on matters 
 relating to the application of a waiver under this 
 section that are likely to have a direct effect on such 
 Indian health programs and that--
 ``
            (i) shall include solicitation of advice 
 prior to submission of any plan amendments, 
 waiver requests, and proposals for 
 demonstration projects likely to have a direct 
 effect on Indians or Indian health care 
 programs; and
 ``
            (ii) may include appointment of an 
 advisory committee and of a designee of such 
 Indian health care programs to the medical care 
 advisory committee advising the State on its 
 waiver under this section.
 ``

    (2) === Definitions. ===
-For purposes of this subsection:
 ``
        (A) The term `Indian' has the meaning given such 
 term in 

section 447.50 of title 42, Code of Federal 
 Regulations (as in effect on July 1, 2010).
 ``
        (B) The term `Indian health care provider' has 
 the meaning given such term in 

section 438.14

    (a) of 
 title 42, Code of Federal Regulations.
 ``
            (i) === 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-

    (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-

    (a) ); and
 ``
        (B) includes any medical coverage or health 
 benefits provided under one or more of the specified 
 Federal health program described in subparagraphs
        (A) through
        (E) of paragraph

    (4) , as applicable to a waiver 
 under subsection

    (a)

    (1) .
 ``

    (2) Resident.--With respect to a State, the term 
 `resident' means an individual--
 ``
        (A) who is--
 ``
            (i) a citizen or national of the United 
 States; or
 ``
            (ii) an alien lawfully residing in the 
 State (including an alien who is granted 
 deferred action or who is otherwise authorized 
 to remain in the United States); and
 ``
        (B) 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 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 Program under 
 title XXI of the Social Security Act.
 ``
            (D) The Federal Employees Health Benefits Plan 
 under chapter 89 of title 5, 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 
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.''.
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