H.R. 4406 — State-Based Universal Health Care Act of 2025

This section designates the Act as the “State-Based Universal Health Care Act of 2025” and states its purpose as establishing a flexible framework under which states can provide comprehensive universal health coverage to their residents.

This section establishes a new waiver authority (new section 1335 of the Patient Protection and Affordable Care Act) under which a state may apply to the Secretary of Health and Human Services to waive, for plan years beginning on or after January 1, 2026, requirements related to health benefits coverage—including ACA Exchanges and related provisions (sections 1301-1324), premium tax credits and employer mandate (IRC sections 36B and 4980H), Medicare (SSA title XVIII), Medicaid and CHIP (SSA titles XIX and XXI), Federal Employees Health Benefits (5 USC ch. 89), TRICARE (10 USC ch. 55), and ERISA (ERISA section 514)—as necessary to implement a comprehensive state universal health care plan. The application must include a description of state legislation or authority, a plan to achieve health coverage for at least 95% of state residents within five years, a 10-fiscal-year budget plan that is budget neutral for the federal government, and an assurance of legal authority. (Thus, for waived federal programs the state assumes, the Secretary must pass through to the state an amount equal to projected federal spending—including premium tax credits, cost-sharing reductions, small-business credits, caseload growth, and inflation-adjusted health care costs—with any savings available to the state for reinvestment.) The Secretary must issue implementing regulations within 180 days of enactment, including processes for public notice and comment (modeled on Medicaid section 1115 waivers), application transparency, periodic state reporting and evaluation, and technical assistance to states.