qotd: Rep. McDermott introduces H.R.3241: State-Based Universal Health Care Act

U.S. House of Representatives
July 28, 2015
Rep. Jim McDermott
Statement Introducing the State-Based Universal Health Care Act of 2015

Mr. Speaker, I rise today to introduce legislation that will give states
the tools they need to guarantee the health security of their citizens.
The State-Based Universal Health Care Act of 2015 establishes a new
procedure through which states may apply for a waiver of federal law in
order to design and implement single-payer health care systems. This
will allow states to achieve universal coverage and control costs by
removing greed and inefficiency from the system.

One of the many achievements of the Affordable Care Act is its
provisions that grant states the authority to innovate in their health
care systems. Under Section 1332 of the law, a state may apply for a
State Innovation Waiver that will provide it with control of federal
dollars that otherwise would have been spent on premium tax credits and
cost-sharing reductions for its residents. Through this waiver, a state
may design a system to cover its residents, so long as benefits are at
least as comprehensive and affordable as those offered by Qualified
Health Plans available on the Exchanges.

However, even with this flexibility, numerous barriers limit states'
ability to design true single-payer systems. Existing waivers are narrow
in scope, requiring states to seek out imperfect and convoluted
solutions to circumvent federal limitations. A sweeping preemption
provision in the Employee Retirement Income Security Act (ERISA) denies
states authority to regulate employer-sponsored health plans. And, due
to the complexities of our existing federal health programs, it is
essentially impossible for a state to design a single benefit package
that can be administered simply and efficiently on behalf of all of its
residents.

The State-Based Universal Health Care Act removes these barriers. It
builds upon the ACA's State Innovation Waiver by offering states new
tools that will allow them to truly innovate in health care. Under this
legislation, a state may apply for a Universal Health Care Waiver that
will grant it authority over federal health care dollars that otherwise
would have been spent on the state's residents. To the extent necessary
to design a universal system, a state may waive provisions of federal
law relating to the following:

* The rules governing premium tax credits and cost-sharing reductions,
as provided for in existing waiver authority under Section 1332 of the ACA.

* Provisions necessary for states to pool funds that otherwise would be
spent on behalf of residents enrolled in Medicare, Medicaid, CHIP,
TRICARE, and the Federal Employee Health Benefits Program.

* ERISA's preemption clause, which currently forbids states from
enacting legislation relating to employee health benefit programs.

Any state seeking a Universal Health Care Waiver must design a system
that covers substantially all of its residents. The benefits that each
citizen receives must be at least as comprehensive and no less
affordable than what would have been provided under any federal health
programs for which its residents otherwise would have been eligible.
Once enacted, the state plan must be publicly administered, and it may
not add to the federal deficit.

The Affordable Care Act was a landmark achievement and a strong first
step toward achieving health security in this country. However, we still
have a tremendous amount of work left to do. The United States spends by
far the most per capita on health care, yet we fail to achieve superior
outcomes or even guarantee coverage as a basic human right. Insurance
companies are a powerful force in our economy, enjoying billions in
profits and growing power in the marketplace. Meanwhile, hospitals are
consolidating at an astonishing rate, raising new questions about the
quality of patient care and the future of medicine. What's more, we have
failed to make meaningful efforts to combat the skyrocketing costs of
prescription drugs, threatening patient access to treatments and the
financial sustainability of the entire system.

As we explore ways to build upon the successes of the ACA, it is
critical that we look for creative solutions to the challenges that
still exist. Granting states tools to design single-payer systems will
help spur necessary innovation, achieve universal coverage, and control
costs. It is time to take this next step as we continue to move forward
in our historic effort to guarantee the health security of every American.

H.R.3241: State-Based Universal Health Care Act of 2015
https://www.congress.gov/bill/114th-congress/house-bill/3241

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Comment by Don McCanne

State efforts to establish single payer systems have had difficulties
because the existing waiver processes for use of federal funds have been
quite limited in their scope, and ERISA restrains state regulation of
employer-sponsored health plans. The workarounds have been difficult and
are a major reason that several states with promising proposals have
backed off on their efforts.

Rep. Jim McDermott has now introduced H.R.3241, the State-Based
Universal Health Care Act of 2015, which would allow states to include
in a universal health insurance risk pool all funds that are currently
used for federal health programs, including Medicare, Medicaid, CHIP,
TRICARE, FEHBP, and the subsidies for plans in the ACA exchanges, plus,
by eliminating ERISA restrictions, states could establish a more
equitable method of financing in replacing funds currently paid into
employer-sponsored plans. Those crafting state single payer legislation
would have a field day if H.R.3241 were to become law, though they would
face many other technical issues which will not be addressed here.

What could be wrong with this proposal? Conservatives are dreaming of
the day that they can receive Medicaid funds as block grants to the
states. It does not take much imagination to think what they would do
with those block grants, especially when you look at their current
behavior. The Medicaid waivers they are requesting both privatize the
program and shift more costs to the patients, and some governors are
even refusing federal funds, calling instead for block grants over which
they would have much greater control. Under H.R.3241, essentially all
federal health program funds would granted to the states in what would
be, in essence, block grants. Although the Act calls for universality,
comprehensiveness, affordability, and public administration, clearly the
conservatives would game the system, much to the detriment of patients.

We really do need a national single-payer health program, and that is
why we cannot allow ourselves to be diverted from supporting legislation
such as H.R.676, the Expanded & Improved Medicare for All Act,
introduced by Rep. John Conyers, now with 63 cosponsors. Whatever else
we do, our advocacy for a national program must be steadfast.

As we work on trying to change the politics on the national scene, it
certainly would be reasonable for state reform advocates to continue
their efforts. Some in the trenches hope that conservatives would be
attracted to shifting more control to the states through legislation
such as this. But keep in mind the risk of this as we watch the
suffering of low-income individuals and families in those states that
already refuse to collaborate with Medicaid, in spite of the gift of
federal funds.

Another risk is that if H.R.3241 gains traction, single payer supporters
may abandon national efforts, just as they abandoned single payer
support when the "public option" was under consideration. Abandoning a
national effort in deference to your own state increases the risk that
our brothers and sisters in other states would be left out.

Everybody in, nobody out.