Letter | FAQ | Summary

Get involved in the effort to make it easier for California to adopt a Medicare for All type guaranteed healthcare system. Urge your Member of Congress to sponsor the State-Based Universal Healthcare Act sponsored by Rep. Ro Khanna to be introduced in June!


April 2021

Dear Congressional Representative:

Healthy California Now is a coalition of unions, community organizations, advocates, retirees and faith-based groups, representing six million Californians. We are asking you to join Congressman Khanna in co-sponsoring the State-Based Universal Health Care Act (SBUHCA).

The COVID 19 pandemic has taught us many lessons. One that was clear prior to the pandemic, but has been amplified over and over, is that our current health care system is broken – fragmented, costly, unjust and unable to keep Americans healthy and safe. This crisis forcefully illustrates the failures of our employment-based health insurance system.

California has been a clear leader for our country in acting swiftly and wisely to address COVID 19 – we must do the same to fix our broken health care system and lead the way for our country to provide health care to all through a single payer system, and eliminate the insurance companies whose bottom line is a higher priority than saving lives and caring for our people. We have seen how other countries with a universal system have been able to provide care more quickly and more successfully, giving their residents the peace of mind that during this pandemic they know that their health care needs, whether virus related or not, will be provided for without fear of cost or bankruptcy. It is time that the U.S. learns from these successful, life-saving and cost saving systems. California, the 5th largest economy in the world, should lead our country to create a true health care for all system.

California can lead the way for our nation with Congressman Khanna’s SBUHCA. California has a long history of passing innovative policies, and is now looking to our Members of Congress, Governor Newsom, and state legislators to implement a guaranteed health care that is affordable for all. Our federalist system allows states to serve as policy laboratories and to pursue the best interests of their residents, and California is uniquely positioned to pursue a state-based single payer system.

Streamlining health care financing through a unified public system would guarantee every Californian with a single standard of quality care and contain the cost of health care. The Employee Retirement Income Security Act (ERISA) and the Affordable Care Act (ACA) currently complicate any efforts for state lawmakers to regulate private insurance and merge federal and employer funding streams.

Healthy California Now is on record of supporting Medicare for All, but we also believe that whatever federal health reforms come to pass, California and other states should be allowed to pursue all possible options to improve its health care system. We thank you for your leadership on health care and on so many other issues. We hope that you will join Congressman Khanna, and Healthy California Now in supporting this legislation.


Cindy Young
President, Healthy California Now


1. Why is this legislation needed?

The State-Based Universal Health Care Act responds to the calls for complete access and greater affordability of health care for all Americans coupled with a uniquely American tradition—namely, capitalizing on the role of states as incubators of policy from our founding. As such, states should have the opportunity to provide health care for all residents if the political will exists.

2. Previous iterations of this bill supplanted ACA Sec. 1332 State Innovation Waivers, but this is a new waiver. Why did you make this change?

Unlike Sec. 1115 waivers, which some states have used to implement harmful Medicaid work requirements, Sec. 1332 waivers have been used by states across the political spectrum to reduce health care costs for residents. In order to prevent perfect from being the enemy of good, this bill leaves 1332 waivers in place, while creating a new waiver option for bold states that wish to implement true universal health care programs.

3. Why did you select these funding streams to be the basis of the state-based universal health care program?

These are the streams of federal dollars that cover the greatest number of people and will be most important for states’ ability to properly fund the ambitious programs necessary to achieve universal health care coverage.

4. How will this bill affect the cost of health care for individuals, employers, states and the federal government?

This bill enables states to bring health care costs under control for the first time with several tools: (1) greatly expanding the risk pool; (2) eliminating much of the administrative and profit-oriented cost of private insurance plans, estimated to represent 15-30 percent of American dollars spent on health care; (3) allowing the creation of global health care budgets with negotiated reimbursement rates for all providers; and (4) reorienting health care towards prevention and primary care.

5. I am satisfied with my current healthcare coverage. Am I able to keep it?

Under this proposal, the coverage you receive for health care will be either equal to what you currently receive or more expansive. You will have free choice of providers. Everyone in the community you live in will have health care.

6. How much will this cost me?

Combining streams, negotiating discounts with providers and eliminating inefficiencies will help drive your out-of-pocket costs down. The savings are hugely significant. In the end, your costs will depend on how each state devises its own individual state-based universal health care program.

7. How does this affect small businesses?

With all residents covered under a state-based universal health care plan, small businesses can reinvest current health insurance costs into other aspects of their business, thus helping them to be more competitive.

8. How would this deal with ERISA plans (multi-state health plans that are regulated at the federal level)?

ERISA regulations are included in the waiver. So, a state could waive ERISA if their waiver was approved. This is another area we left a little bit more flexibility for the state in how they wanted to handle ERISA plans if they did pursue that waiver. Especially given how they vary from state to state. For what it’s worth, many of the most significant ERISA plans are union plans and the Labor Campaign for Single Payer has endorsed the bill, as has the National Union of Healthcare Workers.

9. How is this different from the 1332 waivers in the Affordable Care Act?

The 1332 waiver is far more complex for a state that would be establishing a single payer system. One of the reasons that Vermont’s efforts in establishing their single payer system failed is because they weren’t able to get the necessary funding support from the federal government through the 1332 waiver. In order for a state like Vermont or California to receive the newly created “1335 state universal health care waiver” they would only have to show that their system would reach coverage breadth and depth criteria. The concrete criteria and independent review panel in this bill make the new waiver far more insulated from manipulation by an unfriendly administration in the future.


Sec. 1 Short title and purpose

Bill can be referred to as the ‘State-Based Universal Health Care Act of 2021’ and describes the purpose of the bill as providing flexibility for states to offer comprehensive universal health care coverage to all residents in a given state.

Sec. 2. Waiver for State Universal Health Care

Creates a new State Universal Health Care Waiver in the Affordable Care Act (P.L. 111-148) with a provision that allows states to combine several federal health care funding streams if the state offers a comprehensive universal health care plan that guarantees all residents of their state are covered.

To be eligible for this waiver, states would have to provide a detailed description as to what the proposed state action would be for enacting a comprehensive universal health care plan and provide an implementation plan for meeting the requirements of the waiver.

Implementation plans would have to show how states would provide access to health care for 95 percent of their residents. After five years, participating states would be required to demonstrate that they reached these targets and provide a plan to cover the remaining five percent of their population. States that do not reach the 95 percent target after five years would have to revise their plan to achieve the targets. Technical assistance would be available for states seeking help in developing these plans.

Makes clear that the benefits provided by states have to be equal or greater than what beneficiaries receive now. An independent assessment panel, made up of health care experts and officials, would evaluate for the Secretary of Health and Human Services (HHS) whether a particular state’s proposal meets the requirement of providing as much as or more coverage than the individual streams.

Finally, the state would have to provide an assurance that it has the legal authority to implement its universal health care plan.

In order to combine streams of funding, provide flexibility and allow for states to offer comprehensive universal health care, provisions in law that are waived pursuant to this bill include: (1) the requirements for the establishment, creation and maintenance of health benefit exchanges; (2) cost-sharing reductions under the ACA; (3) premium tax credits and employer mandates under the ACA; (4) Medicare; (5) Medicaid; (6) CHIP; (7) FEHBP; (8) TRICARE; and (9) ERISA pre-emption provision.

Waiver consideration and transparency. Not later than six months after enactment, HHS will issue regulations that provide for public notification and comment, a process for the waiver application process and reporting on the implementation and evaluation process.

The HHS secretary will provide Congress an annual report on the applications received and programs conducted through the waivers granted.

Regional waiver request. Allows two or more states the option of submitting a waiver application together.

Granting of Waivers. Underscores that state coverage, among other things, would:

  1. be no less and cost no more than what residents would have received under the federal program;
  2. provide coverage and cost sharing protections against excessive out-of-pocket spending; and
  3. include all state residents, including DACA recipients, but exempts from these requirements those eligible for benefits through the Indian Health Service, the VA and military treatment facilities.

Coordination between HHS, Treasury, Office of Personnel Management, Defense, and Labor is required though an interagency MOU to ensure that all regulations are administered to have the same effect absent a waiver.

Definitions. The terms ‘health benefits coverage’, ‘resident’, ‘secretary’, and ‘specified federal health program’ are defined.