Honest praise to Rep. Khanna for a reasonable bill to make advancing single payer easier.

I've butted heads with California Democratic Congressman Ro Khanna a few times, most notably nearly four years ago over his misrepresentation of the role private health insurance would play under a theoretical Bernie Sanders-style "Medicare for All" system.

However, I also believe in giving credit where its due, and a new bill introduced by Rep. Khanna (with 29 cosponsors, most of whom seem to be members of the Progressive Caucus, as you'd expect) seems petty damned reasonable to me:

State-Based Universal Health Care Act of 2023

This bill establishes the option for states, or groups of states, to apply to waive certain federal health insurance requirements and provide residents with health insurance benefits plans through a state-administered program. Such programs must cover 95% of the residents in the state within five years and plan benefits must be at least as comprehensive and affordable as the coverage under the equivalent federal program.

State programs are supported with funds from the federal programs the state programs replace, which may include Medicare, Medicaid, the Children's Health Insurance Program, the Federal Employee Health Benefits program, certain federal tax credits, and premium-assistance funds, among others.

The bill requires the Department of Health and Human Services to appoint an Independent Assessment Panel for Comprehensive Care to review and recommend whether to approve state applications. Each approved state program must be independently reviewed every five years to evaluate changes in health benefits access, quality, and coverage, including whether the state has met the 95% coverage requirement.

The federal government must pay all health insurance costs for American Indians and Alaska Natives who enroll in a plan through a state insurance program.

There's both more and less than going on here then meets the eye, depending on how much you know about the current ACA waiver provisions. Section 1332 of the ACA already allows for states to submit waivers to innovate how certain portions of the ACA operate in their states (with federal approval), within certain parameters, including three main rules:

In order for a section 1332 waiver to be approved, the Departments must determine that the waiver will provide coverage that is at least as comprehensive as the coverage provided without the waiver; provide coverage and cost-sharing protections against excessive out-of-pocket spending that are at least as affordable as without the waiver; provide coverage to at least a comparable number of residents as without the waiver; and not increase the federal deficit.

In other words, as long as they can prove that the changes made cover at least as many people at least as comprehensively & at least as affordably without costing the feds more, go for it.

Section 1332 waivers are already being used by over a dozen states, mostly in the form of reinsurance programs, which reduce premiums for those who don't qualify for subsidies (while simultaneously increasing net premiums for many of those who do qualify, but that's a separate discussion). However, they can also be used in other ways, as a few states have done.

Vermont attempted to utilize a Section 1332 waiver as part of its ill-fated attempt to institute a state-based single payer healthcare system as early as 2014, and I think Colorado was also planning on using this process at some point had their own single payer attempt, dubbed "ColoradoCare," not been crushed at the ballot box by an 80-20 margin. However, Section 1332 still leaves some hurdles on this front...so Khanna and his colleagues are proposing a bill which would remove some of those hurdles, as explained in a fact sheet from Health Care for All Oregon:

The “State-Based Universal Health Care Act” (SBUHCA) makes it easier for states to create and fund a comprehensive universal health care plan by allowing a waiver of some federal rules. To waive requirements for a federal program, the state plan must have benefits equal to or greater than those that the beneficiaries of the federal healthcare program would otherwise receive. A group of states can also submit a joint plan. This bill was introduced in late 2023 by U.S. Representative Ro Khanna (CA-17) as H.R. 6270. 

Section 1332 of the Affordable Care Act (ACA) allows states to innovate, but it does not go far enough.  SBUHCA amends the ACA with a 1335 super-waiver, which provides additional federal support for states to develop their own universal healthcare plans. Section 1335 makes it easier for states to model systems and build toward a national healthcare plan. 

What SBUHCA does:

  • Allows states to get federal waivers for a universal, simple, and affordable (USA) plan.
  • Mandates that participating states guarantee healthcare coverage for at least 95% of residents in the first 5 years.

  • Requires any state-based plan to have benefits equal to or greater than those that the beneficiaries of federal healthcare programs now receive.

  • Allows groups of states to come together for joint plans. Section 1332 of the Affordable Care Act (ACA) does not.

  • Enables states to integrate Medicare funds into a state plan. Section 1332 does not.

  • Gives access to an ERISA waiver to reduce legal challenges to a state plan. Section 1332 does not. This gives states more legal certainty in legislative efforts.

  • Creates an HHS Secretary-appointed Independent Assessment Panel, composed of members recommended by political leaders of both parties, health care provider groups, and a patient advocate [see Section 2 (g) (4) of H.R. 6270]. This panel will review and provide the state and the Secretary recommendations regarding waiver approval or disapproval. By contrast, Section 1332 leaves the review process up to the HHS Secretary.

  • Paves the way to nationally guaranteed universal, simple, affordable (USA), and equitable health care.

All of this seems reasonable, though obviously the devils are in the specific legislative text. This bill wouldn't create single payer at either the federal or state level, but it would at least smooth the way for any states which decide to make the attempt...which is fine with me. Just because I don't think M4All is necessarily the best path towards universal healthcare coverage in the U.S. doesn't mean I'm hostile towards states giving it a shot.

Of course this bill isn't going anywhere in the current Congress, but if Democrats retake the House this fall I could see it having a chance next year.