This legislation, titled the "State-Based Universal Health Care Act of 2025," aims to create a flexible framework enabling states to provide comprehensive universal health coverage to their residents. It amends Title I of the Patient Protection and Affordable Care Act to allow states to apply for waivers from numerous federal health care laws and programs, including key sections of the ACA, Medicare, Medicaid, CHIP, FEHBP, TRICARE, and associated tax credits and subsidies.

To obtain a waiver, states must submit a detailed plan outlining how they will achieve health coverage for at least 95 percent of their residents within five years. The application must also include a 10-fiscal-year budget plan demonstrating budget neutrality for the Federal Government. A crucial provision ensures that federal funds that would have been spent on the waived programs will be passed through to the state, adjusted for inflation and caseload growth, with any savings available for reinvestment in health care services.

Waivers will be granted if the state plan provides health benefits coverage that is at least as comprehensive and affordable as existing federal programs, covering all state residents (excluding those eligible for benefits through the Indian Health Service or VA). The plan must be publicly administered by a state agency or public entity and include coverage for reproductive health care services, including abortion, contraception, and gender-affirming care. States are also required to conduct public education activities and establish accessible complaint and appeal systems.

The bill mandates interagency coordination among federal departments, including Health and Human Services, Treasury, Defense, Labor, and the Office of Personnel Management, to streamline waiver processes and ensure consistent regulations. An Independent Assessment Panel for Comprehensive Health Care will be established to review waiver applications and state reports, providing recommendations to the Secretary and Congress.

States granted waivers must submit independent reports every five years detailing spending, uninsured rates, affordability changes, and progress toward the 95 percent coverage goal. If a state fails to meet the 95 percent coverage target after a grace period, its waiver may be terminated. The legislation also includes specific guidance for applying its provisions to American Indians and Alaska Natives, ensuring no enrollment fees or cost-sharing, no mandatory enrollment, and fair payment practices for Indian health care providers.