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The Republican “megabill” (HR 1, the “One Big, Beautiful Bill Act”), President Trump’s signature domestic legislation, has been on a roller coaster ride since arriving on the floor of the Senate on Friday (June 27th). Vice President Vance arrived at the Senate early this morning, prepared to provide the 51st vote for passage which proved necessary. Senators Thom Tillis (R-NC), Rand Paul (R-KY), and Susan Collins (R-ME) voted no, forcing the Vice President to break the tie to pass the legislation. In the end, GOP leadership persuaded Sen. Lisa Murkowski (R-AK), who held out over concerns with deep Medicaid cuts, to vote in favor of the bill after a last-minute maneuver to increase a rural hospital stabilization fund to $50 billion. The bill now heads to the House, where Representatives have just days to make the President’s desired Friday (July 4th) deadline.
The Senate bill would still cut Medicaid by nearly $1 trillion—a deeper cut than the House bill’s already controversial $800 billion cut—which adds to the difficulties in merging the two chambers’ divergent bills.
Here are some highlights from what has been happening since Senate Budget Committee Chair Lindsey Graham (R-SC) released full text of the Senate’s version of the bill on Saturday, June 28th (see Sen. Graham’s press release).
- Medicaid: Most of the estimated $1 trillion in Medicaid savings derive from proposed changes in the law involving tighter deadlines, document requirements, and rules for the Medicaid program that may impose additional “red tape” or new barriers for currently eligible individuals.
- Tax Cuts:
- Senate Republicans directed the nonpartisan Congressional Budget Office (CBO) to use a new approach to scorekeeping under which CBO concluded the tax title would cost $693 billion over a decade and save more than $500 billion, after spending cuts are included.
- In response to a request from Sen. Jeff Merkley (D-OR), Ranking Member of the Budget Committee, CBO estimated that using the traditional current law baseline (i.e., assuming the 2017 tax cuts expired in 2025 as required by law), the Senate measure would add more than $3.2 trillion to the national debt over 10 years and cause an estimated 11.8 million people to lose coverage over the same period (see CBO letter, CBO’s estimate of coverage losses, and Axios coverage).
On Saturday night (June 28th), only 51 Republicans had voted to clear a Senate procedural hurdle allowing the bill to move forward. Sens. Tillis and Paul voted against the motion to proceed – Tillis because of the impact of Medicaid cuts on his state and Paul because of the bill’s $5 trillion debt limit increase. On Sunday, Tillis announced he would not seek reelection in 2026 (see coverage from The Hill). He said he could not vote for the Senate bill because approximately 663,000 residents in his state would lose health care coverage (see coverage from Politico).
On Sunday, the Senate proceeded to debate the bill and on Monday, a full-day of vote-a-rama began. The vote-a-rama is the process following Senate debate on a reconciliation bill that allows all senators to introduce and force votes on an unlimited number of amendments on divisive issues, primarily as a political messaging tool for the next campaign cycle.
The Senate largely opted to maintain its tougher position on Medicaid provider taxes. The changes would incrementally lower the allowable provider tax in Medicaid expansion states from 6 percent down to 3.5 percent, but the drawdown would begin in 2028 rather than 2027. The Senate also retained the House’s limits on retroactive Medicaid coverage to 1 month, amending current law which requires state Medicaid programs to cover all services a beneficiary incurs within 3 months of a successful application to the Medicaid program (tied to date of application, not enrollment). The GOP senators also did not change House provisions for Medicaid establishing a national work requirement, more frequent eligibility checks, limits on State Directed Payments, and cost-sharing requirements for certain expansion populations.
However, the Parliamentarian ruled against including provisions that sought to block implementation of two Biden-era regulations that make it easier for older adults and individuals with disabilities to enroll in Medicaid and maintain coverage. The Parliamentarian also ruled out of order a provision that would prohibit implementation of the Biden Administration’s nursing facility staffing rule, which had been estimated to reduce federal Medicaid spending by $23 billion over 10 years. However, litigation challenging the rule is still pending.
On the other hand, the Parliamentarian allowed a proposal to survive that would prevent refugees, asylum seekers, and people with temporary protected status from being able to enroll in Medicaid. Similarly, she ruled permissible provisions specifying that non-citizens cannot qualify for tax credits and cost-sharing reductions to purchase health insurance through Affordable Care Act marketplaces.
During vote-a-rama, Senate Republicans adopted a provision to protect rural hospitals from the Medicaid cuts by establishing a $25 billion stabilization fund over 5 years (see Politico coverage) then doubled the fund to secure Sen. Murkowski’s support. The Senate GOP also added in a temporary one-year, 2.5 percent patch to the Medicare physician fee schedule for 2026 which omitted the House’s proposal to tie conversion factor updates to 75 percent of the Medicare Economic Index (MEI) next year and, beginning in 2027, 10 percent of the MEI (see section 72102 in Senate bill text as of June 28th).
In other news of interest to AGS members, Senate Republicans' megabill no longer includes provisions to restructure federal employees’ pension plans after the Parliamentarian determined those provisions violated reconciliation rules. In addition, she ruled against several proposed overhauls to federal student aid programs, including a provision that would have blocked loan payments made during medical or dental residencies from qualifying for public service loan forgiveness.
The Senate was supposed to be the easy part. The bill, as revised, may hit even choppier waters when it returns to the House tomorrow, given Speaker Mike Johnson (R-LA) has been trying to tamp down frustrations within the House Freedom Caucus because the Senate’s changes would cut $1.5 trillion in spending in exchange for $4.5 trillion in tax cuts – $500 billion short of the savings Speaker Johnson had promised to achieve. At the same time, GOP moderates in the House are concerned about the Senate’s far deeper Medicaid cuts, which total close to $1 trillion. The gap would have worsened if Sen. Rick Scott (R-FL) had not withdrawn his amendment to scale back the federal share of Medicaid costs for those enrolled under the Affordable Care Act’s expansion of Medicaid starting in 2031 (see Politico coverage of the amendment). If the House deficit hawks stand their ground, it could force GOP leaders to “conference” the legislation between the two chambers – likely delaying the bill’s passage beyond the President’s July 4th deadline (see coverage from Politico and The Hill). Johnson has said he wants to pass another reconciliation bill in the fall to deal with entitlements and the deficit, although that is viewed as a longshot.
During vote-a-rama, the Senate passed, by a vote of 99-1, a bipartisan amendment introduced by Sens. Marsha Blackburn (R-TN) and Maria Cantwell (D-WA), to remove a controversial provision to restrict state-level regulation of artificial intelligence for a decade. Sen. Ted Cruz (R-TX), the proponent of the moratorium, was the single vote against the amendment.
Democratic senators also introduced a number of amendments with a focus on mitigating the impact of the bill on working class Americans and those who are of low socioeconomic status. Forty-five amendments were debated, setting a new record for a reconciliation vote-a-rama. Democrats, for example, pushed to remove provisions shifting costs to states and imposing new barriers to access the Supplemental Nutrition Assistance Program (SNAP) upon which more than 40 million Americans with low income rely. Democrats also attempted to remove burdensome provisions limiting access to Medicaid coverage. All of the amendments introduced by Democratic senators failed on party line votes.
The House is expected to return Wednesday, July 2nd, to vote on the bill as amended.
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