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NBC News
26-06-2025
- Business
- NBC News
Republicans dealt a setback on their big bill as Senate referee disqualifies key provisions
WASHINGTON — Republicans suffered a blow Thursday after the Senate referee ruled that a series of health care cuts and savings in their sweeping domestic policy bill are ineligible for the party-line path they're using to get around the chamber's 60-vote threshold. Senate parliamentarian Elizabeth MacDonough, who adjudicates procedural disputes between the two parties, has disqualified several provisions, including Medicaid rules prohibiting funds without verification of immigration status, reimbursement changes to contracts with pharmacy benefit managers (PBMs), provider tax restrictions aimed at saving federal dollars, and new limitations surrounding eligibility for Affordable Care Act funding. The disqualified provisions total between $200 billion and $300 billion in savings over a decade, said Matthew Fiedler, an expert in health care policy and economics at the Brookings Institution. That's a problem for Republicans, who are aiming to pass the "One Big Beautiful Bill" for President Donald Trump's agenda through the Senate in the coming days. The House-passed version of the legislation was already projected to add $2.4 trillion to the national debt over the next 10 years, and additional red ink could make Republicans even more nervous about voting for the final product. 'Everything is challenging, but they're all speed bumps,' Senate Majority Leader John Thune, R-S.D., told reporters on Thursday. 'And we have contingency plans — Plan B, and Plan C, we'll continue to litigate it.' Thune also admitted that the goal of starting votes on the bill Friday was 'still an open question.' Republican leaders are hoping to send the legislation to Trump's desk by July 4. But while the rulings could set back the timing of Senate votes on the bill, Republican aides maintained that they aren't fatal to the overall bill. In some cases, they indicated they will return to the drawing board and reword the problematic provisions to comply with budget limitations, most notably on the Medicaid provider tax. In other cases, they will accept the outcome of the revoked provisions, which is a normal part of these party-line bills. Republicans are using the "budget reconciliation" process so they can pass the bill in the Senate with a simple majority, cutting Democrats out of the process and avoiding a filibuster. But only certain types of bills are eligible for this process. And it's not all bad news for Republicans from the parliamentarian: the new work requirements for able-bodied adults to access Medicaid were deemed compliant with Senate rules. Those provided the largest share of the health care spending cuts in the legislation. Democrats said they were relieved by the ruling on the provider tax, a provision that some members of both parties worry will create pain for hospitals. 'The provider tax is devastating to our hospitals, particularly our rural hospitals, and so I'm glad it's gone,' Senate Minority Leader Chuck Schumer, D-NY, told reporters. 'But we tell the Republicans, and for the sake of our health care system, don't come up with something just as bad or worse.' The decisions by MacDonough add to a lingering list of disputes that Republicans must resolve. The fate of Medicaid continues to be a thorny subject for many GOP lawmakers. House conservatives like Reps. Andy Harris, R-Md., and Chip Roy, R-Texas, are threatening to torpedo the revised bill for softening the House's clean energy funding cuts. And an expansion of the cap on state and local tax deduction, or "SALT," remains a red line for blue-state House Republicans, while GOP senators don't care for it. Some conservatives lashed out at MacDonough, calling for her to either be overruled by senators or fired by Thune. 'The WOKE Senate Parliamentarian, who was appointed by Harry Reid and advised Al Gore, just STRUCK DOWN a provision BANNING illegals from stealing Medicaid from American citizens,' Sen. Tommy Tuberville, R-Ala., wrote on X. 'This is a perfect example of why Americans hate THE SWAMP.' 'THE SENATE PARLIAMENTARIAN SHOULD BE FIRED ASAP,' he said. MacDonough was appointed by then-Senate Majority Leader Harry Reid, D-Nev., in 2012, and is well-respected by leaders on both sides of the aisle. But Sen. Roger Marshall, R-Kansas, also said MacDonough needs to go and called for term limits for parliamentarians. "She's been here since 2012; she has a lot of power," Marshall told reporters. "I don't think anyone should stay here that long and have power where she doesn't answer to anybody." Thune wouldn't directly answer if he was open to firing her. He suggested Republicans knew the parliamentarian could rule that some provisions in their bill didn't comply with Senate reconciliation rules. "We're pushing the edge of the envelope, trying to get as much done as we can," Thune said. Thune and a handful of other GOP senators — including Sens. Lindsey Graham of South Carolina, and Bill Cassidy and John Kennedy, both of Louisiana — said they oppose overruling MacDonough, meaning there are currently not the votes to do so given the GOP's narrow 53-47 majority. And Sen. Susan Collins, R-Maine, the chair of the Appropriations Committee, pushed back against Tuberville and others Republicans' calls to oust MacDonough. The parliamentarian has rankled both parties in the past: In 2021, she ruled against Democrats' provision hiking the minimum wage to $15 in then-President Joe Biden's Covid relief package. 'I totally disagree' that the parliamentarian should be fired, Collins told reporters. 'What comes around goes around when it comes to the parliamentarian. She may rule a way you like one day, the way you don't the next. She has a job to do.' Meanwhile, Democrats say they will keep challenging the provisions in the legislation under Senate rules, depicting the cuts as a way to pay for "tax breaks for billionaires." 'Democrats are continuing to make the case against every provision in this Big, Beautiful Betrayal of a bill that violates Senate rules and hurts families and workers,' said Sen. Jeff Merkley, D-Ore., the ranking member of the Budget Committee.
Washington Post
15-05-2025
- Health
- Washington Post
How do Republicans plan to cut health coverage? Let us count the ways.
Loren Adler and Matthew Fiedler are fellows at the Brookings Institution Center on Health Policy. The new Republican plan to cut Medicaid and the Affordable Care Act's subsidies for the privately insured can seem complex and arcane, involving tweaks to obscure state taxes and revamped income verification schedules. But the overall story is simple: The plan saves money mainly by removing millions of people from coverage, while offering no alternative means to insure them. A partial analysis from the Congressional Budget Office shows that House Republicans' desired policies would cost 9.5 million people their health insurance by 2034, a figure that appears likely to rise as the CBO continues analyzing the House proposals. Each component builds on the next to push more and more people off government-backed insurance. Here's how. House Republicans are cutting health coverage programs in two basic ways: (1) narrowing eligibility and making it harder to enroll and stay enrolled; and (2) shifting Medicaid costs from the federal government to the states. In justifying their various changes to eligibility and enrollment processes, House Republicans will likely argue that they're merely weeding out ineligible or undeserving applicants — in other words: waste, fraud and abuse. Setting aside the debate about who is 'deserving' of coverage, the evidence is clear that the administrative burdens created by the House proposals would prevent many eligible people from accessing benefits they are entitled to. Take the new work requirements for Medicaid, which can also be met through other approved 'community engagement' activities. Though the overwhelming majority of affected enrollees are likely already working or otherwise complying, proving that to the state is another matter. Prior state experiments with work requirements demonstrated that many enrollees were unable to navigate the extra layers of paperwork and lost their Medicaid coverage as a result. The House proposals would also suspend two Biden-era rules that streamlined Medicaid enrollment processes, such as by automatically signing up eligible low-income seniors for reduced Medicare premiums and cost-sharing, preventing states from requesting unnecessary information when determining eligibility, and limiting states from rechecking eligibility more than once per year. Enrolling and staying on private plans through the Affordable Care Act would also get harder. The House is poised to reduce the window in which people can sign up for coverage through the Affordable Care Act's marketplaces, require some enrollees to do more to prove their eligibility, and force insurers to disenroll consumers who underpay their premiums by small amounts. The proposal also appears to narrow eligibility in other ways, including by barring some legal immigrants from obtaining subsidized private insurance through the ACA marketplaces. (People not lawfully present are already ineligible.) The second main group of proposals would shift more of the cost of Medicaid from the federal government to states. Those changes would squeeze state budgets, leaving them with three unappealing choices: cut Medicaid, cut other programs or raise taxes. In practice, states would do some of each, but Medicaid provisions would likely bear a large share of the burden via policy changes that cut enrollment, benefits or payments to health-care providers. Perhaps the most important provisions in this vein limit 'provider tax' arrangements in which a state taxes health-care providers and then uses the proceeds to finance higher payments to those providers under Medicaid. Provider tax arrangements are often described as an abuse of the program because they increase the share of Medicaid costs borne by the federal government. There is little question that they are inelegant. Thoughtful reforms that eliminated these financial gymnastics — but replaced the federal funding they generate — could make Medicaid simpler, more transparent and perhaps more efficient. But solely limiting provider taxes, as the House proposals envision, is a cut, plain and simple, that will reduce enrollment, alongside other hits to the program and state budgets. Importantly, the proposal's coverage cuts would come on top of the impending expiration of enhancements to the ACA's marketplace subsidies at the end of this year. Accounting for that expiration and the provisions not fully captured in the CBO estimates to date would likely push policy-driven coverage losses in the coming years close to 15 million or beyond. Coverage losses of this magnitude would mean a dramatic reversal of recent declines in the uninsured rate. That rate stood around 8 percent in the first half of 2024, down from 16 percent when the Affordable Care Act was enacted in 2010. The combined effect of these policy changes would be to reverse about half of those gains. The policies reflect a long-standing partisan debate over priorities. Many Republicans will argue that the loss in coverage, particularly for people they consider 'able-bodied,' is acceptable given the large federal savings these proposals would generate. These arguments might include claims that health insurance does little to improve health and well-being, a conclusion at odds with evidence that it improves health and saves lives while bolstering financial security. Democrats are unlikely to share the Republican assessment, particularly since these savings are being used to partially offset tax cuts that predominantly benefit those with the highest incomes. Regardless, if members of Congress choose the path that House Republicans laid out in recent days, they should acknowledge that millions will lose their health insurance and clearly explain why other policy goals should take precedence.
