June 30
After clearing a procedural hurdle on Saturday with a vote to spare, the Senate began a marathon voting session Monday to pass its iteration of Republicans' massive spending bill.
The so-called "vote-a-rama" is a series of proposed amendments that is expected to keep the legislators busy for several hours as Democrats look to voice their opposition and force Republicans to go on the record on various issues. The minority party already delayed the bill's progress over the weekend by requiring clerks to read it aloud in its entirety—a process that took about 16 hours and was followed by debate.
Those developments came after a procedural vote held Saturday in which just two Republicans—Sens. Rand Paul, R-Kentucky, and Thom Tillis, R-North Carolina—voted to oppose advancement. The latter paired his pushback with an announcement that he would not be seeking reelection, as President Donald Trump said he would support other MAGA candidates for the coming primary in Tillis' district.
Since the Saturday advancement, a new Congressional Budget Office analysis estimated that the Senate's legislation would lead to 11.8 million more uninsured Americans by 2034 (about 900,000 more than the House bill). The same analysis projects a nearly $3.3 trillion increase to the deficit during the same window, though an alternate analysis from the office using Republicans' preferred methodology and budget baseline (described as a "gimmick" by Democrats during Sunday debating) showed a $500 billion deficit reduction.
Additionally, the Senate Parliamentarian has continued to flag provisions within the rewritten bill ineligible for the reconciliation process, including hospital outpatient pay bumps to Hawaii and Alaska added to ease concerns from Sen. Lisa Murkowski (R-Alaska). At the same time, cuts to provider taxes previously flagged by the parliamentarian (see below) were greenlit due to a change pushing back the limits by a year.
June 26
GOP hits setback as parliamentarian rules some Medicaid changes don't meet Senate rules
Several controversial healthcare provisions within the Senate’s draft of a massive tax and spending package, including limits to states’ Medicaid provider taxes, are ineligible for inclusion in reconciliation legislation and would require 60 votes to pass, Democrats on the Senate Budget Committee announced Thursday morning.
Other provisions deemed off the table for reconciliation by the chamber’s rule keeper include those restricting Medicaid spread pricing and government health insurance participation and funding for those without verified immigration status, as well as for gender-affirming care services.
Republicans have already been stretched thin to reach the reconciliation process’ 50-vote threshold, working this week to cut deals with party members concerned over Medicaid policy changes that would reduce enrollment and hospital funding.
The nonpartisan Senate parliamentarian’s judgment that such provisions would be subject to the Byrd Rule—a decades-old rule prohibiting “extraneous” federal budget provisions—throws a wrench into those plans, now requiring Senate Republicans to rewrite relevant portions of their bill or, less likely, strike an accord with Democrats.
“Democrats are fighting back against Republicans’ plans to gut Medicaid, dismantle the Affordable Care Act, and kick kids, veterans, seniors, and folks with disabilities off of their health insurance—all to fund tax breaks for billionaires,” Senate Budget Committee Ranking Member Jeff Merkley, D-Ore., said in a release announcing the parliamentarian’s decision. “Republicans are scrambling to rewrite parts of this bill to continue advancing their families lose, and billionaires win agenda, but Democrats stand ready to fully scrutinize any changes and ensure the Byrd Rule is enforced.”
While Senate Majority Leader John Thune, R-S.D., has said that his party would follow rulings from the parliamentarian, some Republican lawmakers took to social media to voice their frustration with the rule keeper.
"This is a perfect example of why Americans hate THE SWAMP,” Sen. Tommy Tuberville, R-Ala., wrote on X. “Unelected bureaucrats think they know better than U.S. Congressmen who are elected BY THE PEOPLE. [The parliamentarian’s] job is not to push a woke agenda. THE SENATE PARLIAMENTARIAN SHOULD BE FIRED ASAP.”
For much of the healthcare industry, the centerpiece of the Senate draft was an increased limit on states' provider taxes. Whereas the bill already passed in the House freezes states’ provider taxes at current rates that, for some, are as high as 6%, the Senate’s version would go further to impose a 3.5% cap.
Democrats and provider groups alike have said the change would threaten hospitals’ financial sustainability, particularly those serving rural areas.
Hospital groups declined to comment on Thursday’s reported parliamentarian’s decision, telling Fierce Healthcare they are still reviewing the development and its implications.
Republicans have broadly characterized the healthcare provisions in the legislation as reforms addressing fraud, waste and abuse. Provider taxes in particular have been described by influential conservative groups, lawmakers and the administration itself as “gimmicks” states use to draw increased federal funding.
Michael Abrams, managing partner at the healthcare consulting firm Numerof & Associates, told Fierce Healthcare that he’s of a similar mindset and called for not just a cap but an end to states’ “gaming the system.”
“What we really should be doing is taking action to get rid of this scam instead of institutionalizing it,” he said. “If we have to make some financial considerations elsewhere to address the matter of the states or hospitals being in financial trouble, so be it, but let's not do it this way.”
Anthony Wright, executive director of the nonprofit healthcare consumer advocacy organization Families USA, said lawmakers should respond to the parliamentarian’s ruling against the proposal’s “harmful provisions” by slowing down the debates rather than rushing a rewrite.
“Americans voted for affordability, not the slashing of our health care system and social safety net,” he said in a statement. “Today’s rulings provide a pivot point for Congress to punt on this unpopular proposal and to go back to the drawing board and work on commonsense, bipartisan solutions to lower healthcare costs for families.”
Senate holdouts, hospitals lukewarm on $15B rural hospital fund proposal
The parliamentarian’s decision is a curveball for Republicans’ congressional leadership, who already faced an uphill battle unifying senators on their proposals.
The GOP holds 53 of the Senate’s 100 seats, with Vice President J.D. Vance on hand to break a stalemate if needed. Recent days, however, found Thune working to settle dissent from two camps—fiscal hawks eager for greater spending cuts and senators in rural or purple states raising the alarm over Medicaid coverage reductions and potential hospital closures.
To satiate the latter group—which reportedly includes Sens. Josh Hawley, R-Mo., Thom Tillis, R-N.C., Susan Collins, R-Maine, and Lisa Murkowski, R-Alaska—the Senate Finance Committee floated a provision Wednesday that would establish a $15 billion fund for states to support rural hospitals and other healthcare providers or programs.
Of that funding, $3 billion would be disbursed annually for five years beginning in fiscal year 2027. Half of that annual appropriation, $1.5 billion, would be distributed equally to all 50 states, with the remaining $1.5 billion directed by the Centers for Medicare & Medicaid Services (CMS) administrator in consideration of “a state’s rural population, proportion of healthcare facilities in rural areas, and the situation of hospitals who serve low-income patients,” according to the memo first reported by Punchbowl News.
The pitch has received a cold response from the concerned senators and hospitals alike.
Collins told multiple outlets that the $15 billion proposal is a step in the right direction but ultimately inadequate and that she believes the country needs a “$100 billion provider-relief fund.”
Chip Kahn, president and CEO of the Federation of American Hospitals, described the fund as “almost a bad joke. It barely puts a Band-Aid on the deep wounds to patient care that the Medicaid cuts will cause for rural America and beyond. If leadership is concerned about the fate of hospitals in rural communities, the right solution is to reverse course on the Senate’s drastic cuts.”
Lisa Smith, vice president of advocacy and public policy for the Catholic Health Association, called the fund a “temporary bandage rather than a lasting solution. The bill still contains harmful provider cuts—including provider taxes and other Medicaid reductions—that pose a serious threat to rural hospitals and the communities they serve.”
Even if Thune and other Republican senators sort out their political and procedural hurdles to pass a package, any changes from the House version would need another sign-off from the lower chamber where they hold a slim, eight-member majority.
There, 16 Republican representatives penned a letter this week telling Thune and House Speaker Mike Johnson, R-La., that they “cannot support” a final reconciliation bill that includes the provider tax limits, changes to state directed payments and other changes affecting hospital funding.