Following a record-breaking “vote-a-rama” session and a tie-breaker vote from Vice President J.D. Vance, the Senate has passed its version of the massive reconciliation bill that includes healthcare industry-opposed changes to federal health programs.
Republican Sens. Susan Collins from Maine, Thom Tillis of North Carolina and Rand Paul of Kentucky joined Democrats in opposing the bill.
The "vote-a-rama", a series of proposed amendments culminating in a final wraparound amendment, ran for more than 26 hours and beat out the prior record of 44 offered amendments.
The bill now goes back to the House for another sign-off before heading to President Donald Trump’s desk, though reports suggest opposing contingents of Republican representatives will take issue with the Senate’s increased healthcare cuts and budget impacts. Republicans have a self-imposed deadline of July 4 for the bill to be signed into law.
"With this legislation, we're fulfilling the mandate we were entrusted with last November and setting our country and the American people up to be safer, stronger and more prosperous," Senate Majority Leader John Thune, R-South Dakota, said shortly after the vote.
The past week, and particularly the past couple of days, have brought a slew of last-minute changes. Rulings from the Senate Parliamentarian to key issues like provider taxes forced rewrites and timeline tweaks, while other provisions were pushed out of the bill entirely—including a bump to non-contiguous states’ Medicaid funding intended to court potential holdout Sen. Lisa Murkowski (who ultimately voted yes on the bill that included a delay to work requirements for SNAP benefits in her state).
The final version, which received changes right up to the passage vote, is that it includes a $50 billion, five-year bridge fund for rural hospitals. That addition was intended to ease rural lawmakers such as Collins’ concerns over broader cuts, though she still voted against.
The final version also dropped a gender-affirming care ban in Medicaid and CHIP, a Federal Medical Assistance Percentage (FMAP) penalty for states using their own dollars to pay for some immigrants’ care and an excise tax on wind and solar energy.
Also of note, the "vote-a-rama" included an amendment to remove a 10-year moratorium on states’ regulation of artificial intelligence, which was supported by the tech industry.
Still included are the Senate’s gradual annual reductions toward a 3.5% cap for state provider taxes, which is lower than the House’s 6%. A 2.5% bump in Medicare payments to physicians is included for 2026 alone, whereas the House bill has longer lasting increases meant to offset inflation.
"When people start losing their Medicaid, when they start losing their jobs, when their electric bills go up, when their premiums go up, when kids and parents lose SNAP funding, the people of America will remember this vote," Senate Minority Leader Chuck Schumer, D-New York, said after the vote. "The American people will remember the Republican betrayal, and Americans will pay the price for this perfidy for generations."
The centerpiece of the bill is an extension of tax cuts first passed by Republicans in 2017, as well as a short-term measures to fulfil Trump's campaign promises of removing tax from tips or overtime pay. Though the budget costs of those provisions is partially offset by spending reductions—primarily related to Medicaid—the Congressional Budget Office projected it would add at least $3.3 trillion to the national debt over the next decade. That tally has raised concerns among the party's fiscal hawks, including Sen. Paul.
Republicans, both to ensure the bill would abide by reconciliation rules and to offset political pressure, instead frame the bill's debt impact as a half-billion surplus by essentially counting the extension of the existing tax breaks as zero—an "accounting gimmick" criticized by Democrats and financial analysts concerned of a new precedent for future budgeting.
Speaker Mike Johnson, R-Louisiana, and other House leaders, said in a joint statement that their chamber "will work quickly to pass the One Big Beautiful Bill that enacts President Trump’s full America First agenda by the Fourth of July. The American people gave us a clear mandate, and after four years of Democrat failure, we intend to deliver without delay."
Healthcare groups condemn funding, coverage cuts
The passage was immediately denounced by healthcare groups who described the package as potentially the "biggest rollback in healthcare coverage in the country's history." Particularly stark condemnation came from the hospital industry, which has said that the provider tax limits and other changes to Medicaid eligibility that will increase the number of uninsured Americans and would force service lines and hospital closures.
“Under the guise of cutting ‘waste, fraud, and abuse,’ the Senate sends a bill to the House that slashes the care and coverage for millions of Americans,” Federation of American Hospitals President and CEO Chip Kahn said in a statement. “The reverberations of this measure will go far beyond the cutting and its injuries to care will be felt across the country in urban and rural communities alike. The measure simply crosses what House members have made clear is unacceptable.”
Kahn also called on members of the House “to stand up for their constituents, abandon harmful cuts to care and local hospitals, and strengthen the original House bill.”
Rick Pollack, president and CEO of the American Hospital Association, said that the nearly $1 trillion in Medicaid cuts and 11.8 million increase in uninsured projected by the Congressional Budget Office will have "irreparable harm" to the country's healthcare system.
"It will force hospitals to make service line reductions and staff reductions, resulting in longer waiting times in emergency departments and for other essential services, and could ultimately lead to facility closures, especially in rural and underserved areas," he said. "We urge the House to mitigate this legislation and protect access to healthcare for patients and communities."
Catholic Health Association President and CEO Mary Haddad said the bill was a “shameful prioritization of the wealthy over millions of other vulnerable Americans.
“Let's be clear: no amount of tinkering changes the underlying, fundamental flaws of H.R. 1 and its devastating impact. This bill inflicts deep harm on essential community health and social safety-net programs, threatening the survival of rural hospitals and long-term care facilities. It places additional financial strain on already overburdened health care providers and state budgets.
“By protecting the most vulnerable among us, we build a healthier, more just society for all. This bill does the opposite," Haddad said.
AHIP, which represents the health insurance industry, warned that "due to new red tape and barriers to enrollment and re-enrollment, people losing eligibility for Medicaid will find an individual market with less choice and higher premiums. The potential expiration of the current health care tax credits later this year would compound the disruption."
Statements expressing similar condemnations and calls for the House to water down healthcare provisions were also shared by the Robert Wood Johnson Foundation, the Association for Community Affiliated Plans, the Alliance of Community Health Plans and the Association of American Medical Colleges, among others.