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Senate Budget Bill Could Be in Trouble

Both sides of the House caucus declared that they could oppose the current Senate version of the budget reconciliation bill if it passes the upper chamber and returns to the House. Senate Majority Leader John Thune, R-SD, has an uprising in his own chamber between moderates and conservatives, but both sides of the House have already declared their concerns.

More than a dozen House Republicans warned they won’t support the Senate’s version because the proposed Medicaid cuts are too steep. The Senate added more reductions in the area of provider taxes, state directed payments, and work requirements. This moderate opposition does not even fully take into account those who oppose the bill if the state and local tax deduction does not come back over with a generous increase. Right now, the Senate has no changes from the low $10,000 limit.

On the conservative side, House Freedom Caucus Chairman Andy Harris, R-MD, said he would oppose the Senate version because it waters down critical savings in the House version, does not do enough on deficit reduction, has insufficient Medicaid reductions, and eliminates major provisions of the Green New Deal. Harris voted present when the bill passed the House but would now vote no. This could lead other conservatives to bail on the bill. Speaker Mike Johnson, R-LA, had no votes to spare the last time.

The House conservatives also want the Health Savings Account (HSA) expansion and related individual premium (ICHRA) provision put back in the bill. They were stripped by the Senate. The House conservatives favor a strengthening of indvidual health insurance options.

In other news, the Congressional Budget Office (CBO) said states would be forced to reduce provider reimbursements to cope with the Medicaid cuts. This is similar to a private study released recently.

Another study from The Third Way think tank finds that the healthcare cuts could push medical debt up by $50 billion. The number of people in families facing medical debt could increase by 5.4 million, with debts increasing by up to $22,800.

As well, a bipartisan group of lawmakers is introducing legislation that would allow the Department of Veterans Affairs to bill Medicare Advantage (MA) plans for care provided to members. They say the current law pays twice for care furnished veterans. MA plans netted $1 billion by pocketing rates without paying back the government agency. The agency can bill Medicare Supplement plans but not MA plans right now.

Additional articles: https://thehill.com/policy/healthcare/5367133-house-gop-moderates-senate-tax-bill-medicaid-cuts/ and https://www.modernhealthcare.com/politics-regulation/mh-medicaid-cuts-tax-bill-provider-pay-cbo/ and https://www.beckerspayer.com/policy-updates/lawmakers-target-medicare-advantage-va-loophole-wsj/ and https://www.cnbc.com/2025/06/23/big-beautiful-bill-health-care-cuts-may-add-to-medical-debts-report.html

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#budgetreconciliation #trump #congress #medicaid #exchanges #medicareadvantage #medicaldebt #coverage

https://thehill.com/homenews/house/5366809-harris-freedom-caucus-senate-trump-bill/?tbref=hp

Plans Announce PA Initiatives To Forestall Regulatory Action

After commitments by Trump administration officials to reform prior authorization (PA), about fifty health plans, including some of the biggest, met with Health and Human Services (HHS) Secretary Robert F. Kennedy, Jr. and Centers for Medicare and Medicaid Services (CMS) Administrator Dr. Mehmet Oz to unveil their plans to streamline PA and tackle claims denials. The health plans represent as many as 75% of America’s insured. The Blue Cross and Blue Shield Association and trade group AHIP also attended the meeting.

Health plans will commit to reduce the number of codes that are subject to PA and to establish a standard framework to increase how many authorizations are adjudicated electronically and in real time. PA changes will occur by 1/1/2026, with electronic PA reforms in one year later. The plans also will increase education on PA and appeals, accountability, and transparency around denials of PAs and claims. Plans will also honor PAs for 90 days when a consumer changes plans.

The federal government will not take regulatory action pending how insurers perform under the new system but will do so if officials are not satisfied. Dr. Oz also noted that this is just a first step, indicating that regulatory changes could be coming down the road anyway.

A healthcare policy group KFF study looked at MA claims denials, appeals and their outcomes from the 2023 contract year. About 6.4% of all claims submitted for prior authorization were denied in full or part. About 12% of those denials were appealed, and 82% of denials were overturned.

Additional articles: https://www.fiercehealthcare.com/regulatory/oz-insurers-prior-auth-pledge-opportunity-industry-show-itself and https://www.modernhealthcare.com/insurance/mh-medicare-advantage-prior-authorization-denial-rates-kff/ and https://www.ahip.org/health-plans-are-making-voluntary-commitments-to-support-patients-and-providers and https://thehill.com/policy/healthcare/5364803-hhs-cms-kennedy-oz-preauthorization/?tbref=hp and https://www.beckerspayer.com/payer/payers-to-reduce-prior-authorizations/ and https://www.cms.gov/newsroom/press-releases/hhs-secretary-kennedy-cms-administrator-oz-secure-industry-pledge-fix-broken-prior-authorization

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#healthplans #priorauthorization #claimsdenials #oz #rfkjr

https://www.fiercehealthcare.com/payers/insurers-pledge-smooth-out-prior-authorization-process

Budget Reconciliation In Senate Still In Limbo

After going to bat for deeper healthcare cuts for conservatives, Senate Majority Leader John Thune, R-SD, is facing an uprising on the right and left. Three conservatives – Mike Lee, Rick Scott, and Ron Johnson, are threatening to be off the bill unless deeper cuts occur, including in healthcare. Rand Paul appears already against the bill due to a provision that increases the debt limit. This would sink the bill.

At the same time, at least three moderates or pragmatists – Lisa Murkowski, Josh Hawley, and Susan Collins – remain very concerned about the depth of certain cuts, especially provider tax restrictions.

Thune wants to vote on the bill next week.

Rural providers, particularly hospitals, continue to argue the bill jeopardizes their livelihoods and that hospitals in under-served areas could shutter.

An impasse over the state and local tax deduction threatens passage of the budget bill in the House even if it passes the upper chamber. The Senate put no increase in the bill, while House moderates have demanded a $40,000 cap, up from $10,000. They say that is what they can live with.

In other news, the Trump administration finalized an Exchange integrity bill that removes special enrollment periods, shortens the open enrollment period, and strengthens eligibility requirements. The change is expected to mean 900,000 people lose enrollment. The administration argues the rule lowers premiums, but insurance regulators are looking at huge rate hikes for consumers due to the likely expiration of the enhanced premium subsidies and cost increases.

As well, the Senate parliamentarian said today that certain portions of the House-passed bill did not meet Byrd rules in the Senate, which would mean the bill as is could not pass on a majority vote.  These provisions will most likely be cut as the GOP is not expected to overrule the parliamentarian on a majority vote. The struck provisions have little or no impact on the healthcare reductions, but the provision to have states take on some nutrition program costs has been tagged as violating Byrd rules.

Additional articles: https://thehill.com/homenews/senate/5360488-parliamentarian-rules-bill-trump-agenda/ and https://thehill.com/homenews/house/5360071-impasse-over-salt-cap-deepens-as-house-moderates-stand-firm/?tbref=hp and https://www.modernhealthcare.com/politics-regulation/mh-one-big-beautlfil-bill-rural-healthcare/ and https://www.cms.gov/newsroom/press-releases/cms-finalizes-major-rule-lower-individual-health-insurance-premiums-americans and https://www.cms.gov/newsroom/fact-sheets/2025-marketplace-integrity-and-affordability-final-rule

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#budgetreconciliation #congress #trump #spending #medicaid #exchanges #hospitals #coverage

https://thehill.com/homenews/senate/5360058-conservatives-demand-deeper-spending-cuts

Opposition To Healthcare Cuts In Budget Bill

All of healthcare is lining up against the cuts to healthcare in the budget reconciliation bill. A new study from the Urban Institute and Robert Wood Johnson (RWJ) Foundation breaks down how providers (hospitals, physicians, and drugs) are impacted in each state by the reductions to Medicaid and the Exchanges. Over the next decade, the bill would decrease spending by $321 billion to hospitals, $81 billion to physicians and $191 billion for drugs. Spending for other healthcare services would decline by $205 billion.

If the Exchange premium tax credits expire, spending would decline by an additional $262 billion — hospitals an additional $103 billion cut, physicians an additional $39 billion cut, and drugs an additional $50 billion cut. Spending on other healthcare services would drop an additional $70 billion.

Now, I have little doubt on the math of what Urban and RWJ did. If you cut a trillion out of healthcare over ten years, it is technically true that it flows through the system down to providers rendering care. What the researchers miss is that we do need real price reform in the system. Done right, money could be taken out of the system without impacting coverage. Those hospitals at risk could even be stabilized under the new paradigm.

In other news, health plan trade and lobbying group AHIP said it will mount an opposition effort to the bill in concert with other healthcare groups. It wants the budget bill reductions reversed and premium credit enhancements extended.

AHIP and health insurers are worried about the massive financial fallout from the Exchange and Medicaid cuts as well as the impact of the recent risk adjustment data validation (RADV) audit announcement for Medicare Advantage (MA).

Additional article: https://www.fiercehealthcare.com/payers/ahip-2025-insurer-coalition-vows-fight-trump-budget-bill-final-hour

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#budgetreconciliation #congress #trump #medicare #exchanges #medicareadvantage #coverage #healthplans #providers

https://www.modernhealthcare.com/latest-news/mh-one-big-beautiful-bill-cuts-states/

Budget Reconciliation Bill Flounders

Senate Majority Leader John Thune, who won his position with backing from prominent conservatives, threw his weight behind budget-cutters in the reframing in the Senate of the House bill. But the move seems to have backfired on him.

He has two conservative holdouts on the bill. He also has an uprising from moderates and pragmatic conservatives due to the Medicaid reductions, which are even deeper than the House had included. Thune essentially ignored a fundamental part of his caucus.

The moderates are worried about impacts on states and providers as well as what will happen to the uninsured rate. At least three moderates or pragmatic conservatives – Josh Hawley, Susan Collins, and Lisa Murkowski – have been vocal on the cuts and expressed doubts about voting for the bill. But there are still others that could vote against them due to the Medicaid cuts. Right now, the unveiled bill likely does not have enough votes to pass.

What’s more, there is an uprising in the House over the Senate version, with conservatives decrying certain changes and moderates up in arms about the fact that the Senate refuses to increase the state and local tax (SALT) deductions.

Strap in for a long rollercoaster ride.

In addition to adding to work requirements for some and furthering limitations on provider taxes, the bill does not include the Affordable Care Act (ACA) ICHRA/HSA insurance-funding expansion provisions or Exchange program integrity provisions. Further, it does not include a physician rate fix in Medicare.

In other news, the Commonwealth Fund released an analysis of the benefits of coverage expansion and found that the uninsured rate for working adults fell from over 20% in 2013 to 11% in 2023. The reconciliation bill could add 16M to the ranks of the uninsured.

As well, healthcare policy group KFF finds that 22 states would have to amend their provider taxes due to the Senate limitations.

Additional articles: https://thehill.com/homenews/senate/5355927-thune-senate-medita-cuts/ and https://www.politico.com/news/2025/06/17/hospitals-senate-medicaid-megabill-taxes-00410769 and https://thehill.com/policy/healthcare/5355932-senate-medicaid-cuts-concern/?tbref=hp and https://www.healthcaredive.com/news/uninsured-rate-falls-across-states-federal-policies-medicaid-cuts-commonwealth-fund/750994/ and https://www.kff.org/policy-watch/which-states-might-have-to-reduce-provider-taxes-under-the-senate-reconciliation-bill/

#budgetreconciliation #congress #trump #medicaid #medicare #obamacare #aca #exchanges #coverage

https://thehill.com/homenews/house/5355954-gop-bill-opposition-house-medicaid-salt/?tbref=hp

— Marc S. Ryan

More Senate Budget News

The Congressional Budget Office (CBO) reaffirmed that the One Big Beautiful reconciliation bill will cost the healthcare sector a $1 trillion reduction over ten years. The Senate bill adds to limitations in the House bill on provider taxes (phasing them down and capping them to 3.5% over time for expansion states) and slightly tightens eligibility further. It also cuts certain existing state-directed payments to hospitals where the House just limited future payments.

Healthcare policy group has good summaries comparing the Senate and House versions for Medicaid and Affordable Care Act (ACA) cuts.

Additional articles: https://thehill.com/homenews/ap/ap-business/ap-trump-tax-bill-would-widen-deficits-by-2-8t-after-factoring-in-economic-impacts-cbo-says/?tbref=hp and https://thehill.com/homenews/senate/5353963-senate-medicaid-taxes-green-energy/ and https://www.kff.org/tracking-the-medicaid-provisions-in-the-2025-budget-bill/ and https://www.kff.org/tracking-the-affordable-care-act-provisions-in-the-2025-budget-bill/

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#budgetreconciliation #congress #trump #spending #medicaid #coverage

https://www.modernhealthcare.com/politics-regulation/mh-gop-tax-plan-cost-cbo

Senate Reconciliation Bill Sets Up Showdown

The Senate version of the House-passed budget reconciliation bill has been unveiled and will create a showdown within the Senate and eventually with the House.

The measure preserves the House reductions to Medicaid but goes further. Beginning in 2027, the legislation would lower healthcare provider taxes to 3.5% (from 6%) in states that chose to expand Medicaid. It also expands those who would be required to work as a condition of Medicaid eligibility. The Senate version says adults with dependent children older than 14 will also have to prove they work, attend school, or perform community service for 80 hours a month. The House-passed version would exempt all adults with dependent children.

A number of moderates and pragmatic conservatives could be off the bill, with Sen. Josh Hawley, R-MO, and Sen. Susan Collins, R-ME, already speaking out. Hawley dislikes the provider tax changes as well as cost-sharing on certain enrollees. At the same time, at least two conservatives appear to be signaling their opposition – Sen. Rand Paul, R-KY, and Sen. Ron Johnson, R-WI. Other conservatives also signaled their reservations earlier. The Senate GOP can afford to lose just three votes.

Thus far, no reductions to Medicare have been included in the draft. Further, the Senate bill rejects the increase in the state and local tax (SALT) deductions to $40,000 and keeps it at $10,000 a year. House moderates would not vote for a bill that does not considerably increase the SALT cap.

In other news, a study published in the Annals of Internal Medicine says the House reductions to Medicaid is projected to cause 16,642 premature deaths among adults each year as Americans lose coverage.

As well, Democrats have introduced new legislation that would establish a “Part E” for Medicare, which would allow people to opt into the program. The new Part E would supposedly sustain itself through premiums. But it would be costly as the bill makes subsidies available through the Affordable Care Act (ACA) plans applicable to Part E coverage as well.

Additional articles: https://www.beckershospitalreview.com/quality/patient-safety-outcomes/medicaid-cuts-will-cause-16500-deaths-annually-study/ and https://www.fiercehealthcare.com/regulatory/democrats-introduce-bill-establish-medicare-part-e-public-option and https://thehill.com/homenews/senate/5353226-senate-medicaid-house-bill/

#budgetreconciliation #spending #medicaid #medicare #coverage #trump #congress #aca #obamacare #exchanges

https://thehill.com/homenews/senate/5352650-senate-republicans-trump-agenda-taxes-medicaid-green-energy

Democrats Propose Bills To Defend Medicaid

Democratic senators have proposed as many as 13 bills regarding Medicaid as the GOP continues its debate over changes to the budget reconciliation bill cuts to the low-income healthcare program. Some of the bills tackle fraud, waste, and abuse (FWA), while others protect expansion of coverage and insulate providers.

#budgetreconciliation #medicaid #trump #congress #coverage

https://www.fiercehealthcare.com/regulatory/democrats-make-pitch-medicaid-improvements-big-beautiful-bill-debate-heats

Medicare Advantage Abuses in Focus

A big day for coverage involving abuses in Medicare Advantage (MA).

First, Scan CEO Sachin Jain has a good Health Affairs Forefront blog on MA enrollment issues. Jain recounts the fact that there are behind-the-scenes compensation schemes between some large MA plans and brokers and marketing organizations that lead to steerage of enrollees into plans, often when it is not in their best interest. He notes enrollment in low-rated plans is a problem.

The Department of Justice filed a complaint against certain brokers and MA plans, alleging plans paid hundreds of millions of dollars in illegal kickbacks to brokers in exchange for enrollments into the plans’ products.

Jain proposes a change in how compensation is made for enrollment by favoring high-performing plans and perhaps making compensation is budget neutral.

Second, healthcare policy group KFF posted an issue brief regarding expected Star bonus payments in 2025. It says federal spending on MA bonus payments will total at least $12.7 billion in 2025, similar to spending in 2023, and more than four times higher than in 2015. While Star ratings have dropped, aggregate payments remain high due to enrollment increases.

Third, these bonuses help fund supplemental benefit offerings and MedPAC, the Medicare congressional policy arm, has published a report on such benefits. It finds spending on supplemental benefits has grown significantly over the past several years. MA plans will receive about $86 billion in rebates to provide supplemental benefits to enrollees. This is about 17% of total payouts in the program, or about $2,530 per person. Rebates in 2018 were $21 billion.

MedPAC notes that there is very little transparency in how these rebates are spent, especially with non-Medicare supplemental benefits. Reforms like mandatory submission of supplemental benefits via encounter data and member education have gone in force.

Expect all three of these areas to see Capitol Hill attention this and next year.

(Some articles may require a subscription.)

Additional articles: https://www.healthaffairs.org/content/forefront/changing-broker-incentives-medicare-advantage and https://www.kff.org/medicare/issue-brief/medicare-advantage-quality-bonus-payments/

#medicareadvantage #star #quality #marketing #fwa #supplementalbenefits

https://www.fiercehealthcare.com/regulatory/medpac-look-payments-ma-plans-supplemental-benefits

Public Supports Trump Drug Pricing Plan

A survey commissioned by the Pharmaceutical Reform Alliance and conducted by National Research Inc. finds that a majority of voters are in favor of lawmakers and candidates who they believe will take on Big Pharma price-gouging. Most say they support President Trump’s most-favored-nation drug pricing policy, where prices in the U.S. are set based on the lowest price in other developed nations.

#drugpricing #mfn #irp #trump

https://thehill.com/homenews/5343025-survey-voters-big-pharma-most-favored-nation