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Budget Reconciliation Saga Continues With Parliamentarian Ruling President Donald Trump took to the so-called campaign trail today to advocate for passage of the tax-cutting Big Beautiful Bill and said he wants the legislation on his desk by July 4. But the “Byrd Bath” process and the Senate parliamentarian threw a monkey wrench into the works today. The parliamentarian, who interprets Senate rules (especially as they relate to the reconciliation process), agreed with Democrats that several provisions on healthcare are not allowable under the Byrd budget reconciliation process rules. In general, provisions in a budget reconciliation bill must be very germane to the process to allow the bill to pass in the Senate with a simple majority and not with a supermajoriy vote of 60. Majority Leader John Thune, R-SD, said he will not seek to overrule the parliamentarian on a majority vote for fear of setting a huge precedent for

Senate And House Jockey On Budget Bill Senate moderates and pragmatic conservatives are working on a rural hospital relief fund to offset the impact of numerous Medicaid and Exchange cuts in the budget reconciliation bill. Their chief complaint is that the $15 billion budget crafters are willing to put up is clearly inadequate. They believe a fund closer to $100 billion is needed to ensure the hospitals’ solvency. At least three senators are very vocal here, with others certainly sympathetic. One pragmatic conservative up for re-election, Thom Tillis, R-NC, believes that the healthcare cuts being considered in budget reconciliation will mean the GOP losing control of Congress. His seat is especially vulnerable as a popular moderate Democratic former governor, Roy Cooper, could challenge Tillis in 2026. Another major sticking point in discussions between the House and Senate is the status of the state and local taxes (SALT) deductions. Primarily to

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,

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

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

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.

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,

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/ (Article may require a subscription.) #budgetreconciliation #congress #trump #spending #medicaid #coverage https://www.modernhealthcare.com/politics-regulation/mh-gop-tax-plan-cost-cbo Fitch Downgrades Health Insurers Fitch Ratings has downgraded the health insurance industry’s outlook to deteriorating from neutral because of rising utilization and Medicaid and Exchange cuts in the budget reconciliation bill. Additional article:

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

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 Trump Pushes Big Pharma To Lower Price With his deadline for brand drug makers to come forward with lower prices, the Trump administration is pushing pharmaceutical companies to begin negotiations to reduce prices. If they do not, the government will begin the process of implementing most-favored-nation (MFN) pricing. “Under President Trump’s direction, HHS is demanding that pharmaceutical companies end their obstruction and come to the table—just as they already do with nearly every other economically comparable nation—to negotiate fair, transparent pricing for Americans,” a Health and Human Services (HHS)