May 22, 2025
House Passes Reconciliation Package. After debating most of the night, the House passed the One Big Beautiful Bill Act in the early morning of May 22 by a 215 – 214 vote. Reps. Massie (R-KY) and Davidson (R-OH) joined Democrats in voting no. Rep. Harris (R-MD), chair of the House Freedom Caucus, voted present. Two Republicans did not vote, Gabarino (R-NY) and Schweikert (R-AZ). Here’s the play-by-play on how it happened.
After regrouping following last week’s failure to advance the bill, the House Budget Committee advanced House Republicans’ reconciliation package late on Sunday, May 18. This step in the process was for the committee to combine, without amending, the eleven committee prints that were advanced by individual committees over the past few weeks into a singular piece of legislation. The final vote to advance the package to the House Rules Committee was 17 – 16. All yes votes were Republicans, and all no votes were Democrats. However, four hardline conservatives, Reps. Norman (R-SC), Roy (R-TX), Brecheen (R-OK), and Clyde (R-GA), who previously voted to stall the package in committee, voted present. Their present vote allowed the package to move to the Rules Committee while showing they continued to have strong reservations about the bill. They specifically urged House leaders to make changes that would expedite Medicaid work requirements and enact more cuts to Medicaid, and they had additional asks on the tax front. Meanwhile, a key group of moderate Republicans from blue states continued to push for changes to the state and local tax deduction (SALT) provisions as a condition of their votes on the House floor.
On May 20, the Congressional Budget Office (CBO) released a preliminary cost estimate of the reconciliation package as it was reported from the House Budget Committee, including scores for each provision. The CBO analysis does not reflect changes made after the Budget Committee, nor does it incorporate all of the interactive effects across titles. CBO estimates that, as a result of the Energy and Commerce Committee health provisions, 8.6 million individuals would become uninsured and, as a result of the Ways and Means Committee health provisions, 2.1 million individuals would become uninsured. At the request of Democrats, CBO also released a letter with a preliminary distributional analysis that found the reconciliation package will cause a decrease in household resources for the lowest 10% of the income distribution and increase household resources for the highest 10% of the income distribution.
The House Rules Committee then met on May 21, in what was a marathon session to finalize the package and prepare it for a floor vote. While the Rules Committee was meeting, moderates and hardliners continued to urge Republican leadership to add provisions they support. Moderates reached a deal with Speaker Johnson to increase the SALT cap, prompting hardliners and members of the House Freedom Caucus to increase their push for more cuts to Medicaid. President Trump then met with the House Freedom Caucus and sent a statement of administration policy urging Republicans to support the package, stating that “failure to pass this bill would be the ultimate betrayal.”
Late May 21, a manager’s amendment was released which included an increase in the SALT cap, along with modifications to other provisions – including health policies – to appease Freedom Caucus members. Changes include expediting work requirement implementation from 2029 to December 31, 2026, expanding the ban on Medicaid funding of gender-affirming care from minors to all Medicaid enrollees, and providing non-expansion states more flexibility to implement state directed payments up to 110% of the Medicare cap. The Rules Committee then voted to bring the bill, now known as H.R. 1, to the floor by an 8 – 4 party line vote.
The House met Speaker Johnson’s goal of House passage by Memorial Day, and the bill now moves to the Senate. Speaker Johnson stated he wants the bill on President Trump’s desk by July 4. However, he no longer controls the timeline, the Senate does. And, if reports to date are accurate, they will be making changes to key provisions. So, we turn our eyes to the Senate now, but first, both bodies will be in recess for the next week for the Memorial Day holiday.
May 16, 2025
Key House Health Committees Advance Reconciliation. On May 13, 2025, and into the next afternoon, the House Energy and Commerce Committee held a 26.5 hour markup of its budget reconciliation committee print, which included sweeping policy changes to Medicaid enrollment process, eligibility, and financing, as well as a Medicare physician payment adjustment, PBM reform, and changes to the Medicare prescription drug negotiation program and the Affordable Care Act (ACA). At the same time, the House Ways and Means Committee held a 15.5 hour markup of its budget reconciliation committee print. The Ways and Means package included provisions related to paid leave, CHOICE health plans (now called ICHRAs), health savings accounts, and research, as well as significant changes to ACA Exchange enrollment. Both committees successfully advanced their committee prints along party lines and did not adopt any amendments.
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Ways and Means Committee
The budget resolution instructed the House Ways and Means Committee to produce policies that would not raise the federal deficit by more than $4 trillion if the spending cuts in the overall bill totaled less than $1.5 trillion, or by more than $4.5 trillion if the bill achieved $2 trillion in savings. The Joint Committee on Taxation found that the Ways and Means Committee’s proposed tax provisions would increase the deficit by $3.18 trillion, meeting the goals stated in the resolution.
Throughout the markup, Democrats spoke out against the Medicaid provisions being considered in the House Energy and Commerce Committee and encouraged the Ways and Means Committee to extend the enhanced APTCs. Democrats argued that if the bill was supposed to help working Americans, healthcare improvements needed to be a key part of the legislation and tax breaks for the wealthy shouldn’t be financed by taking healthcare away from lower- and middle-class working Americans. Republicans offered no amendments. Their talking points focused on how the tax package was designed to limit tax liability of working Americans and restrict provision of government benefits to US citizens only, not individuals in the country illegally.
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Budget Committee
Speaker Johnson (R-LA) aims to pass the reconciliation package on the House floor before Memorial Day. Once all the committees of jurisdiction on the policy have completed their work, the House Budget Committee is tasked with pasting together the various committee prints into a single reconciliation package. That is largely a perfunctory role as they have no authority to make any changes. The Budget Committee met today, May 16, 2025, to do that work. Ultimately, a vote was held to decide if the committee should vote on the package, which failed in a 16–21 vote due to a hardline conservative push to enact larger spending cuts. When voting no, Reps. Clyde (R- GA), Roy (R-TX), Brecheen (R-OK), and Norman (R-SC) cited concerns that the federal spending reductions, particularly the Medicaid cuts, do not go far enough. Rep. Smucker (R-PA) also voted no, clarifying that the no vote was so that the committee could procedurally bring the bill back up later. Specifically, conservatives are unhappy about the Medicaid work requirement provisions. As written, the work requirements do not begin until 2029, and conservatives want to shorten that timeline. The House Rules Committee was expected to meet on Monday, May 19, 2025, to prepare the bill for floor debate, though they can only meet once the bill is advanced out of the Budget Committee, and it is now unclear when the Budget Committee will next meet to try to advance the bill. Republican leadership continues to work behind the scenes to resolve remaining differences related to Medicaid and other issues, such as disagreement on the state and local tax deduction (SALT).
May 9, 2025
Republicans Advance Reconciliation Debate. After key House reconciliation markups expected to occur this week were postponed, Republicans held internal meetings to hash out Medicaid, nutrition, and tax policies to be included in reconciliation. Moderate Republicans continued to urge the House Energy and Commerce Committee not to enact Medicaid policies that could cut coverage or reduce funding for the expansion population. Policies rumored for potential inclusion include work requirements for able-bodied adults, repeal of Biden-era regulations, restrictions on state coverage of undocumented immigrants, and increased eligibility checks. Conservative Republicans led by House Budget Committee Vice Chair Smucker (R-PA) sent a letter to Speaker Johnson stating that if net savings targets aren’t met, tax cuts must be reduced. Senate Majority Leader Thune (R-SD) and Senate Finance Committee Chair Crapo (R-ID) also joined the debate, stating that the House is not pursuing enough spending cuts, including in Medicaid.
The Energy and Commerce Committee announced its markup for May 13, 2025, at 2:00 pm EDT. It is important to remember that just because a markup is announced, it doesn’t mean it has to happen. If it goes forward as planned, the markup will likely last all evening and into May 14, 2025. Language will need to be released by 2:00 am EDT on Monday. While nothing is officially off the table, Republicans do not appear to have support for policies that target states, such as provider taxes, state directed payments, or a cap on the expansion population. Once bill text and a Congressional Budget Office (CBO) analysis are released, we will see if the Energy and Commerce Committee has been able to meet its $880 billion savings target. Democrats will focus on offering amendments to try to undermine the legislation.
As Democrats work to prevent significant Medicaid cuts from moving forward, the CBO, in response to a request from Senate Finance Committee and House Energy and Commerce Committee Ranking Members Wyden (D-OR) and Pallone (D-NJ), released savings estimates for five Medicaid policies that have been under consideration in reconciliation, along with estimates of Medicaid coverage losses attached to those policies. The policies scored include reducing the expansion population federal match, limiting state provider taxes, capping federal spending for all enrollees, capping federal spending for the expansion population, and repealing the Biden-era eligibility and enrollment final rule. CBO previously scored most of these policies, but the figures are now updated. Estimates of Medicaid coverage losses for each proposed policy range from 2.3 million to 8.6 million people.
May 2, 2025
House Committees Begin Reconciliation Markups. Multiple committees in the House – although none in the healthcare space – advanced their “committee prints” this week, which include the provisions within their jurisdiction for the House’s budget reconciliation package. This process will continue into the week of May 12, when the House Energy and Commerce Committee is tentatively scheduled to hold its markup to finalize the $880 billion in savings across Medicaid, the Children’s Health Insurance Program, and Medicare. The Ways and Means Committee is also signaling that it may be ready to move a tax package forward the same week.
Several Republicans representing competitive seats have been discussing with committee and House Republican leadership their concerns about policies that they perceive as cutting Medicaid. Rep. Bacon (R-NE) has publicly stated that he will not support more than $500 billion in Medicaid savings. The components most widely expected to be included in the Energy and Commerce Medicaid package include work requirements, more stringent and frequent eligibility verifications, and repeal of Biden-era Medicaid eligibility regulations. In recent days, focus also has been on Medicaid provider tax changes and potentially converting the Medicaid expansion population to a per capita cap. Read more about these options here. The challenge facing Energy and Commerce is the need to get to $880 billion in savings across its jurisdiction. While the committee is expected to get some savings out of energy policy changes and spectrum auction, Medicaid is its largest target. Meanwhile, Energy and Commerce Democrats released a report showing how many individuals would lose coverage if national work requirements were implemented.
Once all House committees have passed their packages, the House Budget Committee will combine the legislative texts and vote on the entire package, followed by a vote on the House floor. (Note that the Budget Committee’s package does not need to directly resemble the packages passed out of each committee.) Then, it will be the Senate’s turn to act. Speaker Johnson’s (R-LA) goal is for the House to pass the package before Memorial Day, and to have it signed into law by July 4, 2025, although that timeline is not guaranteed. The biggest factor that would enforce a real deadline is if the US Department of the Treasury were to announce an earlier date than anticipated for the United States hitting the debt ceiling. That pronouncement was expected this week but appears to have slipped. There is no indication that the date will be earlier than late summer or early fall. This is directly relevant to reconciliation because Republicans hope to address the debt limit increase as part of that process.
April 11, 2025
House Passes Concurrent Budget Resolution for Reconciliation Process. Over the weekend, the Senate passed the concurrent budget resolution by a 51 – 48 vote, with Sens. Paul (R-KY) and Collins (R-ME) joining Democrats in voting no. The resolution includes differing instructions for House and Senate committees, requiring the committees to continue debating spending and savings levels. Democrats introduced 800 amendments, including a bipartisan amendment from Sens. Wyden (D-OR) and Hawley (R-MO) to strike instructions for the House Energy and Commerce Committee to find at least $880 billion in savings, likely to come from Medicaid. The amendment failed, but Sens. Collins, Hawley, and Murkowski (R-AK) voted with Democrats in support.
House Republican leadership’s plan to pass the resolution before leaving for the two-week Easter recess was complicated by opposition from multiple members of the party, including House Budget Committee Chairman Arrington (R-TX). Those members were opposed to separate spending cut instructions for the House and Senate, as they wanted to stick with the House’s version of a budget resolution, which called for at least $1.5 trillion in federal spending cuts. Leadership repeatedly postponed a Rules Committee meeting to discuss the resolution, and President Trump met with House Republicans to urge them to support the concurrent resolution. Ultimately, a vote on the concurrent resolution was brought to the House floor Wednesday night but was cancelled amid strong opposition.
Senate Majority Leader Thune (R-SD) stated on Thursday that the Senate is “aligned with the House . . . in terms of savings,” noting that some senators believe the $1.5 trillion threshold is a minimum and that the Senate will “do everything we can to be as aggressive as possible to see that we are serious about the matter.” While this still leaves wiggle room as reconciliation continues, the House passed the resolution by a 216 – 214 vote. Reps. Spartz (R-IN) and Massie (R-KY) were the only Republicans to oppose it. As the vote was happening, Senate Democrats issued a letter to the public criticizing the budget resolution, arguing that it would provide a tax cut for the wealthy while cutting Medicaid. In related news, the Congressional Budget Office (CBO), in response to a request from Sen. Merkley (D-OR), released a report showing that if the Trump-era tax cuts were made permanent, the federal deficit would increase by $6 trillion over the next 10 years.
April 4, 2025
Reconciliation Moves Forward with Senate Introduction of Concurrent Budget Resolution. This move initiates the next stage in the reconciliation process, which requires the Senate and House to pass a unified budget resolution. Rather than resolving the different approaches of the previously passed resolutions in the two chambers, the resolution unveiled in the Senate this week takes the unusual, but permitted, approach of having the Senate and House stick with their preferred policies and funding levels. This would defer the tough decisions – including agreements on the level of spending cuts, tax extensions, and raising the debt limit – until later in the process.
In the healthcare space, this would mean that the House maintains its instruction to the Energy and Commerce Committee to cut $880 billion, much of which is anticipated to come from Medicaid, while the Senate instructs the Finance Committee (which has jurisdiction over Medicaid) to achieve a minimum of $1 billion in spending cuts.
The Senate cleared a procedural hurdle on the budget resolution and is moving toward advancing the measure by this weekend. President Trump met with Members and threw his strong support behind the effort. If the Senate passes the resolution, the House plans to advance it next week, which would likely require the intervention of the president, as near-unanimity among House Republicans would be necessary. Some conservative members of the House, including House Budget Committee Chair Arrington (R-TX), have come out in opposition to the Senate budget resolution, fearing that it would ultimately lead to a final reconciliation bill that does not achieve the level of spending cuts included in the House’s preferred plan.
