Shelley Feist, 61, of Washington, D.C., who was raised in North Dakota, protests outside the U.S. Capitol on Wednesday, July 2, 2025, as House Republicans try to pass the "big beautiful bill." Feist said she's worried about effects on rural hospitals as a result of Medicaid cuts because her parents, in their 80s, depend on rural health care in Minot, North Dakota. (Photo by Ashley Murray/States Newsroom)

WASHINGTON — Protesters demonstrated against the “big beautiful bill” outside the U.S. Capitol Wednesday as House Republicans whipped votes to get the bill across the finish line and to President Donald Trump’s desk by a self-imposed July Fourth deadline.

Shelley Feist stood on Independence Avenue near the entrance to the House of Representatives holding signs above her head, one reading “Cruel Corrupt Cowards,” the other a Republican elephant with the word “Treason” written on it.

“I think they’re being cruel. I think cruelty is the point,” Feist, 61, of Washington, D.C., and originally from North Dakota, told States Newsroom. “It’s also extremely alarming that there’s such cowardice in the GOP.”

The massive budget reconciliation package, passed by Senate Republicans Tuesday with a tie-breaking vote by Vice President JD Vance, extends and expands 2017 tax cuts at a cost of roughly $4.5 trillion over the next decade. It also yanks funding from federal food and health safety net programs.

The bill aggressively rolls back clean energy tax credits, as well as raising the nation’s borrowing limit to $5 trillion.

Latest figures from the nonpartisan Congressional Budget Office show the package would add $3.4 trillion to the nation’s deficit over the next decade, when the country is mired in record-breaking debt. That office’s earlier analysis of the House-passed bill found the package would reduce resources for low-income families while padding higher earners.

Rep. Virginia Foxx of North Carolina, who chaired an hours-long final committee hearing about the bill overnight, said Wednesday the package is an “embodiment of the America First agenda and we would all do well to remember that.”

Medicaid cuts

Top of mind for Feist is the bill’s cuts to Medicaid, the federal-state health insurance program for low-income individuals and some with disabilities. The Senate version of the package, passed Tuesday, included a  $1 trillion cut to Medicaid over 10 years, according to the CBO.

“I have parents in North Dakota who are 85 and 86. They already have difficulty seeing their doctor. For every doctor that leaves, he takes on 14 times more burden. Rural health care is already extremely difficult. I would expect there will not be a hospital near where my parents live if this bill is signed into law,” said Feist, whose parents live near Minot.

Rural hospitals rely on Medicaid payments. In a last-minute move before Tuesday’s vote, Senate Republicans doubled a fund to $50 billion to subsidize hospitals that will lose funding. Critics say that amount is not enough to fill the gap.

GOP Sens. Susan Collins of Maine and Thom Tillis of North Carolina voted no after voicing concerns over Medicaid cuts.

Nadine Seiler, 60, of Waldorf, Maryland, stood near a press conference by the Congressional Hispanic Conference protesting the bill. Seiler held a large spray-painted sheet above her head with a message on each side: “Free America from Big Bad Bill” and “Coming Soon Freedom in Name Only.”

“I’m concerned about my fellow citizens who are going to be losing Medicaid, food stamps, human health services. People are going to die,” Seiler said.

“And I know Joni Ernst says that we all gonna die, but we gonna die faster and unnecessarily and I care about that.”

Seiler was referring to Sen. Ernst’s response to her Iowa constituents who expressed concern about Medicaid cuts at a town hall on May 30.

SNAP and ICE

Mark Starr sang a protest song he wrote about the “big beautiful bill” as he played guitar and harmonica outside the Longworth House Office Building Wednesday.

The 39-year-old Albuquerque, New Mexico, native told States Newsroom he drove to the capital in late April to begin protesting the bill. He said he’s particularly focused on additional funding for Immigration and Customs Enforcement contained in the package as well as cuts to the Supplemental Nutrition Assistance Program, or SNAP, which provides food benefits to low-income households.

“New Mexico is pretty poor, and so if these cuts to SNAP go, kids can go hungry in New Mexico,” Starr said. “It’s just, like, really gonna mess us up, and we’re just one of the many states that will be affected that way.”

New Mexico has one of the highest poverty rates in the nation.

A provision in the bill will shift food assistance costs to state governments for the first time in the federal program’s history. Critics worry that states could tighten eligibility requirements or drop the program because of the financial burden.

The left-leaning Center for Budget and Policy Priorities estimates 55,000 teens age 14 and up, and adults up to age 64 could lose food assistance in New Mexico because of the bill’s cuts to state work requirement waivers. Children would remain eligible but households would overall see significantly decreased SNAP dollars.

The CBO found in late May that the House-passed bill would result in over 3 million people nationwide losing food assistance.

Starr said he’s also against additional funding provided for immigration enforcement.

“I think they have enough,” he said, pointing to Trump’s visit to a new detention facility in Florida that the White House is touting as “Alligator Alcatraz.”

The Senate-approved version includes an additional $45 billion for ICE detention facilities and $29.9 billion for ICE enforcement and deportation, among billions more directed toward the Southern border.

Clean energy to take a hit

Tiernan Sittenfeld, of the League of Conservation Voters, huddled just outside the House with a group wearing t-shirts that read “Hands off our air, land and clean energy.”

Sittenfeld, the organization’s senior vice president of government affairs, argues the rollbacks of clean energy tax credits in the Senate version will “kill clean energy jobs.”

“It is bad for our economy. It’s bad for jobs. It’s going to raise people’s energy bills. And of course, it’s bad for the planet,” she said.

Senate Republicans accelerated the phase-out of some residential, manufacturing and production credits at a faster rate than the House bill. A last-minute change loosened the timeline on some tech-neutral energy credits though, and removed a previously added tax on wind and solar projects.

Industry groups and energy companies small and large have warned early termination of the credits will have a major impact on growth.

The tax credits for solar, wind, batteries for energy storage, and electric vehicles, among others, were enacted under Democrats’ own 2022 budget reconciliation bill known as the “Inflation Reduction Act.”

The majority of investment in new clean energy manufacturing and production has been concentrated in rural states and states that elected Trump to his second term, according to data collected since 2022 by the Clean Investment Monitor, a joint project by the Rhodium Group and the Massachusetts Institute of Technology’s Center for Energy and Environmental Policy Research.

“Any Republican who votes for this legislation is voting against the interest of their constituents, voting to kill jobs in their district, voting to kill clean energy projects, voting to make their constituents’ energy bills go up,” Sittenfeld said.

Far-right House members who as of Wednesday afternoon were withholding their votes maintain the rollbacks on the clean energy tax cuts, which they’ve dubbed the “green new scam,” do not go far enough.

Senate Minority Leader Chuck Schumer, D-N.Y., walks back onto the Senate floor after speaking to reporters at the U.S. Capitol Building on June 30, 2025 in Washington, D.C. (Photo by Andrew Harnik/Getty Images)

WASHINGTON — Senate Republicans were closing in Monday on passing their version of the “big beautiful” tax break and spending cut bill that President Donald Trump wants to make law by a self-imposed July Fourth deadline.

But the chamber’s Democrats first kicked off a marathon of amendment votes, forcing their GOP colleagues to go on the record on tough issues, including cuts to health and food safety net programs. As of early evening, Democrats had not prevailed on any votes.

The tactic is used by the opposition party during massive budget reconciliation fights to draw attention to specific issues even as their amendments are likely to fail.

Democrats decried numerous measures in the mega-bill, including new work reporting requirements for Medicaid, the federal-state health insurance program for low-income people and people with disabilities.

Loud opposition has also swelled as legislative proposals shift significant costs of the federal Supplemental Nutrition Assistance Program, or SNAP, to states for the first time.

“I say to our colleagues, ‘Vote for families over billionaires,’” Sen. Amy Klobuchar of Minnesota said on the Senate floor.

The heart of the nearly 1,000-page legislation extends and expands the 2017 tax law to keep individual income tax rates at the same level and makes permanent some tax breaks on business investments and research and development costs.

The bill would also put in motion some of Trump’s campaign promises, including no tax on qualifying tips, overtime or car loan interest, but only for a few years.

The tax cuts are estimated to cost nearly $4.5 trillion over 10 years, and a provision in the bill raises the nation’s borrowing limit to $5 trillion as the United States faces record levels of debt.

Overall, the Senate bill is projected to add $3.25 trillion to deficits during the next decade, according to the latest calculation from the nonpartisan Congressional Budget Office.

Here are some key votes so far:

Planned Parenthood 

Washington Democratic Sen. Patty Murray tried to remove language from the bill that would block Medicaid payments from going to Planned Parenthood for one year unless the organization stops performing abortions.

Federal law already bars funding from going toward abortions, with limited exceptions, but GOP lawmakers have proposed blocking any other funding from going to the organization, effectively blocking Medicaid patients from going to Planned Parenthood for other types of health care.

Murray said the proposal would have a detrimental impact on health care for lower-income women and called it a “long-sought goal of anti-choice extremists.”

“Republicans’ bill will cut millions of women off from birth control, cancer screenings, essential preventive health care — care that they will not be able to afford anywhere else,” Murray said. “And it will shutter some 200 health care clinics in our country.”

Mississippi Republican Sen. Cindy Hyde-Smith opposed efforts to remove the policy change and raised a budget point of order, which was not waived following a 49-51 vote. Maine Republican Sen. Susan Collins and Alaska’s Lisa Murkowski voted with Democrats.

“There was a time when protecting American tax dollars from supporting the abortion industry was an uncontroversial, nonpartisan effort that we could all get behind,” Hyde-Smith said.

Medicaid for undocumented immigrants

Senators from both political parties crossed the aisle over whether the federal government should reduce how much a state is given for its Medicaid program if that state uses its own taxpayer dollars to enroll immigrants living in the country without proper documentation.

The provision was included in an earlier version of the bill, but the Senate parliamentarian ruled it didn’t comply with the complex rules for moving a budget reconciliation bill.

The vote was 56-44, but since it was on waiving a budget point of order, at least 60 senators had to agree to set aside the rules and move forward with the amendment, so the vote failed.

Democratic Sens. Catherine Cortez Masto of Nevada, Maggie Hassan of New Hampshire, and Jon Ossoff and Raphael Warnock of Georgia voted with GOP senators. Maine’s Collins voted with most of the chamber’s Democrats against moving forward.

Texas Republican Sen. John Cornyn asked for the vote, saying he believes the policy change would reduce undocumented immigration.

“Border patrol talks about push and pull factors,” Cornyn said. “One of the pull factors for illegal immigration is the knowledge that people will be able to receive various benefits once they make it into the country.”

Senate Budget Committee ranking member Jeff Merkley, D-Ore., opposed Cornyn’s attempt to get the language back in the bill, saying the policy change would financially harm states that expanded Medicaid under the 2010 health care law for simple mistakes.

“What this amendment says is that if one person, despite state law, through a bureaucratic mistake, is receiving funds, then the whole state pays the price and has their rate on expanded Medicaid changed from 90% to 80%,” Merkley said, referring to the percentage paid by the federal government.

Reduction in funding for Consumer Financial Protection Bureau

An amendment to stop a nearly 50% reduction in funding for the Consumer Financial Protection Bureau was blocked by Republican Sen. Tim Scott of South Carolina, who chairs the Senate Committee on Banking, Housing and Urban Affairs.

Sen. Elizabeth Warren, a Democrat who championed the CFPB after the 2008 financial collapse, attempted to bring the amendment to the floor saying the agency “is the financial watchdog to keep people from getting cheated on credit cards and mortgages and Venmo and payday loans and a zillion other transactions.”

“When this financial cop can’t do its job there is no one else in the federal government to pick up the slack,” Warren said.

Scott blocked her using a budget point of order, saying the reduction still provides “ample funding” for the agency. Democrats tried to waive that procedural tactic, but failed following a 47-53 vote.

An original provision to completely zero out the budget for the CFPB was not included because it did not meet the reconciliation process’ parameters.

Medicaid hospitals and maternal mortality

Senators voted 48-52 to reject Delaware Democratic Sen. Lisa Blunt Rochester’s proposals to send the legislation back to committee to remove language cutting certain funding for Medicaid, which she said would negatively impact “vital hospital services, especially labor and delivery rooms.”

“Today, Medicaid is the single largest payer of maternity care in the United States, covering 40% of births nationwide and nearly half of the births in our rural communities,” Blunt Rochester said. “Obstetric units, particularly in rural hospitals, are closing at alarming rates, actually creating maternity deserts.”

No Republicans spoke in opposition to the proposal, though Maine’s Collins voted in support. 

Supplemental Nutrition Assistance Program

New Mexico Democratic Sen. Ben Ray Luján offered a motion to commit the bill back to committee in order to remove all changes related to the Supplemental Nutrition Assistance Program, or SNAP. It was rejected following a 49-51 vote, though Alaska Republican Sens. Dan Sullivan and Murkowski voted in favor.

“I’m offering my colleagues the opportunity to step away from these devastating cuts, to show our fellow Americans that in this country we care for our friends, family and neighbors who need support,” Luján said.

Senate Agriculture Chairman John Boozman, R-Ark., opposed the proposals, saying that SNAP is “on an unsustainable path wrought with mismanagement and waste.”

“This program has devolved into viewing success as enrolling more individuals to be dependent on government assistance,” Boozman said. “SNAP is long overdue for change.”

Medicaid work requirements

Senators voted 48-52 to reject a proposal from Delaware Democratic Sen. Chris Coons that would have sent the bill back to committee to remove language requiring Medicaid enrollees to work, participate in community service, or attend an educational program at least 80 hours a month. Alaska’s Murkowski was the only member of her party to vote in favor of the effort.

Democrats have expressed concern for weeks that some people would lose access to Medicaid if they forgot to complete paperwork proving that time commitment or didn’t understand how to show the government they met the new requirement.

“It is cruel and dishonest to bury patients, kids and seniors in paperwork and then blame them when they lose their health care, all to further rig our tax code for the very wealthiest,” Coons said.

Kansas Republican Sen. Roger Marshall urged opposition to the proposal, saying that working helps people.

“My question is, don’t you think a job brings value, that it brings dignity?” Marshall said. “Do you not think it brings purpose and meaning to life?”

Rural hospitals and Medicaid

Maine’s Collins and Alaska’s Murkowski both voted for a proposal from Massachusetts Democratic Sen. Ed Markey that would have removed parts of the bill changing Medicaid.

But even with some bipartisan support, the changes were rejected on a 49-51 vote that would have technically sent the bill back to committee for three days to implement the changes.

“My Republican colleagues’ so-called Medicaid cuts replacement fund is like giving aspirin to a cancer patient,” Markey said. “It is not enough. It is pathetically inadequate to deal with the health care crisis Republicans are creating here today on the Senate floor. No billionaire tax break or Donald Trump pat-on-the-back is worth the risk of people’s lives.”

Senate Finance Committee Chairman Mike Crapo, R-Idaho, spoke out against the proposal, saying that rural hospitals have long had financial challenges and that it was clearly “intended to derail this very bill.”

“Unfortunately for far too long some rural hospitals have struggled to achieve financial stability, even with a wide-range of targeted payment enhances,” Crapo said. “These issues pre-date the consideration of the reforms that we are including in the legislation today.” 

 

U.S. Sen. Josh Hawley, R-Mo., talks to reporters at the U.S. Capitol on Saturday, June 28, 2025. Hawley said he will vote for the budget reconciliation measure after a rural hospital fund was added. (Photo by Ashley Murray/States Newsroom)

This report has been updated.

WASHINGTON — The U.S. Senate voted mostly along party lines late Saturday night to move forward with Republicans’ “big, beautiful bill” that President Donald Trump wants on his desk in less than a week, after a dramatic three-hour pause when several GOP senators withheld their votes.

Republican Sens. Thom Tillis of North Carolina  and Rand Paul of Kentucky voted against moving forward with the sweeping tax break and spending cuts package that contains many of the GOP’s campaign promises. All Democrats were opposed. Vice President JD Vance came to the Capitol in case a tie-breaking vote was required, but in the end was not needed.

Tillis, who is up for reelection in 2026, had told reporters earlier that he would vote “no” on what is called a motion to proceed and on final passage. 

He said in a statement the legislation would result in tens of billions of dollars in lost funding for North Carolina and force the state to make “painful decisions” about Medicaid. Trump in a post on social media later threatened to find primary candidates to challenge Tillis.

The 51-49 vote doesn’t guarantee the bill will make it through a final passage vote but does make it significantly more likely, even with Republicans’ narrow 53-47 majority.

The procedural vote kicked off a maximum of 20 hours of floor debate on the bill, with half of that time controlled by Democrats and the other half by Republicans — though Democrats after the motion to proceed vote forced a reading of the giant bill expected to take as long as 15 hours. That would mean floor debate would not begin until sometime Sunday.

Unlike regular bills, budget reconciliation packages are not subject to the Senate’s 60-vote legislative filibuster, so as long as at least 50 Republicans support the package, and Vance casts the tie-breaking vote if needed, the measure will go back to the House.

The vote on the motion to proceed that began at about 7:30 p.m. Eastern was held open for more than three hours, with the votes of four senators in suspense — Lisa Murkowski of Alaska, Mike Lee of Utah, Cynthia Lummis of Wyoming and Rick Scott of Florida. All four eventually voted aye and Wisconsin Sen. Ron Johnson switched his vote to aye after earlier voting against the measure.

Lee, however, just before the vote was over, announced he had pulled from the bill an extremely controversial proposal to sell some public lands that was opposed by other lawmakers from the West. He said because of the process being used for the bill, he was unable to obtain enforceable safeguards to ensure the land would be sold to American families and not China or foreign interests.

The latest version of the measure had set up the Interior Department to sell at least 600,000 acres of public land and up to 1.2 million acres of public land within 10 years, advocates said.

Critics, including hunters, anglers and other Western state constituents, have ripped the measure as a “land grab,” as put by Jennifer Rokala, executive director for the Center for Western Priorities.

A summary of the provisions by the Energy and Natural Resources Committee said the Bureau of Land Management “must sell a minimum of 0.25% and a maximum of 0.50% of their estate for housing and associated community needs. This will increase the supply of housing and decrease housing costs for millions of American families.”

Golfing with Trump

Senate GOP leaders released new bill text just before midnight Friday that satisfied rural state lawmakers’ worries about financial threats to rural hospitals posed by cuts in Medicaid. The bill also addresses concerns by Murkowski and Dan Sullivan of Alaska about access to food assistance for their constituents despite new restrictions on a USDA program for low-income people.

As talks continued on Capitol Hill Saturday afternoon, a handful of Senate Republicans, including Missouri’s Eric Schmitt and Lindsey Graham of South Carolina, were on the golf course with Trump, according to the White House. Graham said on social media that Kentucky’s Paul also played.

Senate Democrats said a fresh financial analysis from the nonpartisan Congressional Budget Office estimated the preliminary Senate text would result in $930 billion in cuts to Medicaid, the joint federal-state low-income health insurance and disability assistance program.

The CBO score was not yet publicly available but Sen. Ron Wyden, the top Democrat on the Senate Committee on Finance, pointed to it and slammed the Medicaid provisions as “cruel” in a statement Saturday afternoon. 

Sen. Elizabeth Warren of Massachusetts, ranking Democrat on the Senate Banking, Housing, and Urban Affairs Committee, also cited the preliminary analysis, pointing to the nearly $1 trillion in Medicaid cuts.

Collins promises amendments

Senate Republicans planned to take their negotiations to the floor and push for amendments after the procedural vote that triggered official debate on the bill, which in its current public version runs 940 pages.

GOP Sen. Susan Collins of Maine, who voiced concerns throughout negotiations about rural hospitals and health cuts that would harm low-income individuals, said her vote on the motion to proceed “does not predict my vote on final passage.”

“I will be filing a number of amendments,” she told reporters as she headed into a closed-door working lunch before the Senate convened at 2 p.m. Eastern.

While Sen. Tim Sheehy wrote on social media Saturday afternoon that he was a “no” on the motion to proceed because of a provision to sell off federal public lands, the Montana Republican changed his mind nearly an hour later and declared he would propose an amendment to strip the provision — which was later removed by its sponsor.

GOP Sen. Markwayne Mullin of Oklahoma painted somewhat of a rosier picture of the mood in the Senate, telling reporters “we’re good.”

“We won’t bring it to the floor if we don’t have the votes,” said Mullin, who was the lead negotiator with House Republicans on state and local tax deductions, or SALT — a sticking point for Republicans who represent high-tax blue states like New York and California.

The lawmakers settled on a $40,000 deduction through 2029 for taxpayers who earn up to $500,000 annually. The level then reverts to $10,000, the current limit under the 2017 tax law.

Medicaid turmoil

Proposed changes to Medicaid have been strongly resisted by rural medical providers who say they are already financially strapped.

Missouri Republican Sen. Josh Hawley told reporters Saturday he would be a “yes” on both the motion to proceed vote and the final bill based on the new rural hospital “transformation program” Senate leadership included in the bill overnight. The measure has yet to be finalized.

The bill’s new version includes $25 billion in a stabilization fund for rural hospitals from 2028 through 2032. The amount is frontloaded to give more of the funds in the first two years.

Critics warn that amount will not fill the financial gaps that rural medical providers will face from losing a sizable portion of federal funding via Medicaid cuts.

While Hawley called the fund a “win” for Missouri over the next several years, he said his party needs to do some “soul searching” over the “unhappy episode” of wrangling over Medicaid cuts.

“If you want to be a working-class party, you’ve got to deliver for working-class people. You cannot take away health care for working people,” he said.

Senators had not yet agreed on other Medicaid provisions as of Saturday afternoon, including a phase-down of the provider tax rate from 6% to a possible 3.5% that’s become hugely controversial.

States use a combination of general revenues, provider tax revenues and in some cases local contributions to fund their Medicaid programs.

Advocates warn that it’s not a guarantee states would be able to backfill the lost revenue, and if they can’t, provider rate cuts and losses of benefits for patients could be on the horizon.

The nonpartisan Congressional Budget Office found that the House version’s provider tax changes — not as deep as the current Senate proposal — could lead to 400,000 people losing Medicaid benefits.

A full and final financial score for the Senate bill is not yet out as the several provisions remain up in the air.

Hawley also praised the inclusion of the Radiation Exposure Compensation Act fund, or RECA, that revives payments for survivors and victims who suffered cancer as a result of U.S. atomic bomb testing and radioactive waste dumps.

Clean energy tax credits

In what clean power advocates dubbed a “midnight dumping,” Senate GOP leadership added language to accelerate the phase out of clean energy tax credits that were enacted under Democrats’ own massive mega-bill in 2022 titled the “Inflation Reduction Act.”

The language, which wasn’t yet finalized by Senate GOP tax writers as of 6 p.m. Eastern Saturday, tightened restrictions on foreign components in wind and solar projects — and added a new tax on those that don’t comply.

Senators largely targeted wind and solar credits, ending them for projects not plugged into the electricity grid by 2028. Additionally credits for wind turbine manufacturers would terminate in 2028.

Other tax credits would be phased out at a faster pace, including those for the production of critical minerals, though a credit for metallurgical coal, used in steelmaking, was added in.

Clean energy industry manufacturers and small businesses had hoped Senate Republicans would ease up rollbacks in the House version.

Kurt Neutgens, president and chief technology officer of Orange EV, told States Newsroom in an interview Friday that any further rollbacks would amount to “cutting our legs out from underneath us.”

Neutgens, whose Kansas City, Kansas-based company manufactures heavy duty electric trucks and chargers, was watching for changes to credits to the commercial clean vehicles credit. New Senate GOP text would terminate the credit in September of this year.

Jason Grumet, president of the Clean Power Association, said in a statement Saturday that imposing new taxes on the industry “will strand hundreds of billions of dollars in current investments, threaten energy security, and undermine growth in domestic manufacturing and land hardest on rural communities who would have been the greatest beneficiaries of clean energy investment.”

Alaska carve-outs

Proposed cuts to federal food assistance remained largely unchanged in the new text released Friday night except for a few carve-outs for Alaska.

If the bill were enacted as written, Alaska’s state government could request a waiver for its citizens from stricter work reporting requirements that critics say will result in some SNAP recipients losing their food benefits.

GOP lawmakers also slightly shifted the timeline for when states will have to begin shouldering SNAP costs — the first time states will be on the hook for the federal food assistance outside of administrative costs.

States would be required to pick up a portion of the costs depending on their “payment error rate” — meaning how accurate states are at determining who needs SNAP, including both overpayments and underpayments.

States that have error rates at 6% or above would responsible for up to 15% of the food program’s cost. According to SNAP error rate data for 2023, the latest available, only seven states had an error rate below 6%.

The new text delays the cost-sharing for states until 2028 and allows states to choose the lesser of their two error rates in either 2025 or 2026.

Starting in 2029, states will be required to use their error rate from three years prior to the current year.

The new text includes the option for Alaska and Hawaii to waive their cost share burden for up to two years if their governments implement an improvement plan. In 2023, Alaska had the highest payment error rate of all states, reaching just above 60%. 

Advocates for low-income families worry the cost, which will amount to billions for most state governments, will incentivize states to tighten eligibility requirements for the program, or even drop SNAP altogether.

The left-leaning Center on Budget and Policy Priorities estimates the cuts will affect up to 40 million people who receive basic SNAP assistance, including 16 million children and 8 million seniors.

The Senate bill would also increase a state’s share of administrative costs for the program to 75%, up from the previous 50% cost-sharing responsibility with the federal government.

Despite inaccurate public statements from Republicans as recently as in a bill summary released overnight, the bill does nothing to limit food assistance to immigrants without documentation because SNAP was never available to them.

SNAP benefits will remain available to legal permanent residents, and Republicans loosened some language to allow certain immigrants from Cuba or Haiti to access the program.

But if the bill passes, federal food assistance will not be available to refugees and asylees who are already in the U.S. — for example, people from Afghanistan, Ukraine and other war-torn places.

Education revisions

Republicans on the Senate Committee on Health, Education, Labor and Pensions revised or scrapped several measures that the parliamentarian deemed to not comply with the “Byrd Bath,” a Senate process named for the late Sen. Robert Byrd, according to a summary and new bill text out Friday.

Under the revised text, for any loans made starting July 1, 2026, borrowers will have only two repayment plan options: a standard repayment plan and an income-driven repayment plan. The original proposal would have applied these restrictions to existing borrowers, but the parliamentarian struck that down.

Republicans also nixed a proposal that opened up the Pell Grant — a government subsidy that helps low-income students pay for college — to institutions that are not accredited.

The new plan also scraps a restriction that barred payments made by students enrolled in a medical or dental internship or residency program from counting toward Public Service Loan Forgiveness.

‘Even worse than any draft’

Senate Democrats remain united in opposition to the bill and are expected to slow down final passage by introducing numerous amendments on the floor during what is called the vote-a-rama.

Senate Minority Leader Chuck Schumer continued to rally against the package during remarks on the Senate floor Saturday afternoon, saying it’s “hard to believe this bill is worse — even worse — than any draft we’ve seen this far.”

The New York Democrat said “it’s worse on health care, it’s worse on SNAP (the Supplemental Nutrition Assistance Program), it’s worse on the deficit.”

Schumer added that “if Republicans proceed, Senate Democrats will hold them to account.”

“We’ll gear up for another night of vote-a-rama very soon. We’ll expose this bill piece by piece. We will show how it cuts health care, raises costs, rewards the ultra rich.”

The Center on Budget and Policy Priorities condemned the cuts to safety net programs as “all in service to tax cuts that are heavily skewed toward the wealthy and corporations.”

“None of this harm has anything to do with fiscal responsibility: our deficits and debts would soar under this bill,” said Sharon Parrott, the think tank’s president, in a statement Saturday.

The Committee for a Responsible Federal Budget, a nonpartisan watchdog, released a new analysis Saturday finding the Senate version will add roughly $4 trillion to the national deficit over 10 years.

“If you thought the House bill borrowed too much — and it did — the Senate manages to make things even worse,” CRFB’s president Maya MacGuineas said in a statement.

House action

Senate Republicans have spent more than a month rewriting the bills that make up the measure in order to meet the strict rules for moving a budget reconciliation package and to earn support from enough Republicans to actually pass the legislation.

The lawmakers have been struggling to maintain spending cuts passed by House Republicans that will pay for the nearly $4 trillion price tag for extending and expanding the 2017 tax cuts.

The House voted 215-214 to approve its 11-bill version of the package in May. Many of that chamber’s GOP lawmakers hoped the Senate wouldn’t change much, though that hasn’t been the case.

The Senate has modified numerous proposals, including those addressing tax law; Medicaid; and SNAP. The Senate bill also raises the country’s debt limit by $5 trillion, a full $1 trillion more than the House version.

The revisions have led to concerns among both centrist House GOP lawmakers and far-right members of the party, muddying the waters around whether Speaker Mike Johnson, R-La., can cobble together the votes needed to clear the package for Trump’s signature.

Republicans hold a 220-212 majority in the House, so leaders there can only lose four members if all of the chamber’s lawmakers are present and voting.

Trump has encouraged Congress to approve the legislation before the Fourth of July, but with time running short and some tempers rising over how the legislation will impact the country’s deficits, that might not be possible.

“The Great Republicans in the U.S. Senate are working all weekend to finish our ‘ONE, BIG, BEAUTIFUL BILL’,” Trump posted on social media Friday.

“The House of Representatives must be ready to send it to my desk before July 4th — We can get it done,” he added. “It will be a wonderful Celebration for our Country, which is right now, ‘The Hottest Country anywhere in the World’ — And to think, just last year, we were a laughingstock. Thank you for your attention to this matter!”

U.S. Senate Majority Leader John Thune, R-S.D., speaks to reporters at the Capitol as lawmakers work on the "One Big Beautiful Bill Act" on June 25, 2025 in Washington, D.C.  (Photo by Joe Raedle/Getty Images)

WASHINGTON — U.S. Senate Republicans appeared deeply divided Wednesday over how to establish a fund for rural hospitals to offset the budget impacts of Medicaid cuts in the “big, beautiful bill.”

The hospitals, which are generally already hurting financially, rely heavily on Medicaid, a state-federal partnership that provides health insurance for low-income households and for some people with disabilities.

GOP senators haven’t yet reached agreement on how to structure the fund, or on dozens of other unresolved provisions in the sweeping package, even though leaders hope to begin voting as soon as Friday. Still up in the air were agreements on major provisions of the measure involving the U.S. Department of Agriculture’s food aid program for low-income people and a proposed selloff of certain public lands.

Republican leaders continued to project optimism. “We’re well on our way to getting this bill passed this week,” Senate Majority Leader John Thune, R-S.D., said during a floor speech, continuing to press ahead toward a self-imposed Fourth of July deadline. 

Others saw it differently. Wisconsin Republican Sen. Ron Johnson cast doubt on the short timeframe leaders have set to reach final agreement and move the bill through both chambers.

“We’re still discussing some pretty fundamental issues,” Johnson said. “I’m just laying out the reality of the situation. We’ve got a lot of work to do.”

‘The only person up here that’s ever ran a rural hospital’

Dueling plans to establish the rural hospital fund to ease the threat of Medicaid cuts circulated among senators working to finalize the massive tax and spending cut measure, but an agreement had not surfaced by late afternoon.

Unofficial details showed Senate Republicans eyeing the inclusion of a $15 billion fund — $3 billion a year between fiscal 2027 and fiscal 2031 — to help rural hospitals, according to multiple reports.

But Sen. Roger Marshall, who sits on the Senate Committee on Finance, said he wants to increase that fund to $5 billion annually, with “half of that going to rural hospitals, and half of it going to primary care and prescription drugs and throw in physical therapy and occupational therapy, all the others as well.”

The Kansas Republican and physician said “we should probably only do it for four or five years and then regroup and see where we are.”

“I’m the only person up here that’s ever ran a rural hospital — I actually know something about them,” he added.

While Marshall said he loves “90%” of the broader bill, he said not nearly enough is being cut.

“But I can’t get the votes to do that, so it’d still be the largest cut in spending in my lifetime anyway,” he said, noting that “it’s going to be hard for the House to vote against it.”

Fund size criticized

On a midday call with reporters, Traci Gleason with the Missouri Budget Project said the stabilization fund being batted around by lawmakers “would fall well short of addressing these problems.”

“Forty-three percent of Missouri’s rural hospitals are at risk of closing, and 17% are considered to be at immediate risk,” said Gleason, who spoke during a virtual press briefing organized by the left-leaning Center for Budget and Policy Priorities.

“Those figures don’t account for all of the other health care providers in rural communities, like federally qualified health centers and others that operate on these incredibly thin margins. So the massive cuts to Medicaid are what is creating the problem and the only real way to address it is for Congress to not make these massive cuts,” she said.

‘Problematic’ Medicaid cuts

Sen. Susan Collins was advocating for a much bigger rural hospital stabilization fund, at $100 billion.

“I don’t think that solves the entire problem,” the Maine Republican and chair of the Senate Appropriations Committee said.

“The Senate cuts in Medicaid are far deeper than the House cuts, and I think that’s problematic as well.”

Sen. Jim Justice of West Virginia said that the $15 billion “is better than zero.”

“You know, naturally, I’d want it to be as high as it possibly can,” he said, adding that rural hospitals are the “lifeblood” of his state.

Sen. Josh Hawley of Missouri, a loud voice against Medicaid benefit cuts, said a stabilization fund is a “good idea but we’re still going to have to address the longer term effects of this.”

When asked for a dollar figure, Hawley said “it depends on the structure of it.”

Texas Republican Sen. John Cornyn said he keeps hearing the Senate will take a procedural vote on Friday, though that isn’t set in stone. 

“Should be a fun weekend for all of us,” Cornyn said. “Can’t wait.”

Once the Senate votes on what is called a motion to proceed, there’s a maximum of 20 hours of floor debate before the chamber must begin its marathon amendment voting session and eventually a passage vote.

SNAP provisions

Senate Agriculture Chairman John Boozman, an Arkansas Republican, said a revised version of his committee’s bill had not yet been reviewed by the parliamentarian.

The updated text alters a section restructuring the cost-share of the Supplemental Nutrition Assistance Program, or SNAP, a key food assistance program for low-income people.

The provision would require states for the first time to shoulder some of the cost of the program’s benefits. The amount a state owes would be determined by its error payment rate, with greater error rates requiring a higher state share.

Complex rules govern what can and can’t be included in the measure. The Senate parliamentarian ruled the language in the initial proposal did not comply with the chamber’s reconciliation rules.

The updated proposal would allow states more flexibility during the policy’s phase-in in fiscal 2028, allowing them to choose either the error rate in fiscal 2025 or fiscal 2026.

Boozman told reporters that change sought to respond to the parliamentarian’s ruling.

The parliamentarian “asked us to allow them (states) to use a different time frame — essentially gave them more time to understand what their error rate would be and to plan for it,” Boozman said. “And so we adjusted for that and I think we satisfied it.”

Lee and public lands

Senate Energy and Natural Resources Chairman Mike Lee of Utah reportedly narrowed a provision that would mandate the sale of Bureau of Land Management lands. He has not publicly said where it stands with the parliamentarian.

A committee spokesman did not return messages seeking clarification Tuesday and Wednesday, but a version of the changes obtained by news media shows changes consistent with what Lee proposed Monday.

Those changes include limiting the mandated sales to only the BLM — and not U.S. Forest Service lands, as Lee had initially proposed — and lowering the percentage of the agency’s lands that must be sold to between .25% and .5%. The initial proposal required between .5% and .75%.

The updated provision would also only require lands located within 5 miles of a population center to be sold and exempts lands that are currently used for grazing or another “valid existing right that is incompatible with the development of housing,” according to a copy of the changes obtained by hunting and angling publication Outdoor Life.

The provision has sparked opposition from Western lawmakers, including a handful of conservatives.

But it also has its share of supporters. Alaska Republican Dan Sullivan told reporters he had not seen the updated text but remained supportive of the idea.

“I’ve been supportive of what Sen. Lee is trying to do,” he said. “We have a lot of public lands in Alaska that the federal government abuses. But we’re in a good discussion on that, so I need to see the update.”

 

House Speaker Mike Johnson of Louisiana speaks to reporters about the Republican budget reconciliation package at a weekly press conference on Tuesday, June 24, 2025, at the U.S. Capitol. (Photo by Ashley Murray/States Newsroom)

This report has been updated.

WASHINGTON — U.S. Senate Republicans were scrambling Tuesday to restructure several proposals in the “big, beautiful bill” that don’t meet their chamber’s strict rules for passing a reconciliation package, while GOP lawmakers on the other side of the Capitol warned those changes may doom its passage in the House.

Senate Majority Leader John Thune, R-S.D., said he and several others are working on a way to bolster rural hospitals, which could experience financial strain as a result of the various changes to Medicaid and other health care programs in the package.

“We are working on a solution for rural hospitals and that’s something that’s been in the works now for several days in response to a number of concerns that our colleagues have mentioned in ensuring that the impact on rural hospitals be lessened, be mitigated,” Thune said. “And I think we’re making good headway on that solution.”

Thune said GOP lawmakers shouldn’t let the “perfect be the enemy of the good,” though he predicted there “could be” two or three Republicans who vote against the package.

“We’ve got a lot of very independent-thinking senators who have reasons and things that they’d like to have in this bill that, in their view, would make it stronger,” Thune said. “But at the end of the day this is a process whereby not everybody is going to get what they want. And we have to get to 51 in the United States Senate.”

More objections to Medicaid cuts

Missouri Sen. Josh Hawley, who has been vocal about Medicaid changes and rural hospitals, said he had “no details whatsoever” about the rural hospital fund or how it would work if it’s added to the bill.

But he said he’s not going to support a bill that takes away working people’s health care.

“We’ve got 1.3 million people on Medicaid in Missouri, hundreds of thousands of kids. That’s 21% of my population. Most of these people are working people. They’re on Medicaid, not because they’re sitting around at home; they’re on Medicaid because they don’t have a job that gives them health care and they cannot afford to buy it on the exchange,” Hawley said. “They don’t want to be, but it’s their only option. And I just think it’s wrong to take away health care coverage from those folks. Now if they’re not working, then sure, they should be.”

Senate Republican Policy Committee Chair Shelley Moore Capito, R-W.Va., said she had a “lengthy discussion” with her home state’s hospital association earlier in the day.

“This has a lot of impacts and we want to make sure we have a lot of rural hospitals. That’s why this rural hospital fund idea is developing,” Capito said. “I don’t think anything is set yet but that is an issue. I think Medicaid, we need to preserve it for the people it’s intended for and get rid of the people who don’t deserve it and don’t qualify and are bilking the system.”

Capito said she hadn’t yet formed an opinion on the rural hospital fund since there isn’t yet a formal proposal written down.

Public lands

In one major development, the Senate parliamentarian ruled Monday that a controversial provision championed by Senate Energy and Natural Resources Chairman Mike Lee to mandate the sale of at least 2 million acres of public lands in 11 Western states did not comply with the chamber’s rules for reconciliation.

Lee, a Utah Republican, has said the provision would free up land to build new housing. But Democrats and some Republicans from the affected states strongly opposed it.

Lee said on social media Monday evening that he was working to rewrite the proposal to comply with reconciliation rules. A spokesperson for his office did not return a message seeking comment Tuesday morning.

SNAP cost-sharing under debate

In another turn of events, Senate Agriculture Chairman John Boozman, R-Ark., earlier Tuesday had announced the panel successfully reworked a provision that would transfer some of the cost of the Supplemental Nutrition Assistance Program to state governments.

But a spokesperson for the panel said later that the parliamentarian actually has not yet made a ruling. The spokesperson said “we’ve gotten some clarification from leadership and it’s steering in the direction it would be compliant but not official.”

Boozman earlier had said his proposal would improve SNAP. “Our commonsense approach encourages states to adopt better practices, reduce error rates, be better stewards of taxpayer dollars, and prioritize the resources for those who truly need it,” Boozman wrote in a statement.

The new language, if accepted, would give states the option of selecting fiscal year 2025 or 2026 as the year that the federal government uses to determine its payment error rate for SNAP, which will then impact how much of the cost the state has to cover starting in fiscal year 2028. Afterward, a state’s payment error rate will be calculated using the last three fiscal years.

Any state with an error rate higher than 6% will have to cover a certain percentage of the cost of the nutrition program for lower income households.

Rushing toward deadline

The internal debates among lawmakers about how to rewrite major pieces of the tax and spending cuts package have led to a rushed feeling among Republican leaders, who have repeatedly promised to approve the final bill before the Fourth of July — an exceedingly tight timeline.

Speaker Mike Johnson, R-La., said during a press conference shortly after a closed-door House GOP conference meeting Tuesday that he’s hopeful the final bill that comes out of the Senate won’t make too many changes to what the House approved earlier this year.

“I remain very optimistic that there’s not going to be a wide chasm between the two products — what the Senate produces and what we produce,” Johnson said. “We all know what the touchpoints are and the areas of greatest concern.”

Republicans, he said, know they need to focus on preserving a fragile compromise on the state and local tax deduction, or SALT, that helps offset the cost of living in some higher-tax states like California, New Jersey and New York.

A deal Johnson brokered with GOP lawmakers in the SALT Caucus has been significantly rewritten in the Senate, but is expected to move back toward the House version, though not entirely.

Johnson also mentioned GOP efforts to roll back certain clean-energy provisions that Democrats approved and President Joe Biden signed into law in their signature climate change, health care and tax package, called the Inflation Reduction Act, or IRA, in 2022.

“We’ve got to get the SALT negotiation number right. We’ve got to make sure the IRA subsidies are handled in an appropriate manner,” Johnson said. “Look, you’ve got a number of provisions.”

Johnson said he expects the Senate to vote on its final bill by Friday or Saturday and that he’s told House lawmakers to “keep your schedules flexible” on being in Washington, D.C., for a final House vote. 

Trump goads Republicans

President Donald Trump sought to spur quick approval of a final bill, posting on social media that GOP lawmakers should get the package to him as soon as possible.

“To my friends in the Senate, lock yourself in a room if you must, don’t go home, and GET THE DEAL DONE THIS WEEK. Work with the House so they can pick it up, and pass it, IMMEDIATELY,” Trump wrote Tuesday. “NO ONE GOES ON VACATION UNTIL IT’S DONE. Everyone, most importantly the American People, will be much better off thanks to our work together. MAKE AMERICA GREAT AGAIN!”

Oklahoma Sen. Markwayne Mullin said there are concerns among his fellow Republicans about all of the provisions that must be removed or significantly reworked to meet the complex rules for moving a reconciliation bill through that chamber.

“Every time something comes out that we’re using as a pay for, it takes the deficit reduction down. And they’ve taken out nearly $300 billion so far. We’ve got to make that up,” Mullin said after leaving the closed-door House GOP meeting. “The Senate can’t come in below the House version as far as deficit reduction. So that makes it difficult.”

Mullin, who has been acting as his chamber’s top negotiator with SALT Republicans in the House, told reporters he expects the deduction for state and local taxes to remain at the $40,000 level negotiated in the House. But said the Senate will likely rewrite the $500,000 income ceiling to qualify for the tax deduction.

“I think 40 is a number we’re going to land on,” Mullin said. “It’s the income threshold that’s in negotiations.”

Sen. Kevin Cramer of North Dakota said “most of us would like to make it zero.”

“I hate the idea of $40,000 but if that’s what it takes to pass the bill, I probably could do it. I would like to maybe find some other tweaks to it, somehow, like changing the income levels,” he said.

Treasury Secretary Scott Bessent told reporters he expects a resolution on SALT in the next 24 to 48 hours.

“I had a very successful lunch meeting with the senators. I think that we are on track,” Bessent said.

The ‘red line’ in the House

New York Republican Rep. Mike Lawler told reporters following the closed-door meeting that Senate leaders shouldn’t assume whatever they pass will be accepted by the House.

“I’ve been very clear about where my red line is. So, you know, we’ll let this process play out,” Lawler said. “I think the Senate should recognize the only number that matters is 218, and 50 plus 1. That’s it. And how do you get there?”

Republicans hold 53 seats in the Senate, so leadership cannot lose more than four votes and still approve the package, given that Democrats are universally opposed.

In the House, GOP leaders have 220 seats and need nearly every one of their members to support whatever the Senate sends back across the Capitol for it to make it to the president’s desk before their self-imposed deadline.

In addition to the SALT tax compromise, Lawler said he has concerns about how the Senate has changed other provisions, including those addressing Medicaid, the state-federal health program for lower income people.

“Yeah, there are a number of concerns about decisions that they’re making,” Lawler said. “And obviously, the bill on their side is not final, so we’ll see where it goes.”

Missouri Republican Rep. Jason Smith, chairman of the Ways and Means Committee that crafted the tax provisions in the reconciliation bill, stood by the House’s version of the Opportunity Zone Tax Incentives. The House version extends the incentive from the 2017 Tax Cuts and Jobs Act for a year, while the Senate’s version makes it permanent.

The Opportunity Zone Tax Incentive was pushed by South Carolina Sen. Tim Scott during the first Trump administration, which aimed to create tax cuts for businesses and real estate to invest in low-income communities, but it had mixed results.

“The tax bill that we’re going to deliver is gonna deliver for working families, small businesses and farmers,” Smith said.

Thumbs down from one House Republican

House Freedom Caucus Chairman Andy Harris, R-Md., posted on social media that he doesn’t support how the Senate has changed the bill and that he would seek to block it from becoming law. 

“The currently proposed Senate version of the One Big Beautiful Bill weakens key House priorities—it doesn’t do enough to eliminate waste, fraud, and abuse in Medicaid, it backtracks on Green New Scam elimination included in the House bill, and it greatly increases the deficit – taking us even further from a balanced budget.

“If the Senate tries to jam the House with this version, I won’t vote ‘present.’ I’ll vote NO.”

Rattlesnakes and the Senate

West Virginia Republican Sen. Jim Justice told reporters that it’s important for the Senate to take its time in its changes to the reconciliation package and that GOP lawmakers need to be patient.

“If you’re walking through the woods and you look right over there at that wall and there’s a rattlesnake all curled up there and everything, what do you do?” Justice asked. “Most people just jump and take off runnin’, well … rattlesnakes run in pairs and if you just jump left or right or behind, that one can hurt you right there.”

Rattlesnakes are typically solitary creatures, but new research has shown that rattlesnakes are more social than previously thought.

Justice said the best course of action when dealing with a rattlesnake, or two, is to stand still for a moment.

“Look to the left, look to the right, look behind you, and then decide which way you’re going,” he said. “That’s what I think we need to do (in the Senate).”

U.S. Senate Minority Leader Chuck Schumer, D-N.Y., speaks during a press conference inside the Capitol building on Wednesday, June 18, 2025. Oregon Democratic Sen. Ron Wyden is at right. (Photo by Jennifer Shutt/States Newsroom)

WASHINGTON — The next hurdle for Republican leaders in the U.S. Senate and the “big, beautiful bill”: Democrats — and possibly a few of their own members — in a marathon voting session will make last-ditch attempts to change the tax and spending cut measure.

The vote-a-rama, as it’s known, is expected to begin sometime during the last full week of June as Congress heads toward the Fourth of July recess. It will likely begin in the afternoon and  last overnight into the next morning. Senators will debate and vote on dozens of amendments attempting to revise the massive legislation that could have an effect on nearly every American.

Democrats, who have 47 votes in the Senate compared to 53 for Republicans, plan to zero in on Medicaid, taxes, corruption, policies that could raise energy costs and proposals that would increase the deficit, according to Senate Minority Leader Chuck Schumer.

Senate Majority Leader John Thune, R-S.D., and the committee chairs tasked with drafting pieces of the package have spent weeks combing through the House-passed bill to figure out what needs to be altered to avoid divisive floor votes. 

They’ve rewritten numerous policy proposals to comply with the strict rules that go along with the complex reconciliation process and are now trying to work out disagreements among GOP senators that could doom or complicate a final deal.

The goal is to avoid a protracted debate over core GOP provisions in full public view once the vote-a-rama begins, though some senators are already predicting votes on GOP amendments.

‘A potentially messy process’

Missouri Republican Sen. Josh Hawley, who has raised concerns about the bill’s impact on rural hospitals, said he hopes GOP leaders reach a consensus before vote-a-rama but didn’t rule out offering his own amendments if they don’t settle their disputes.

“Amending it on the floor, that’s a potentially messy process,” Hawley said. “I would hope that we could get to a good place before that. But we have to fix the rural hospital issue.”

Alabama Republican Sen. Tommy Tuberville said he will likely propose amendments during floor debate, though he declined to say what specific policies he’d seek to change or eliminate from the package.

“Yeah, we’ll have some,” Tuberville said. “And we’ve got them all, we just haven’t turned them in yet.”

Thune said he and other negotiators are making “headway” toward consensus on the more significant provisions in the package, which in many respects is far from its final form.

“The meetings right now are on the major provisions in tax and health. We have sort of pre-litigated a lot of that,” Thune said. “But there are a lot of the other provisions in the bill, chapters in the bill that are still subject to going through the Byrd bath, and we’re in the process of doing that. But hopefully that’ll be done by early next week.”

Republicans are using the reconciliation process to pass their sweeping tax and spending cuts package through the Senate with just a simple majority vote, requiring them to comply with the Byrd rules.

That includes the Byrd bath — going before the Senate parliamentarian to explain how each provision has an impact on federal revenue or spending that is not “merely incidental.” Democrats then usually debate before the parliamentarian the various changes that don’t meet that threshold. The process is named after the late Sen. Robert Byrd, a West Virginia Democrat.

Once the parliamentarian rules what elements comply and which need to be removed, the bill can go to the floor and senators can trudge through vote-a-rama. Eventually, all 100 lawmakers will vote to approve or disapprove of the legislation.

GOP senators passing their version of the package would send it back to the House, which passed its version on a slim 215-214 vote earlier this year — and could make yet more changes in the Senate bill.

Democrats develop strategy

Democrats are hoping to highlight policy divisions among Republicans during the vote-a-rama. And even if they don’t succeed in getting any of their amendments adopted, several votes could serve as fodder for campaign ads during next year’s midterm elections.

Schumer said Wednesday during a press conference it would be “difficult” for Democrats to peel off at least four GOP senators from the rest of the party in order to get an amendment adopted, but said he’s hopeful Republicans will “vote with us on some things they’ve all said they’ve agreed with.”

Democratic senators, he said, have created a task force to reach out to Republicans on major issues in the package, including how it would impact rural hospitals.

“Many of these hospital administrators and employees are Republican,” Schumer, a New York Democrat, said. “In many of the rural hospitals, they are the largest employer in the county, and in most they’re the only supplier of health care. It infuriates the rural counties, and they tend to be Republican.”

‘It’s just a show, it’s a charade’

West Virginia Republican Sen. Shelley Moore Capito said she’s not concerned about having to vote on dozens of amendments. 

“We’re here to vote,” Capito said. “As a creature of the House, we voted all the time on everything, so this doesn’t bother me. And, you know, just let the body work its will. If some changes are made, those will have to be dealt with. But I’m not worried about that.”

Arkansas Republican Sen. John Boozman said he expects the vote-a-rama will be “a very late night” and that he’s not planning to offer any of his own amendments.

As chairman of the Agriculture, Nutrition and Forestry Committee, Boozman expects to spend a considerable amount of time during vote-a-rama arguing against amendments seeking to change those provisions — including controversial cuts in the Supplemental Nutrition Assistance Program, which provides food aid for lower-income families.

Wisconsin Republican Sen. Ron Johnson said he plans to spend much of the vote-a-rama “going back and forth from my hideaway,” the ceremonial office that every senator holds in the Capitol building.

But Johnson cast doubt on actually being able to amend the package during that process, saying changes to the various bills that Senate committees have released need to be agreed to before then.

“You’ve got to get this before it ever goes to the floor. I mean, you’re not going to change things substantially or significantly with amendments. I know people have some idealized version that happens. It doesn’t,” Johnson said. “You’ve got to get these things in the base bill. Amendments; it’s just a show, it’s a charade.”

Vote-a-rama after vote-a-rama

The Senate has held two vote-a-ramas so far this year, and both demonstrated how difficult it is to change a piece of legislation.

The first all-nighter in February went along with Senate debate on its budget resolution and included votes on 25 amendments, with lawmakers adopting just two — one from Alaska Republican Sen. Dan Sullivan and one from Utah Republican Sen. Mike Lee.

The second vote-a-rama took place in April just before the Senate voted to approve the budget resolution that ultimately cleared the way for Congress to use the budget reconciliation process to advance the “big, beautiful bill.” Senators debated 28 amendments, voting to adopt one change from Sullivan.

Oregon Democratic Sen. Ron Wyden, ranking member on the Finance Committee, said he and staff on the panel will continue to parse through details of the panel’s bill, which Republicans just released Monday.

Wyden said he plans to hold several town hall meetings in GOP areas of his state over the weekend to gauge how residents there view the policy revisions Republican senators have put forward.

“We’ve had this bill for basically 36 hours. The first time I had it, I stayed up all night, so last night I got a little sleep,” Wyden said on Wednesday. “But on the plane, I’ll be working through it. And I expect to be working through it all through the next few days, except when I’m having these town hall meetings where I’ll have a number of questions.”

Senate Majority Leader John Thune, R-S.D., center, accompanied by Sen. John Barrasso, R-Wyo., left, and Sen. Shelley Moore Capito, R-W.Va., right, speaks to reporters following a weekly Republican policy luncheon at the U.S. Capitol on Feb. 19, 2025 in Washington, D.C. (Photo by Andrew Harnik/Getty Images)

WASHINGTON — U.S. Senate Republican leaders expressed confidence Tuesday they’ll be able to tamp down opposition to various elements of the party’s “big, beautiful bill” in time to approve the measure before the Fourth of July, though they acknowledged there’s considerable work left to do. 

GOP senators from across the political spectrum have debated the broad strokes of the tax and spending cut legislation for weeks, but raised fresh concerns after the influential Finance Committee released its portion of the package, which addresses taxes and Medicaid. Some GOP senators objected to a change in Medicaid policy they said could harm rural hospitals.

Senate Majority Leader John Thune, R-S.D., said during a press conference that reducing the Medicaid provider tax rate that states can charge from the current 6% to 3.5% by 2031 represented “important reforms.”

“We think they rebalance the program in a way that provides the right incentives to cover the people who are supposed to be covered by Medicaid,” Thune said. “But we continue to hear from our members specifically on components or pieces of the bill that they would like to see modified or changed or have concerns about. And we’re working through that.”

While the complex provision is deep in the weeds of Medicaid policy, several GOP senators expressed concern during interviews Tuesday that changing the provider tax rate in states that expanded Medicaid coverage under the Affordable Care Act would be a problem for rural hospitals.

Missouri Sen. Josh Hawley said he opposes that provision and wants to see GOP leaders put back in the House language that would freeze the Medicaid provider tax rate at 6%.

“We have to do something,” Hawley said. “If we pass this as it is, there’s going to be a lot of rural hospitals in Missouri that close. So that’s a big problem.”

West Virginia Sen. Jim Justice said he had “all kinds of concerns” about provisions in the Finance Committee’s portion of the “big, beautiful bill,” which the panel released Monday.

“The House side on the provider tax and everything said, freeze it,” Justice said. “Now there’s a whole lot (of) different gyrations going on with that and everything. And there’s other things that we just need to — just give us some time. We need to work our way through it.”

Justice said he didn’t plan to be a “rubber stamp” on anything and appeared to discourage GOP leaders from bringing the package to the floor next week ahead of their self-imposed Fourth of July deadline.

“I would love to get it done, like the president wants to get it done, by the Fourth of July. I would love for us to be able to do that and everything,” Justice said. “But I think, way more importantly than anything, we got to get it right.”

Other Medicaid issues

Alaska Sen. Lisa Murkowski declined to weigh in on the changes to the Medicaid provider tax rate since her state doesn’t use it the way many others do.

“I don’t have a dog in that fight, because we don’t have provider taxes in Alaska,” Murkowski said. “We’re the only state that’s actually maybe playing by the rules.”

But Murkowski told reporters she does have issues with other ways the legislation would change Medicaid, the state-federal health program for lower income people, and expects the bill will undergo revisions before a final floor vote.

“I don’t think it’s going to stay in this form, let’s just put it that way,” Murkowski said.

Wisconsin Sen. Ron Johnson said he’d vote against the package if leaders bring it to the floor next week as planned and said he expects that if they rush floor consideration, the entire bill will fail to pass.

“I hope not because my guess is it’ll fail and I don’t want to see it fail. I want this thing to succeed,” Johnson said. “Again, the ball has been in the Senate court for two weeks — two weeks. But now we’re seeing language. Now we’re finally seriously considering some of these ideas, let’s have time to seriously consider it and hopefully get them incorporated in the bill.”

The House voted mostly along party lines to approve its version of the package in late May, but Senate Republicans have been reworking the bill in the weeks since.

Among the changes in the Senate, Republicans plan to raise the country’s debt limit by $5 trillion, a full $1 trillion more than House GOP lawmakers proposed in their version.

Possible recess delay

Arkansas Sen. John Boozman said that if the Senate doesn’t vote to approve the package the week of June 23, they’ll likely stay in town the following week to debate the bill, instead of heading home for the Fourth of July week break.

But he cautioned that “the longer it hangs out, the more difficult it is” to pass.

Iowa Sen. Chuck Grassley declined to answer questions about whether he supports or wants to change his chamber’s newly unveiled Medicaid provisions.

“Ask me that question in a couple days because there’s still discussion going on about it,” he said.

Sen. James Lankford praised aspects of the bill, including, “long-term tax policy that’s actually permanent,” which he said is “important for individuals and for small businesses.”

“We’re doing the full expensing, making that permanent — that doesn’t change a dollar as far as the income coming into the Treasury, but very significant for our economy,” the Oklahoma Republican said.

Lankford said he also likes “the R&D tax credit piece to make sure we’re competing with China on it,” “modernization of the air traffic control system,” as well as “some dollars that are going to border security, which has been very important to me, which they have been asking for for a long time and trying to get into structural things to the border that are needed there.” 

U.S. Senate Majority Leader Sen. John Thune, R-S.D., left, listens as Sen. Mike Crapo, R-Idaho, center, speaks to reporters outside of the West Wing of the White House on June4, 2025 in Washington, D.C.  (Photo by Anna Moneymaker/Getty Images)

WASHINGTON — U.S. Senate Republican Leader John Thune will spend a crucial next few weeks working behind the scenes with other top GOP senators to reshape the party’s “big beautiful bill” — a balancing test accompanied in recent days by incendiary exchanges between President Donald Trump and billionaire Elon Musk over whether the current proposals are so bad that Congress should just go back to the drawing board.

South Dakota’s Thune will need to gain support from deficit hawks, who want to see the mega-bill cut at least $2 trillion in spending, and moderates, who are closely monitoring how less federal funding for safety net programs like Medicaid and food assistance could harm their constituents and home-state institutions like rural hospitals.

Interviews by States Newsroom with Republican senators in early June showed many major elements of the package could change, including provisions that would put states on the hook for unanticipated costs. Arkansas Sen. John Boozman, for example, indicated the Senate may rewrite a proposal in the House-passed bill that would shift some of the cost of the Supplemental Nutrition Assistance Program, which provides food aid to low-income people, to state governments.

“We can do whatever we want to do,” the Agriculture, Nutrition and Forestry Committee chairman said when asked by States Newsroom about amending that policy.

The final deal — intended to extend the 2017 tax cuts — cannot lose more than three GOP senators and still make it back across the Capitol to the House for final approval, since all Democrats are expected to oppose the bill. Thune only needs a majority vote in the Senate for the special process being used by Republicans.

Internal debates about just how to rework the Trump-backed tax and spending cuts measure began in the first week of June during meetings on Capitol Hill and at the White House, as GOP senators began critiquing the House-passed package line-by-line to ensure it complies with their strict rules for the complex reconciliation process and their policy goals.

Republicans said during interviews that several provisions in the House version likely won’t comply with the chamber’s Byrd rule, which could force lawmakers to toss out some provisions.

Complicating all of it was the very public back-and-forth between not just Trump but GOP leaders and former White House adviser Musk over the bill, which Musk on social media labeled “a disgusting abomination” and a “big, ugly spending bill” for its effect on the deficit and debt limit. “KILL the BILL,” Musk said on X, the platform he owns. Senate leaders so far have dismissed Musk’s criticisms.

Fragile House coalition

The talks, and whatever the legislation looks like after a marathon amendment voting session expected in late June, have already raised deep concerns among House GOP lawmakers, who will have to vote on the bill again in order to send it to Trump.

The extremely narrow majorities mean House Republican leaders cannot lose more than four of their own members if all the lawmakers in that chamber vote on the party-line bill.

Any changes the Senate makes could unbalance the fragile coalition of votes Speaker Mike Johnson, R-La., cobbled together last month for a 215-214 vote. But GOP senators are adamant they will amend the legislation.

Complicating matters is a new report from the nonpartisan Congressional Budget Office that shows the proposed changes to tax law, Medicaid, the Supplemental Nutrition Assistance Program and higher education aid wouldn’t actually help to reduce deficits during the next decade but raise them by more than $2.4 trillion.

The numbers are the exact opposite for what Republicans hoped their sweeping tax and spending cuts package would accomplish.

Scrutiny begins

The first stop for the House-passed reconciliation package in the Senate appears to be the parliamentarian’s office, where staff have begun evaluating whether each provision in the current version of the bill complies with the upper chamber’s strict rules.

Boozman said staff on his panel have already begun meeting with the parliamentarian to go over the House provisions within its jurisdiction.

He expects that section of the package will have to change to comply with the strict rules that govern the reconciliation process in the Senate and to better fit that chamber’s policy goals.

“We can’t really decide exactly what we want to use in the House version until we know what’s eligible,” Boozman said. “We’ve got some other ideas too that we asked them about. But we need to know, of the ideas that we have, what would be viable options as far as being Byrd eligible.”

The Byrd rule, which is actually a law, requires reconciliation bills to address federal revenue, spending, or the debt limit. This generally bars lawmakers from using the special budget process to change policies that don’t have a significant impact on those three areas.

Alabama Sen. Tommy Tuberville, who is campaigning to become his home state’s next governor, said pushing some of the cost of the nutrition program to states may be problematic.

“We’re trying to send more costs to the states. Most states can’t afford that, so we want to take care of people, but we need people to go back to work,” Tuberville said. “It’s not a forever entitlement. It’s for part-time, you know, take care of yourself until you get a job, go back to work and let people that need it really, really get it.”

Rural hospitals on edge

Senate GOP leaders will have to navigate how best to reduce federal spending on Medicaid, the state-federal health program for lower-income people and some with disabilities, that is relied on by tens of millions of Americans, many of whom are loyal Republican voters.

The nonpartisan Congressional Budget Office projects that 7.8 million people would lose access to Medicaid during the next decade if the House’s policy changes are implemented as written.

There are also concerns among GOP lawmakers about how losing the revenue that comes with treating Medicaid patients would impact rural health care access and hospitals.

Missouri Sen. Josh Hawley said under no circumstances would he vote for a bill that cuts benefits to Medicaid recipients and is worried about how provisions in the House package would affect rural hospitals.

“They’re very concerned about it, rightly so,” Hawley said, referring to conversations he’s had with health care systems in his home state.

“This is something that we need to work on. I don’t know why we would penalize rural hospitals,” he added. “If you want to reduce health care spending, then cap the price of prescription drugs. I mean, that’s the way to do it. If you want to get major savings in the health care sector, don’t close rural hospitals, don’t take away benefits from working people. Cap the costs, cap the price that (the Centers for Medicare & Medicaid Services) is going to pay for prescription drugs.”

West Virginia Sen. Shelley Moore Capito said she’s not yet come to a decision about whether to keep, amend, or completely scrap some of the House changes to Medicaid.

“I talked to a lot of our hospitals when I was home to see what the impacts would be, because we have a very high Medicaid population,” Capito said. “I want to see it work and be preserved, but I want it to be there for future generations. And it’s just getting way out of control on the spend side. So right now, we’re looking at everything.”

Louisiana Sen. Bill Cassidy — chairman of the Health, Education, Labor and Pensions Committee — said he doesn’t expect all of the health care provisions in the House bill make it through the “Byrd bath” with the parliamentarian. But he declined to go into detail.

“Some of it is more regulatory, that’s all I can say,” Cassidy said.

West Virginia’s Sen. Jim Justice said he is in favor of requiring some Medicaid enrollees to work, participate in community service, or attend an educational program at least 80 hours a month to stay on the program, a sentiment shared by many of his GOP colleagues.

“I’m good with every bit of that,” he said. 

But Justice expects the Senate will make its own changes to the package and that it will be “proud of their own pond.”

“Any frog that’s not proud of your own pond’s not much of a frog,” Justice said.

He did not go into detail on what those changes would entail.

SALT shakers

The state and local tax deduction, or SALT, represents another tightrope  for Thune, who is no fan of the changes made in the House. But he has said repeatedly this week he understands altering that language too much could mean a Senate-amended version of the bill never makes it back through the House to actually become law.

Thune said outside the White House following a June 4 meeting with Trump and others that there will very likely be changes to SALT.

“There isn’t a single Republican senator who cares much about the SALT issue,” Thune said. “It’s just not an issue that plays.” States that are most affected generally don’t elect Republicans to the Senate.

The House tax-writing panel originally proposed raising the SALT cap from $10,000 to $30,000, but Johnson had to raise that to $40,000 in order to secure votes from House Republicans who represent higher tax states like California, New Jersey and New York. The revised cap would benefit more high-income taxpayers in their states.

“In 2017, that was one of the best reforms we had in the bill,” Thune said. “But we understand it’s about 51 and 218. So we will work with our House counterparts and with the White House to try to get that issue in a place where we can deliver the votes and get the bill across the finish line.”

Republicans hold 53 seats in the Senate, but can rely on Vice President J.D. Vance to break a tied vote if necessary.

At least 218 House lawmakers must vote to pass bills when all 435 seats are filled. But with three vacancies at the moment, legislation can move through that chamber with 216 votes. The GOP has 220 seats at the moment, meaning Johnson can afford four defections on party-line bills.

North Dakota Sen. John Hoeven told reporters this week that he’d like to see GOP senators rework the SALT section of the bill, even if that causes challenges for Speaker Johnson’s ability to pass a final version.

“Let’s talk about SALT, for example. The House has a very large SALT number. The Senate is probably going to take a look at that,” Hoeven said. “There’ll be a lot of areas we can look at. There’ll be other things we’re going to look at. We’d like to get to $2 trillion in savings.”

Ohio Sen. Bernie Moreno joined in putting his House colleagues on notice that they likely won’t get the agreement they struck with the speaker in the final version of the bill.

“I think we’re going to make common-sense changes. For example, the SALT cap, by the way, something that definitely helps very wealthy people in blue states,” Moreno said. “I think that cap, the 400% increase, is too much, so we’re going to work on tweaking that.”

Hawley, of Missouri, speaking more generally about the tax provisions, said he would like the Senate to make sure middle-class Americans benefit from the tax changes, just as much as companies.

“I want to be clear, I’m in favor of additional tax relief for working people. So my view is this corporate tax rate, which they lowered in 2017, they made that permanent back then. I know some workers that would like permanent tax relief,” Hawley said. “So I think it’s imperative that we do some addition to tax relief for workers. So I think that’s important.”

A new $4 trillion debt limit

Deficit hawks in the Senate have also voiced objections to raising the nation’s debt limit by $4 trillion, arguing that GOP leaders haven’t done enough to assuage their concerns about the nation’s fiscal trajectory.

Kentucky Sen. Rand Paul argued that the debt limit increase is more about next year’s midterm elections than good governance.

“​​This is really about avoiding having to talk about the debt during election times because people like to go home and talk to the Rotary or the Lions Club and tell them how they’re fiscally conservative and they’re against debt,” Paul said. “It’s embarrassing to them to have to vote to keep raising the debt. But they’re unwilling to have the courage to actually look at all spending.”

Paul suggested that House Republicans created problems by inflating some of the spending levels in their package, including to continue construction of a wall along the U.S.-Mexico border. Paul is chairman of the Homeland Security and Governmental Affairs Committee.

“The $46.5 billion for the wall is eight times higher than the current cost of the wall. If you’re going to do 1,000 miles, you can actually do it for $6.5 billion. They want $46.5 billion,” Paul said. “We can’t be fiscally conservative until it comes to the border, and then we’re no longer fiscally conservative.”

The border wall has been a constant focus for Trump, who made it a central part of his 2016 presidential campaign, when he said repeatedly that the United States would build it and Mexico would pay for it.

South Carolina’s Lindsey Graham, chairman of the Budget Committee, hinted during a brief interview that Congress can only cut so much spending without going near programs like Social Security, which accounted for $1.5 trillion in expenditures last year, or Medicare, which spent $865 billion. Both are normally considered untouchable.

“I think we’re going to make some changes to try to find more spending reductions. I think that’s a fair criticism of the bill, but you can’t do Social Security by law,” Graham said, referring to one of the many rules that govern the reconciliation process. “Nobody’s proposed anything in the Medicare area.”

Graham added that “trying to make the bill more fiscally responsible is a good thing, but we need to pass it.” 

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• Health care systems including SSM Health, Aurora Health, UW Health and, most recently, Ascension have removed from their websites language related to diversity, equity and inclusion (DEI).

• The changes have come in the months since President Donald Trump has signed executive orders abolishing federal DEI programs.

• UW Health publicly announced changes such as the removal of anti-racism modules titled “Being a leader in anti-racism” and “anti-racism funding” and replacement with modules called “Being a social impact leader” and “Community giving.”

Multiple Wisconsin health care systems have removed diversity, equity and inclusion language or resources from their websites in the wake of President Donald Trump’s federal ban on funding for DEI programming.

The systems include SSM Health, Aurora Health, UW Health and, most recently, Ascension. Froedtert ThedaCare Health has maintained its DEI webpage, though it removed a link to its equal employment opportunity policy in recent months. 

Aurora Health, Ascension, Froedtert and SSM Health made the changes quietly, without directly alerting the public. UW Health, however, released an op-ed in Madison 365 April 8 explaining the changes.

“As we enter the next phase of this important work, we are further aligning with our organizational mission under the name of Social Impact and Belonging,” the op-ed said. “This reflects both the evolved nature of the work and our desire that these mission-focused priorities endure despite the current tumultuous political environment.”

The changes occurred in the weeks after President Donald Trump’s executive order abolishing DEI programs from all federally funded institutions and programs. 

The executive order, issued Jan. 20, states the “Biden Administration forced illegal and immoral discrimination programs, going by the name ‘diversity, equity, and inclusion’ (DEI), into virtually all aspects of the Federal Government, in areas ranging from airline safety to the military.” 

In response to attacks on DEI programs by the federal government, some organizations have pushed back, arguing Trump’s actions are a threat to a multiracial democracy. Some institutions are also suing the federal government for its actions, such as threatening to withhold federal grants and funding. 

Harvard University has filed a lawsuit, citing First Amendment principles to protect “academic freedom” and “private actors’ speech.”

But while some federally funded institutions are pushing back, others are not.

Different approaches to DEI purge

In the past couple of months, SSM Health removed the word “diversity” from its website, including changing a page titled “Our Commitment to Diversity” to “Our Commitment to Healthy Culture.”

SSM has hospitals located throughout Wisconsin including Ripon, Fond du Lac, Waupun, Baraboo, Janesville, Madison and Monroe.

In changing the webpage, SSM Health also removed an entire section regarding its commitment to fostering a diverse workplace and health care center, including a section that read, “​​SSM Health makes it a point to work with diverse organizations broadening our reach into the communities we serve to support and promote a more inclusive society.”

SSM Health also notably replaced the section discussing diversity with comment on SSM Health’s mission as a Catholic ministry. On the updated page, the system discusses its commitment to follow in the footsteps of its founders to ensure “all people have access to the high-quality, compassionate care they need.” 

In removing the word “diversity,” SSM replaced the statement “At SSM Health, diversity is an integral part of who we are and a reflection of our mission and values” with “At SSM Health, inclusion is an integral part of who we are and a reflection of our Mission, Vision and Values.”

”Today, our belief that every person was created in the image of God with inherent dignity and value calls us to foster a healthy culture, inviting each person to be the best version of themselves,” SSM Health communications consultant Shari Wrezinski said when asked for comment. 

Wrezinski said the organization’s mission has remained the same, and its communications, policies, programs and practices reflect the organization’s mission.

“This has not and will not change,” Wrezinski said. “As such, our website and other communications materials are continually updated as we strive to clearly convey our commitment to a welcoming environment where everyone feels valued and respected.”

Despite removing the section on diversity, SSM Health has maintained its equal opportunity section.

Froedtert did the opposite, by maintaining its webpages on diversity, equity and inclusion, but removing its equal opportunity policy document from the pages. 

The equal opportunity document, which can still be found online but was removed from the DEI website, specifically outlines Froedtert’s commitment and policy to maintain equitable and nondiscriminatory recruitment, hiring and human resources practices. 

The document outlines two policies specifically: “FH is committed to its affirmative action policies and practices in employment programs to achieve a balanced workforce” and “FH will provide equal opportunity to all individuals, regardless of their race, creed, color, religion, sex, age, national origin, disability, military and veteran status, sexual orientation, gender identity, marital status or any other characteristics protected by state or federal law.”

Froedtert did not respond to requests for comment. 

The Froedtert system serves patients primarily in the Milwaukee area. Froedtert recently merged with ThedaCare, serving Wisconsin residents in the Fox Valley and Green Bay. In 2020, the system reported receiving tens of millions in federal funding through the CARES Act in response to the COVID-19 pandemic.

While removing a link to an equal opportunity document may be a simple change, the Rev. Marilyn Miller, a partner in Leading for Racial Equity LLC, said every small change pushes society further back in achieving full access and equity. 

“So it might be a small tweak now, but what does that open the door to later? So, yeah, it’s impactful because any change that’s stepping back from full equity is a problem,” Miller said. “There’s populations that don’t feel any security anymore.”

Aurora Health Care also has removed DEI language in the past couple of months since the executive order. 

In 2018, Aurora merged with Advocate Health, a system with more than 26 hospitals throughout the Midwest. Advocate Aurora Health later merged with Atrium Health in 2022, creating the third largest nonprofit in the nation.

Earlier this year, Aurora removed an entire page on diversity, equity and inclusion. The page now redirects to Advocate’s page titled “Access & Opportunity.”

That change cut statements such as: “Our diversity, equity and inclusion strategy is anchored by our purpose to help people live well and to deliver safe, consistent, and equitable health outcomes and experiences for the patients and communities we serve.” 

A spokesperson for Aurora Health Care said the organization will continue to “deliver compassionate, high-quality, consistent care for all those we serve.”

“As our newly combined purpose and commitments state, we lift everyone up by ensuring access and opportunity for all,” the spokesperson said. “To provide our patients and communities clear and consistent information that explains our programs, policies and services, we are making various changes to our websites.”

Ascension, one of the largest nonprofit hospital systems in the nation, took down the entire page on diversity, equity and inclusion. The health care system currently operates at over 165 locations in Milwaukee, Racine, Appleton and Fox Valley.  The system still has modules on “Identifying & Addressing Barriers to Health” and “Ensuring Health Equity.” Ascension did not respond to a request for a comment.

Making a statement

UW Health removed its page on diversity, equity and inclusion, replacing it with a page titled “social impact and belonging.” In doing so, UW Health removed “anti-racism” from its entire website. It used to be one of the main themes.

UW Health removed the anti-racism modules titled “Being a leader in anti-racism” and “anti-racism funding,” and now in their place are modules called “Being a social impact leader” and “Community giving.” 

Chief Social Impact Officer Shiva Bidar-Sielaff and CEO Alan Kaplan addressed the changes in a video, stating social impact and belonging align with their mission, values and strategies as a health care organization.

“At UW Health, social impact refers to the effects health care policies, practices and interventions have on the well-being of individuals and communities, improving health outcomes, access to care and quality of life,” Bidar-Sielaff said. “Belonging is the understanding that you are valued and respected for who you are as an individual.”

The UW-Madison School of Medicine and Public Health, which has faculty who also work for and provide clinical care at UW Health, reported receiving $315 million in federal research funding last year. That total is 37% of all grant funding awarded to UW-Madison. UW Health received roughly $5.1 million in federal grants.

Despite claims by health care centers that missions remain the same, advocacy groups in Wisconsin are raising concerns regarding the impact these changes could have on communities in Wisconsin.

Chris Allen, president and CEO of Diverse & Resilient — an advocacy group focused on health inequities for LGBTQ+ people in Wisconsin — said these quiet language shifts are significant. 

“They send a message that commitments to addressing disparities may be weakening, even if that’s not the stated intention,” Allen said. 

William Parke Sutherland, government affairs director at Kids Forward, a statewide policy center that advocates for low-income and minority families, said many health care partners feel pressured to preserve funding sources.

In Wisconsin, maternal mortality rates are 2.5 times higher for Black women than white women. Maternal morbidities — or serious birth complications — were the highest among Black women and people enrolled in BadgerCare, the state’s largest Medicaid program. From 2020 to 2022 there were 7.8 stillbirth deaths per 1,000 births among Black babies, compared with 4.5 among white babies.

Disparities in maternal and infant mortality rates could be attributed to stress caused by poverty, lack of access to quality care, or systemic racism, according to health care researchers. If a mother is stressed over a long period of time, that can cause elevated levels of stress hormones, which could increase premature births or low birth weights for infants.

For Black women, midwives have been found to reduce the disparities they otherwise may experience during pregnancy, reducing the risk of maternal mortality or morbidity. Access to midwives is currently covered by Medicaid, so losing federal funding could harm these services.

Regardless of language, “Wisconsin’s racial disparities in health access and outcomes aren’t going away on their own,” Sutherland said in an email.

Removing language that acknowledges DEI efforts will not reduce the health care disparities felt by Wisconsin residents, Sutherland said. Federal funding cuts could also hurt rural families in Wisconsin, specifically those who rely on Medicaid for their health care needs. 

“We cannot begin to address these challenges if we’re not willing to acknowledge them,” Sutherland said. “A colorblind approach has not helped in the past.”

Editor’s note: This story was updated to correct a reference to how much federal funding UW Health receives.

We don’t talk about DEI: Wisconsin hospital systems are quietly removing diversity language is a post from Wisconsin Watch, a non-profit investigative news site covering Wisconsin since 2009. Please consider making a contribution to support our journalism.