The U.S. Capitol as lawmakers worked into the night on the "big beautiful bill" on July 2, 2025. (Photo by Ashley Murray/States Newsroom)

WASHINGTON — U.S. House Republicans cleared the “big, beautiful bill” for President Donald Trump’s signature Thursday, marking an end to the painstaking months-long negotiations that began just after voters gave the GOP unified control of Washington during last year’s elections.

The final 218-214 vote on the expansive tax and spending cuts package marked a significant victory for Speaker Mike Johnson, R-La., and Senate Majority Leader John Thune, R-S.D., who were able to unify centrist and far-right members of the party against long odds and narrow majorities.

But the legislation’s real-world impacts include millions of Americans expected to lose access to Medicaid through new requirements and slashed spending, and state governments taking on a share of costs for a key nutrition program for low-income families. If voters oppose Republicans at the ballot box in return, it could mean the GOP loses the House during next year’s midterm elections.

In the end just two Republicans in the House and three in the Senate opposed the measure, which the Senate approved earlier in the week with Vice President JD Vance casting the tie-breaking vote.

Trump posted on social media numerous times in the days leading up to the vote, thanking supportive Republicans who were praising the bill during interviews and threatening to back primary challenges against GOP lawmakers who stood in the way of passage.

“Largest Tax Cuts in History and a Booming Economy vs. Biggest Tax Increase in History, and a Failed Economy,” Trump posted just after midnight when it wasn’t yet clear the bill would pass. “What are the Republicans waiting for??? What are you trying to prove??? MAGA IS NOT HAPPY, AND IT’S COSTING YOU VOTES!!!”

Trump told reporters while on his way to Iowa for an event that he would sign the bill at 5 p.m. Eastern on Friday, with military aircraft flying over the White House and Republican lawmakers in attendance.

Johnson said during a floor speech the legislation is a direct result of the November elections, when voters gave the GOP control of the House, Senate and the White House.

“That election was decisive. It was a bellwether. It was a time for choosing,” Johnson said. “And I tell you what — the American people chose, overwhelmingly, they chose the Republican Party.”

The package, he said, would make the country “stronger, safer and more prosperous than ever before.”

“We’ve had spirited debates, we’ve had months of deliberation and now we are finally ready to fulfill our promise to the American people,” Johnson said.

Republicans were spurred to write the tax provisions in the legislation to avoid a cliff at the end of the year, created by the party’s 2017 tax law. But the legislation holds dozens of other provisions as well, spanning border security, defense, energy production, health care and higher education aid.

The bill raises the country’s debt limit by $5 trillion, a staggering figure that many fiscal hawks would have once balked at, but is enough to get Republicans past the midterm elections before they’ll have to negotiate another deal to raise the country’s borrowing limit.

The nonpartisan Congressional Budget Office’s latest analysis of the measure projects it would add $3.4 trillion to deficits during the next decade compared to current law.

Jeffries: “It guts Medicaid’

House Minority Leader Hakeem Jeffries, D-N.Y., called the health care provisions “reckless” during a speech that lasted nearly nine hours, forcing the vote to take place in the afternoon rather than early morning, and said the “bill represents the largest cut to health care in American history.”

“Almost $1 trillion in cuts to Medicaid,” Jeffries said. “This runs directly contrary to what President Trump indicated in January, which was that he was going to love and cherish Medicaid. Nothing about this bill loves and cherishes Medicaid. It guts Medicaid.”

The speech broke the eight-hour-and-32-minute record that then-Minority Leader Kevin McCarthy, R-Calif., set in 2021 when he sought to delay Democrats from passing a $1.9 trillion coronavirus relief package. House leaders are allowed to exceed normal speaking limits through a privilege called the “magic minute.”

The nonpartisan health research organization KFF’s analysis of the package shows it would reduce federal spending on Medicaid by nearly $1 trillion during the next decade and lead to 11.8 million people becoming uninsured.

Republicans made numerous changes to the state-federal health program for lower income people and some people with disabilities, including a requirement that some enrollees work, participate in community service, or attend an educational program for at least 80 hours a month.

Medicaid patients will no longer be able to have their care covered at Planned Parenthood for routine appointments, like annual physicals and cancer screenings, for one year. Congress has barred federal taxpayer dollars from going to abortions with limited exceptions for decades, but the new provision will block all Medicaid funding from going to Planned Parenthood, likely leading some of its clinics to close.

Overnight drama

House passage followed several frenzied days on Capitol Hill as congressional leaders and Trump sought to sway holdouts to their side ahead of a self-imposed Fourth of July deadline.

The Senate, and then later the House, held overnight sessions followed by dramatic votes where several Republicans, who said publicly they didn’t actually like the bill, voted to approve it anyway. 

GOP leaders didn’t have much room for error amid a narrow 53-seat Senate majority and a 220-212 advantage in the House. That delicate balance hovered in the background during the last several months, as talks over dozens of policy changes and spending cuts in the bill appeared deadlocked.

Any modifications meant to bring on board far-right members of the party had to be weighed against the policy goals of centrist lawmakers, who are most at risk of losing their seats during next year’s elections.

The House passed its first version of the bill following a 215-214 vote in May, sending the legislation to the Senate, where Republicans in that chamber spent several weeks deciding which policies they could support and which they wanted to remove or rework.

The measure changed substantially to comply with the complex rules for moving a budget reconciliation bill through the upper chamber. GOP leaders chose to use that process, instead of moving the package through the regular legislative pathway, to avoid having to negotiate with Democrats to get past the Senate’s 60-vote legislative filibuster.

In the end nearly every one of the 273 Republicans in Congress approved the behemoth 870-page bill.

Maine’s Susan Collins, Kentucky’s Rand Paul and North Carolina’s Thom Tillis voted against it in the Senate and Pennsylvania Rep. Brian Fitzpatrick and Kentucky Rep. Thomas Massie opposed passage in the House.

Fitzpatrick wrote in a statement that while he voted to approve the House’s original version of the bill, he couldn’t support changes made in the Senate.

“I voted to strengthen Medicaid protections, to permanently extend middle class tax cuts, for enhanced small business tax relief, and for historic investments in our border security and our military.” Fitzpatrick wrote. “However, it was the Senate’s amendments to Medicaid, in addition to several other Senate provisions, that altered the analysis for our PA-1 community.”

Massie posted on social media that he couldn’t vote for the measure because it would exacerbate the country’s annual deficit.

“Although there were some conservative wins in the budget reconciliation bill (OBBBA), I voted No on final passage because it will significantly increase U.S. budget deficits in the near term, negatively impacting all Americans through sustained inflation and high interest rates,” Massie wrote. 

GOP holdouts delay passage

Floor debate on the bill in the House, which began around 3:30 a.m. Eastern Thursday and lasted 11 hours, was along party lines, with Democrats voicing strong opposition to changes in the package and GOP lawmakers arguing it puts the country on a better path.

GOP leaders didn’t originally plan to begin debate in the middle of the night while most of the country slept, but were forced to after holdouts refused to give their votes to a procedural step.

When the House did finally adopt the rule, Pennsylvania’s Brian Fitzpatrick was the sole member of his party to vote against moving onto floor debate and a final passage vote.

Fitzpatrick had posted on social media earlier in the day that he wanted Trump “to address my serious concern regarding reports the United States is withholding critical defense material pledged to Ukraine.”

“Ukrainian forces are not only safeguarding their homeland—they are holding the front line of freedom itself,” he wrote. “There can be no half-measures in the defense of liberty. We must, as we always have, stand for peace through strength.”

Tax breaks and so much more

House Ways and Means Chairman Jason Smith, R-Mo., made significant promises to middle-class Americans during floor debate about the tax provisions in the bill that many voters will be watching for in the months ahead. 

“Households making under $100,000 will see a 12% tax cut compared to what they pay today. The average family of four will see nearly 11,000 more in their pockets each year,” Smith said. “Real wages for workers will rise by as much as $7,200 a year. A waitress working for tips will keep an extra $1,300, a lineman working overtime after a storm will keep an extra $1,400.”

Massachusetts Democratic Rep. Richard Neal, ranking member on the tax writing panel, said the legislation’s benefits skew largely toward the very wealthy.

“If you made a million dollars last year, you’re going to make a plus of $96,000 in the next tax filing season,” Neal said. “If you made under $50,000 last year, you’re going to get 68 cents a day in terms of your tax relief.”

The extension of the 2017 tax law would predominantly benefit high-income earners. The top 1% would receive a tax cut three times the size of those with incomes in the bottom 60% of after-tax income, according to analysis from the left-leaning Center on Budget and Policy Priorities.

Some other tax incentives that critics say skew toward wealthier families include a $1,000 deposit from the federal government for babies born between 2024 and 2028, known as a “Trump account.” The program would track a stock index and gain interest accordingly and families with disposable income could contribute additional funding.

And while Republicans included an extension of the child tax credit to $2,200 per child, it requires the parents to have a Social Security number to claim the tax credit.

The bill will give the president more than $170 billion to carry out his campaign promise of mass deportations of people in the country without permanent legal status. The package would give the Department of Homeland Security $45 billion for the detention of immigrants and give its immigration enforcement arm another $30 billion to hire up to 10,000 Immigration and Customs Enforcement agents.

Food aid, higher education

The legislation will overhaul federal loans for higher education and how states pay for food assistance that roughly 42 million low-income people rely on, known as the Supplemental Nutrition Assistance Program, or SNAP.

The bill would cap federal graduate loans to $100,000 per borrower and $200,000 per borrower who is attending law school or medical school. It would also cap the ParentPLUS loans to $65,000.

Under the SNAP changes, the package would require states to shoulder more of the burden in food assistance. Currently, the federal government covers 100% of the cost. The legislation tightens eligibility for SNAP, requiring parents with children aged 6 and older to meet the work requirements when they were previously exempt.

Current estimates from CBO show that changes in  federal nutrition programs including SNAP would reduce federal spending by roughly $186 billion over 10 years.

The GOP megabill cuts clean energy tax credits and claws back some of the funding in former president Joe Biden’s signature climate bill, known as the Inflation Reduction Act.

Some of those cuts to clean energy tax credits include terminating at the end of September a nearly $8,000 rebate for the purchase of an electric vehicle, ending a tax credit by December for energy efficient home upgrades such as solar roof panels and heat pumps.

The package rescinds funds to help local governments and states adopt zero emission standards, and eliminates environmental justice block grants that communities used to address health impacts due to environmental pollution, among other things.

The roof of the Hotel Verdant in Downtown Racine received federal tax credits for installing solar panels. Labor and environmental advocates are attacking the Congressional Republicans' tax cut megabill for rolling back clean energy programs enacted in the Biden administration. (Photo by Erik Gunn/Wisconsin Examiner)

The tax cut megabill in Congress with a historic rollback on Medicaid also includes provisions reversing U.S. clean energy policies, advocates warned Wednesday, harming not only the environment but the economy.

“This legislation will kill economic growth and jobs, raise energy prices, and cede clean energy technology manufacturing to other countries,” said Carly Ebben Eaton, Wisconsin Policy Manager for the Blue Green Alliance, a coalition of labor unions and environmental groups.

Eaton took part in two online news conferences Wednesday to draw attention to the federal budget reconciliation bill and its repeal of key portions of the 2022 Inflation Reduction Act.

The budget bill has been the top priority of the Republican majority in Congress as well as the administration of President Donald Trump. It was drawn up to extend tax cuts enacted in 2017 during Trump’s first term that will expire at the end of 2025.

The package returned to the U.S. House for final action after a tied vote in the U.S. Senate that required Vice President JD Vance to pass the measure on Tuesday.

Steep cuts to Medicaid and federal nutrition programs have drawn the most attention during debate on the bill, along with the Congressional Budget Office finding that the wealthiest taxpayers will benefit most from its tax cuts.

The bill also includes measures that would undo several provisions in the Inflation Reduction Act (IRA), one of the signature pieces of legislation enacted during President Joe Biden’s four years in office. After its passage the act was lauded by environmental advocates for provisions to address climate change by encouraging clean energy through tax credits as well as federal investments.

The House version of the GOP bill “already dealt a serious blow to clean energy tax credits and investments,” Eaton said Wednesday, “but the Senate took it even further, doubling down on cuts that will cost jobs, stall progress and raise energy costs.”

Consumer, business renewable energy incentives

The IRA’s tax breaks were designed to encourage consumers to move to energy-efficient and clean energy appliances and vehicles and encourage utilities and other businesses to increase their use of renewable resources such as solar energy and wind power.

Eaton said Wednesday that clean energy tax credits are supporting more than $8.6 billion in private investments in Wisconsin.

Garrik Harwick, assistant business manager of the International Brotherhood of Electrical Workers union Local 890 in Janesville, said that over the past three years more than 300 members have worked on solar projects in Southern Wisconsin. He spoke at a news conference with Eaton and several other union leaders.

The IRA tax breaks have encouraged those developments, Harwick said, and the investments have included increased apprenticeship slots, bringing in new trainees.

“These investments don’t just deliver clean energy,” Harwick added. “They create good paying union jobs that strengthen our local communities.”

He warned that repealing the tax credit will likely reduce the use of clean energy technologies and increase energy costs by 6% for homeowners and more than 9% for business customers.

The IRA’s provisions that encouraged apprenticeships helped “open doors that many didn’t even know existed,” said Andy Buck, government affairs director for the Wisconsin and Upper Michigan district of the International Union of Painters and Allied Trades.

He said the union has added a number of jobs, including apprentices, installing energy-efficient glass in buildings on projects that were facilitated by the Inflation Reduction Act.

“When someone enters a registered apprenticeship program, they aren’t just learning a trade,” Buck said. “They’re building a career, gaining self-respect, and finding a path to a better life.”

Another provision of the 2022 law opened up tax credits for renewable energy to nonprofit organizations and government agencies, allowing them to receive direct payments to the federal government comparable to the value they’d receive from the tax credit if they paid taxes.

A new middle school being built in Menasha will include solar panels and energy storage, said Matt VanderPuy, a business agent for the Sheet Metal workers union in Sheboygan. The direct pay program will reimburse the district $3 million, he said, while the energy savings is projected at $190,000 per year.

“This is money that they can reinvest into the students, the teachers and the school district,” while saving on property taxes, VanderPuy said.

‘Very ugly impacts,’ says advocate

At another news conference, former Lt. Gov. Mandela Barnes observed that more than 90% of the jobs that IRA incentives helped create are in Republican congressional districts — although no Republicans in the state delegation voted for the bill. Barnes leads Forward Wisconsin, a nonprofit established during Biden’s term in the White House to inform people about the Biden administration’s infrastructure and climate investments and to defend them.

But business uncertainty this year, which Barnes blamed on GOP positions including Trump’s tariff executive orders, has led nationally to the cancellation of projects worth $15.5 billion, he said.

“The so-called big beautiful bill is going to have some very ugly impacts in Wisconsin, ripping away tax incentives for wind and solar farms, for rooftop solar, for farm sustainability programs, for clean cars and school buses,” said Amy Barrilleaux, communications director for Clean Wisconsin, at the event with Barnes. “And giving more tax breaks to big oil and gas companies does absolutely nothing to create jobs here or any opportunities here — it’s a gift to big oil at the expense of Wisconsin families and at the expense of our environment.”

Heather Allen, policy director for Elevate, an energy efficiency nonprofit, said as many as 11,000 clean energy and manufacturing jobs in Wisconsin could be at risk.

Plans for a $2.5 billion network of electric vehicle charging stations in the state have stalled, Allen said, and Wisconsin manufacturers that would have supplied components “are going to lose that opportunity now.”

“This legislation is going to strangle our solar businesses with red tape,” Allen said. “What you have here is an attack on small businesses that are delivering clean energy solutions to help families save money on their energy bills. And that includes solar installers, but it also includes other home energy contractors, other construction jobs.”

In four recent polls, a majority of those surveyed disapproved of the Republicans’  megabill — making it “more unpopular than any piece of major legislation that’s been passed since at least 1990,” Barnes said.

At the labor news conference, Emily Pritzkow, the Wisconsin Building Trades Council executive director, said advocates are urging people to contact their members of Congress.

“The polling on this is abysmal, and as long as people continue to call and deliver that message , that is what we need to do right now,” Pritzkow said. “Now is the time to weigh in, not once it’s coming to your front door, impacting you, your community, and people you care about.”

Tami Jackson of the Wisconsin Board for People with Developmental Disabilities describes how unpaid family caregivers could be affected by proposed Medicaid cuts in the Republican budget reconciliation package in Washington, D.C. Janet Zander of the Greater Wisconsin Agency on Aging Resources, seated at right, also spoke. (Photo by Erik Gunn/Wisconsin Examiner)

Among the many people whose health care could be in jeopardy from possible Medicaid cuts, one group may be even less visible than the rest.

“Medicaid is the primary thing that supports family caregivers,” said Tami Jackson, policy analyst for the Wisconsin Board for People with Development Disabilities (BPDD), in a presentation to social workers Thursday in Dodgeville. 

The person under the caregiver’s care could be living at home, but will probably still require long-term support of some kind — support covered by Medicaid, Jackson said. Medicare provides coverage only for a limited time, such as when a person has come home after being hospitalized.

Private long-term care insurance plans “are unaffordable and they have not been workable for many years,” she added. “So Medicaid is it — and we happen to have a lot of people who need long-term care.”

Jackson and Janet Zander of the Greater Wisconsin Agency on Aging Resources met with Iowa County social workers in Dodgeville Thursday to explain the likely effect of Medicaid cuts that are part of the budget reconciliation bill that has passed the U.S. House and is now in the Senate.

The GOP majorities of both houses want to pass the legislation so they can extend tax cuts enacted in 2017, when President Donald Trump was in his first term. Those tax cuts have been found to heavily benefit wealthy Americans. Without action they will expire at the end of 2025.

Cutting Medicaid, hiking other costs

Medicaid is the single largest source of federal funds in the state budget — about $9 billion a year.

Under the U.S. House version of the budget reconciliation bill, the Wisconsin Department of Health Services (DHS) has projected between 71,000 and 111,000 Wisconsinites would lose Medicaid coverage, including more than 3,800 people with disabilities and 2,400 older adults. The state’s federal Medicaid revenues would be cut by $501 million to $663 million.

The Medicaid cuts on the scale of those in current iterations of the bill “are too large to not cause states to have to cut many things in their state budget,” Jackson said.

The bill’s Medicaid cuts as well as changes it would make to the Affordable Care Act’s health insurance marketplace — including ending subsidies that have made marketplace plans more affordable for lower-income people — would increase the number of uninsured Americans by 16 million in the next decade, according to the Congressional Budget Office.

“Whether you’re a caregiver, whether you’re on Medicaid, whether you’re working for somebody who’s on Medicaid,” everyone will be affected by 16 million more uninsured people, Zander said.

With more uncompensated care for hospitals and providers, she predicted that the cost for other payers will increase.

“We’re going to see premiums for any kind of [health] insurance skyrocket — the employer’s portion, the employee’s portion,” Zander said.

Reduced Medicaid care, more unpaid care

Family caregivers feel Medicaid’s impact in several ways. For many people who are elderly or have disabilities it enables them to get paid, professional care at home. If that care is cut back, that means more work for the unpaid family member.

“Those paid caregivers — they’re paid for by Medicaid dollars and there aren’t enough of them. There haven’t been enough of them for years,” Jackson said.

 If Medicaid cutbacks reduce the pay for those caregivers, the workforce that is already underpaid is likely to be even harder to find — making access to paid care even more difficult, she added, to the point where “it’s either the unpaid caregiver or nothing.”

Family caregivers who take on more unpaid care responsibilities may have to cut back on their own paid jobs.

“The amount of people who are reducing, limiting [work hours or] leaving the workforce because there isn’t a stable, paid caregiving workforce to provide what they need is huge,” Jackson said.

A BPDD survey found that for unpaid family caregivers in Wisconsin providing or coordinating care or filling in for missing care workers took 80% of their time. Two-thirds said caregiving had a negative impact on their family finances and 50% said they left jobs or reduced hours to provide care because there were no care workers to hire.

Unpaid caregivers who leave the workforce not only lose income but reduce the earnings that contribute to their Social Security retirement, Jackson said.

Kristin Voss, a Madison public school teacher for 24 years, had to retire to help manage and care for her 23-year-old daughter. Her daughter has epilepsy, autism and an intellectual disability and “functions at about anywhere from 6 to 12 years old,” Voss said in a panel discussion that was part of Thursday’s presentation.

Until her daughter was 21, she was entitled to public education, where she got “tons of support” including in her transition period that started when she was 18, Voss said. At 21, those supports were no longer available, however.

Her daughter enrolled in the state’s self-directed long-term care program called IRIS. The program includes a caseworker, but Voss also has responsibility as her daughter’s family caregiver, helping to manage day-to-day changes in her daughter’s placement and activities.

“I don’t mind doing these things, but there’s things that I don’t always know about and I’m not always prepared for,” Voss said. “And so, no, I couldn’t do this and be a public school teacher.”

Instead, she has put together a collection of part-time positions that give her flexibility that she needs — although none of them have health insurance, Voss said.

Unpaid caregivers ‘untangling the mess’

Some unpaid caregivers who leave the workforce may also turn to Medicaid for their health coverage because they can’t afford health insurance or work at a job that doesn’t provide insurance.

“About 4 million people nationally are unpaid caregivers who are in Medicaid themselves,” Jackson said.

Among the changes proposed for Medicaid is a requirement for participants in the program to prove every six months that they are still eligible for the program, instead of once a year, the current standard. Another change proposed is to add a work requirement for certain Medicaid participants.

Both of those changes will mean more paperwork. “Unpaid caregivers are the folks that are keeping people who are in Medicaid programs already,” Jackson said — by filling out the forms that are required to prove the person is still eligible.  

“Often these processes are so complex,” Jackson said. And when something goes wrong, because of an error in an eligibility form or a billing mistake, family caregivers “are the people who are untangling the mess.”

The current version of the bill in the Senate gives caregivers an exemption from the work requirement — but Jackson said the definition has raised concerns.

The current proposal limits the exemption to people who are caring for a person under the age of 14. National advocates have said that “really narrows that caregiver exemption and doesn’t quite fit with the reality that most unpaid caregivers are providing care for people with disabilities and older adults,” Jackson said.

Including exemptions in the proposed work requirement provisions also doesn’t necessarily reduce the paperwork.

“You either have to prove you’re meeting the work requirements, or you have to prove that you’re exempt for those requirements,” Jackson said. “And if you’re a caregiver who’s in Medicaid, you have to do that for yourself and probably the person you’re supporting.”

U.S. Senate Majority Leader John Thune, R-S.D., right, and Speaker of the House Mike Johnson, R-La., hold a press conference on the Republican budget bill at the U.S. Capitol on April 10, 2025 in Washington, D.C. (Photo by Kayla Bartkowski/Getty Images)

WASHINGTON — U.S. Senate Republicans unveiled Monday that they plan to raise the country’s debt limit by $5 trillion in the “big, beautiful bill,” a full $1 trillion more than House GOP lawmakers proposed in their version.

The provision is tucked into the Senate Finance Committee’s 549-page section of the package, which also includes tax law changes and how Republicans in the upper chamber plan to rework Medicaid.

The bill is one of 10 the Senate will bundle together in the days ahead before bringing the full package to the floor for debate and amendment votes.

Senate Majority Leader John Thune, R-S.D., hopes to approve the legislation before the Fourth of July break, but because the chamber is changing the House bill in numerous ways, it will have to go back across the Capitol.

Given the extremely narrow majorities in each chamber, GOP leaders cannot lose more than a handful of their own members and still have the measure make it to President Donald Trump for his signature.

Earlier debt limit suspension expired Jan. 1

The debt limit change released Monday could frustrate some far-right members of the party, who believe it sends the wrong message about how the mega-bill will affect the country’s fiscal future.

Congress must raise the debt limit by a dollar amount or suspend it through a future date before the Treasury Department runs out of accounting maneuvers known as extraordinary measures.

The previous debt limit suspension, which was agreed to by both Democrats and Republicans, expired on Jan. 1, leaving the Treasury Department to move money around to keep paying all of the country’s bills in full and on time.

Treasury Secretary Scott Bessent wrote to congressional leaders in May, urging them to address the debt limit before leaving on their customary August recess.

The nonpartisan Congressional Budget Office estimates that lawmakers have until sometime between mid-August and the end of September to address the debt limit before default would hit.

Traditionally, the White House and congressional leaders from both political parties negotiate a debt limit deal. But GOP leaders are hoping to raise the debt limit in their mega-bill since that avoids having to make any concessions to Democrats in order to avoid a default on the debt. 

Planned Parenthood has identified 200 of its clinics in 24 states that are at risk of closure through federal cuts under the budget reconciliation package before the U.S. Senate. (Photo by Michael B. Thomas/Getty Images)

If the budget reconciliation package before the U.S. Senate becomes law in the coming weeks, reproductive health advocates say the provision that would cut federal funding to Planned Parenthood clinics could serve as a backdoor nationwide abortion ban, eliminating access to 1 in 4 abortion providers.

The Republican-led bill, which already passed the House by a slim margin, is more than 1,000 pages and includes sweeping tax cuts that mostly benefit the wealthy coupled with steep spending cuts to social services, including Medicaid.

On page 339 of the bill, Republicans included a provision prohibiting Medicaid funding from going to any sexual and reproductive health clinics that provide abortions and received more than $1 million in federal and state Medicaid funding in fiscal year 2024. While there may be a few independent clinics with operating budgets that high, it effectively singles out Planned Parenthood clinics.

Planned Parenthood clinics rely heavily on Medicaid funding, not to provide abortions, which is not permitted by federal law (except in cases of rape, incest or life-threatening health emergencies), but to provide standard reproductive health care at little to no cost, including treatment for sexually transmitted infections and cancer screenings, as well as contraception. Planned Parenthood provides services for about 2 million patients every year, and 64% of its clinics are in rural areas or places with health care provider shortages.

A Planned Parenthood spokesperson said people who use Medicaid make up half of the total patient volume nationwide for essential health care services provided by their clinics. Even though those patients aren’t seeking abortion care, funding cuts would affect the financial sustainability of those clinics, the spokesperson said.

The organization already identified that 200 of its clinics in 24 states are at risk of closure with the cuts but told States Newsroom on Thursday that further analysis revealed nearly all of those clinics — 90% — are in states where abortion is legal, and in 12 states, approximately 75% of abortion-providing Planned Parenthood health centers could close. The entire organization has about 600 clinics in 48 states.

The “One Big Beautiful Bill” would result in nearly 11 million people losing access to health insurance by 2034, according to the nonpartisan Congressional Budget Office, and add $2.4 trillion to the federal deficit over the next 10 years.

Alexis McGill Johnson, president and CEO of Planned Parenthood Action Fund, told States Newsroom she and other advocates have been meeting with senators to lobby against the bill’s passage, emphasizing that it will have an outsized negative effect on rural clinics and hospitals.

“We are encouraging everyone to reach out to their representatives about this,” McGill Johnson said. “They know that they’re doing this under a watchful eye, and we want to make sure their constituents know about it.”

The defunding effort would be a win for several prominent anti-abortion organizations that have long lobbied for this change and nearly achieved it in 2017 with a similar budget bill. Americans United for Life sent a fundraising email to its supporters Thursday saying this is a “crossroads” for abortion in America. 

“So far in 2025 more than a dozen Planned Parenthood clinics have closed, their taxpayer funding is hanging by a thread, and the highest-ranking federal health officials are undertaking a ‘top-to-bottom review’ on the abortion pill,” the email attributed to CEO John Mize said. “It’s possible that very soon, mail-order abortion could be walked back, and more Planned Parenthood locations could be closing their doors for good.”

Susan B. Anthony Pro-Life America, another anti-abortion organization that helped draft the Heritage Foundation’s Project 2025 blueprint for the next Republican president, told States Newsroom in an emailed statement that the budget provision should be no surprise, and there are better uses for the funding, like community health centers.

“Republicans have identified budgetary concerns with funding Big Abortion since 2015, and the bill language to do so has remained substantially the same,” said SBA President Marjorie Dannenfelser.

Closures would affect already fragile health care system, Midwest doctor says

Planned Parenthood has already closed some clinics around the country, including eight clinics across Iowa and Minnesota at the end of May. Dr. Sarah Traxler, chief medical officer of Planned Parenthood North Central States, which includes Iowa and Minnesota, said the U.S. Health and Human Services’ decision to freeze Title X family planning funding to many reproductive health clinics at the beginning of May contributed to the decision to close those clinics. The North Central States affiliates serve more than 93,000 patients each year, about 20,000 of which use telehealth services.

About 30% of those patients use Medicaid to access care, she said.

“When Planned Parenthood isn’t able to provide services to patients as an essential safety net provider, it has ripple effects across the health care system at large,” Traxler said. “We are already sitting in a time in our country, and have for several decades, where we have patients who can’t access care.”

Clare Coleman, president and CEO of the National Family Planning and Reproductive Health Association, told States Newsroom that 865 Title X clinics in 23 states are impacted by the federal freeze. She said there are no Title X services in eight states: California, Hawaii, Maine, Mississippi, Missouri, Montana, Tennessee and Utah. She said the funding freeze affects one-quarter of all Title X funding grantees, translating to about 842,000 patients who have lost access to care.

“In the two months since HHS withheld federal funding for nearly two dozen Title X family planning grants, affected grantees have been struggling with the unknown of whether they will ever receive the vital funds,” Coleman said in an email. “Some have had to close clinics, lay off staff, and reduce essential contraceptive and sexual health care services. … On top of the Title X funding freeze, proposed Medicaid cuts will be devastating for Title X grantees. Rates of unintended pregnancies and STIs will increase, cancer screenings and diagnoses will be delayed, and decades of public health progress will be reversed.”

After the Iowa Legislature axed Planned Parenthood from its family planning program, Traxler said, the rates of sexually transmitted infections increased considerably across the state — an outcome verified by a 2022 medical study. She expects similar effects from these cuts.

People already travel long distances for abortion care, she said, and that will only get worse if more cuts come to pass. But she also expects to see patients start traveling long distances for routine gynecological care.

‘Changes to Medicaid … only adds to the chaos’

Like many independent abortion clinics, the all-trimester Maryland abortion clinic Partners in Abortion Care does not receive Title X funding. But because Maryland is one of 17 states whose Medicaid program covers abortions, they do see a lot of patients who are on Medicaid, at a significant cost to the clinic. Certified nurse-midwife and Partners co-founder Morgan Nuzzo said the clinic did not receive more than $1 million in federal or state Medicaid dollars in fiscal year 2024, and in fact loses about $1 million annually for seeing Medicaid patients.

Nuzzo said Maryland’s Medicaid program reimburses first-trimester abortions at a “decent rate,” but at a very low rate for later abortion cases, which are more medically complex.

“After about 15 to 16 weeks [gestation], we’re losing money on these cases,” Nuzzo said. “We’ve been billing now for almost a year through the state. In second and third-trimester abortion care, we’re losing about 85% of what we would charge for a cash pay fee. So that comes out to about $250,000 a quarter that we are losing just by the under-reimbursement from Maryland Medicaid.”

For that reason, Nuzzo is hopeful about Maryland’s new $25 million Public Health Abortion Grant Program, recently approved by Gov. Wes Moore. The program will be open to clinics like Partners and abortion funds like the Baltimore Abortion Fund, but Nuzzo said it could be a while before that funding is available. Right now she is uncertain and concerned about how the federal reconciliation bill could potentially impact Maryland’s Medicaid program. 

Because Partners provides abortions for all trimesters, they see patients from all over the country, and even the world, and the vast majority need financial assistance, Nuzzo said.

“People are traveling further for their procedures, just like they were before,” she said. “The landscape is constantly changing, almost week to week, about where you can access abortion, which is confusing and chaotic to patients. Changes to Medicaid and insurance coverage of abortion only adds to the chaos.”