President Donald Trump holds up the "big, beautiful bill" that was signed into law as during a Fourth of July military family picnic on the South Lawn of the White House on July 4, 2025 in Washington, D.C. (Photo by Alex Brandon - Pool/Getty Images)

WASHINGTON — President Donald Trump signed into law Friday evening his massive spending cut and tax break package to fulfill his domestic policy agenda on immigration and defense and overhaul American energy production.

The “big, beautiful bill,” which Trump signed on Republicans’ self-imposed Fourth of July deadline, will make permanent the 2017 tax cuts from his first term and provide billions to carry out his plans of mass deportations, an immigration crackdown and increased defense spending.

The nonpartisan Congressional Budget Office estimates that the bill could add $3.4 trillion to deficits over the next 10 years, according to its most recent analysis.

“America is winning, winning, winning like never before,” said Trump, speaking to military families at a Fourth of July picnic on the White House lawn prior to the bill signing. Military aircraft including a B-2 bomber flew over the White House as the national anthem was sung.

Trump saluted 150 airmen and their families at the event from Whiteman Air Force Base in Missouri, where the B-2s that bombed Iran in June originated their flights.

But he also attacked Democrats who opposed his legislation, including House Minority Leader Hakeem Jeffries, D-N.Y., who gave a speech on the floor in opposition on Wednesday that broke a House record for its length.

Members of the Cabinet were present for the bill-signing as well as Speaker of the House Mike Johnson and House Majority Leader Steve Scalise of Louisiana, House Majority Whip Tom Emmer of Minnesota, Sens. Lindsey Graham of South Carolina, Marsha Blackburn of Tennessee and Mike Crapo of Idaho and other top GOP members of Congress.

The president signed the bill seated at a desk in front of the picnic-goers, with lawmakers and Cabinet members surrounding him. Johnson presented Trump with the gavel that Johnson said he used when the vote closed to pass the “big, beautiful bill.” Trump pounded on the desk with the gavel and handed out pens to those gathered around him.

Medicaid slashed

In order to fulfill priorities in the tax and spending cut bill, congressional Republicans scaled back spending on Medicaid, food assistance for low-income people and clean energy programs.

Democrats objected to the cuts to Medicaid, the Supplemental Nutrition Assistance Program, or SNAP, and other provisions. But because Republicans have unified control of Congress, the GOP was able to pass the bill through a complex process known as reconciliation, skirting the Senate’s 60-vote threshold.

The Senate passed its version of the bill after Vice President JD Vance cast the tie-breaking 51-50 vote Tuesday. The House managed Thursday to pass the new version of the bill after two chaotic days negotiating with far-right members who initially objected to the bill and later acquiesced, with a vote of 218-214.

The only Republicans to object in the Senate were Maine’s Susan Collins, Kentucky’s Rand Paul and North Carolina’s Thom Tillis. The House GOP members who voted with Democrats were Kentucky’s Thomas Massie and Pennsylvania’s Brian Fitzpatrick.

Also tucked into the bill is a provision that raises the country’s debt ceiling by $5 trillion, which has brought objections from Republican fiscal hawks like Paul.

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.

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.

Speaker of the House Mike Johnson, R-La., talks with reporters before heading to the House chamber for a procedural vote on the "One, Big, Beautiful Bill Act" at the U.S. Capitol on July 2, 2025 in Washington, D.C.  (Photo by Chip Somodevilla/Getty Images)

This report has been updated.

WASHINGTON —  U.S. House Republican efforts to pass the “big, beautiful bill” hit a roadblock Wednesday, when leaders left the chamber in a holding pattern for more than seven hours before calling a procedural vote that stalled amid opposition from hard-right members and others.

The House must adopt the rule in order to set up floor debate and a final passage vote for the tax break and spending cut package. But with four Republicans voting against it and nine withholding their votes, the House remained at a standstill around 11 p.m. Eastern.

GOP Reps. Andrew Clyde of Georgia, Brian Fitzpatrick of Pennsylvania, Keith Self of Texas and Victoria Spartz of Indiana had cast votes against approving the rule, though they could flip since leadership hadn’t closed the vote. Freedom Caucus Chairman Andy Harris of Maryland was among the members withholding their votes in protest.

Far-right members of the House GOP objected strongly to the Senate version passed Tuesday, which reflected changes made during the past month compared to an earlier version passed in the House. Members of the House Freedom Caucus opposed provisions dealing with immigration and the repeal of clean energy tax credits, as well as the measure’s increase in the deficit.

The nonpartisan Congressional Budget Office released an analysis after the Senate voted, showing the bill would increase deficits by $3.4 trillion during the next decade compared to current law.

‘We can’t make everyone 100% happy’

Speaker Mike Johnson, R-La., said earlier in the day he felt ​​”very positive about the progress” made during ongoing negotiations, but didn’t commit to having the necessary votes.

“The thing about it is, when you have a piece of legislation that is this comprehensive and with so many agenda items involved, you’re going to have lots of different priorities and preferences among people because they represent different districts and they have different interests,” Johnson said. “But we can’t make everyone 100% happy. It’s impossible.”

Johnson said he would never ask lawmakers to “compromise core principles, but preferences must be yielded for the greater good.”

South Dakota Republican Rep. Dusty Johnson told reporters before the delay that “the rule going down would be a very unfortunate development.”

But he expressed confidence in Speaker Johnson’s ability to bring holdouts on board eventually, potentially by making commitments tied to future bills.

“Speaker Johnson has not made any promises. He has been really good about talking about legislative vehicles that will exist in the months to come,” Dusty Johnson said. “Reconciliation is not the only tool in the Republican, or I should say in the congressional toolbox. Mike Johnson’s done a good job of making people understand there are other ways we can get things done.”

Texas Republican Rep. Chip Roy said a few hours before the rule vote began that holdouts were “exploring all of the options legislatively and through the executive.”

“We were not happy with what the Senate produced,” Roy said. “We thought there was a path forward as of late last week, even though I had concerns. I’ve been public about them. But then they jammed it through at the last minute in a way that we’re not overly excited about.”

Roy said that “everything is on the table at the moment,” when asked by States Newsroom if he hoped to get concessions from leaders on this package or deals struck for future bills.

Trump presses House GOP

Several House GOP lawmakers traveled to the White House earlier in the day to meet with President Donald Trump, who was also attempting to assuage concerns through several social media posts.

“It looks like the House is ready to vote tonight,’ Trump posted minutes before the rule vote began. “We had GREAT conversations all day, and the Republican House Majority is UNITED, for the Good of our Country, delivering the Biggest Tax Cuts in History and MASSIVE Growth. Let’s go Republicans, and everyone else – MAKE AMERICA GREAT AGAIN!”

House Rules Chairwoman Virginia Foxx, R-N.C., urged support for approving the rule during floor debate, arguing it was essential for GOP lawmakers to deliver on campaign promises.

“This legislation is the embodiment of the America First agenda and we would all do well to remember that,” Foxx said. “Failure at this critical juncture is not an option. This clock is ticking, the president and the American people are waiting. ”

Massachusetts Democratic Rep. Jim McGovern, ranking member on the panel, railed against the dozens of provisions Senate Republicans bundled together in the 870-page package, including some added just Tuesday.

“This process — an abomination, legislative malpractice,” McGovern said. “Final text of this bill came out less than 24 hours ago. We met in committee an hour after it was posted and now we’re here considering a rule that only allows for one hour of debate.

“This bill is within the jurisdiction of 12 different committees. One hour is ridiculous. And every minute we’re finding out new things that were snuck into the bill: a tax cut for whalers and now we’re learning about a gambling tax.”

Tax cuts favor higher incomes

The bill — which underwent weeks of revisions in the Senate after a prior version barely passed the House in May — will extend and expand the 2017 GOP tax law while overhauling several safety-net programs and slashing spending on Medicaid.

Those tax cuts skew toward wealthier income earners. The top 1% would receive a 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. It also makes permanent some tax breaks on business investments and research and development costs.

The package makes substantial changes to Medicaid, including requiring some people on the program to work, participate in community service, or attend an educational program for at least 80 hours a month.

It will block any Medicaid funding from going to Planned Parenthood for one year, essentially requiring enrollees to find other health care options for routine appointments such as cancer screenings, birth control and sexually transmitted infections treatment and screening. Using federal taxpayer dollars for abortion coverage has been restricted for decades, with limited exceptions.

The legislation requires state governments to pay for a portion of the Supplemental Nutrition Assistance Program for the first time if they cannot get error payment rates under a certain percentage. SNAP is the primary federal nutrition program that feeds low-income people and roughly 42 million rely on it.

It bolsters spending on border security and defense by hundreds of billions of dollars, including line items for the “golden dome” missile defense system and additional barriers along the southern border.

The measure would provide a substantial funding increase to federal immigration enforcement for detention and removal of people without permanent legal status, aiding the president in carrying out his campaign promise of mass deportations.

The bill would raise the debt limit by $5 trillion, a figure designed to get Congress past next year’s midterm elections before the country would once again bump up against the borrowing limit.

Protesters milled about and held signs on street corners outside the U.S. Capitol as Republicans worked to pass the megabill. Several spoke out against cuts to Medicaid and SNAP, as well as rollbacks to clean energy tax credits contained in the budget reconciliation package.

Senate turmoil

The House voted 215-214 mostly along party lines to approve the first version of the package in late May.

Senate Republicans spent much of the last month reading through that, trying to determine what proposals their members supported and which elements would need to come out to comply with the strict rules that go along with writing a budget reconciliation bill.

The parliamentarian, that chamber’s referee, continued to issue rulings on whether various policies in the legislation were in bounds for days before the Senate officially began debating the measure and even after they launched into vote-a-rama Monday morning.

That “Byrd bath” process eventually wrapped up, allowing Senate GOP leaders to release updated text of the package shortly before the chamber took its final vote.

Even with near-constant negotiations among Senate Republicans, Senate Majority Leader John Thune, R-S.D., was unable to get everyone on board.

3 Senate Republicans voted no

Maine Sen. Susan Collins, Kentucky Sen. Rand Paul and North Carolina Sen. Thom Tillis opposed the measure, which the Senate approved on Tuesday with Vice President JD Vance casting the tie-breaking vote.

Collins wrote in a statement that while she supported “extending the tax relief for families and small businesses,” her opposition to the legislation “stems primarily from the harmful impact it will have on Medicaid, affecting low-income families and rural health care providers like our hospitals and nursing homes.”

Collins also cited “additional problems” with how the legislation addressed tax credits for certain forms of energy production, which she wrote “should have been gradually phased out so as not to waste the work that has already been put into these innovative new projects and prevent them from being completed.”

Tills spoke about his opposition to the bill’s changes to Medicaid during a floor speech before the Senate’s vote, arguing its cuts to spending to the state-federal health program for low-income people and some people with disabilities weren’t in the best interest of GOP voters.

“I’m telling the president that you have been misinformed,” Tillis said. “You supporting the Senate mark will hurt people who are eligible and qualified for Medicaid.”

Tillis said he supports a policy change in the bill that would require people on Medicaid to work, participate in community service, or attend an educational program. But he was critical of other changes implemented by his Senate colleagues, and announced he won’t seek reelection hours after voting against advancing the package.

“I love the work requirement. I love the other reforms in this bill. They are necessary and I appreciate the leadership of the House for putting it in there,” Tillis said. “In fact, I like the work of the House so much that I wouldn’t be having to do this speech if we simply started with the House mark.”

Paul said he decided to vote against the legislation because it will increase federal deficits during the next few years. 

“To me the most pertinent question is, how will the bill affect the deficit in the next year?” Paul said. “Currently our deficit is estimated to be a little under $2 trillion this year. What will happen to the (deficit) in 2026 if this bill passes? Well, using the math most favorable to the supporters of the bill, referred to as the policy baseline, the deficit in 2026 will still be $270 billion more than this year.”

Paul added “that’s just not good if you profess to be fiscally conservative.”

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• Sauk County’s public nursing home will remain county-owned — and open — after a resolution to begin closing the facility failed to advance during a chaotic Board of Supervisors meeting. It was a win for organizers who have relentlessly resisted efforts to privatize the facility. 

• Tensions have escalated since last year, when the board approved selling the nursing home to the for-profit Aria Healthcare. Opponents sued the county to halt the sale, and Aria backed out of the deal. 

• Some county board members say a sale is the best way to keep the facility open as costs increase. Opponents argue the board should prioritize investing in the home, rather than risking inferior privatized care. 

• Similar debates have unfolded in at least four other Wisconsin counties over the last two years.

Sauk County’s public nursing home will remain county-owned — for now. That’s after a resolution to begin closing the facility failed to advance to the full county board during a meeting that ended in chaos last week.

It was the latest twist during a relentless campaign by local residents to keep county control of services that have existed locally in some form since the 1800s. Heading into a special meeting Thursday, proponents of keeping the Sauk County Health Care Center public feared defeat. 

The Sauk County Board of Supervisors was expected to vote on a resolution to close the nursing home if it weren’t sold. The meeting drew more than 80 attendees to the county board room. Several held signs, declaring “SAVE OUR SAUK CO. HEALTH CARE,” and “WE LOVE OUR SAUK COUNTY NURSING HOME.”   

Instead, no vote took place, and the board adjourned the meeting within two minutes without allowing public comment.

Organizers yelled “shame on you” as board members left the room.

 “You won,” County Board Chair Tim McCumber shouted at the chanting organizers. “The damn nursing home hasn’t been sold, and it hasn’t been closed.”

Tensions have escalated since last year, when the board approved selling the nursing home to the for-profit Aria Healthcare. Opponents sued the county to halt the sale. The litigation and broader opposition prompted Aria, which did not respond to a request for comment, to back out this month, according to Thursday night’s tabled resolution. 

Board members supporting a sale call it the best way to keep the facility open as costs increased. Opponents argue the board should prioritize investing in the home, rather than risking inferior privatized care. 

Wisconsin counties debate nursing home sales

Similar debates have unfolded in at least four other Wisconsin counties over the last two years. St. Croix found new revenue streams to keep its nursing home public, while Washington County sold its facility to a private nursing home chain. Lincoln County approved a sale this month, and Portage County continues seeking buyers.  

Wisconsin still maintains more county-owned nursing homes than most states, but that number has shrunk in recent years, concerning nursing home residents and their loved ones.

County-owned nursing homes tend to be better staffed, have higher quality of care and draw fewer complaints than facilities owned by for-profits and nonprofits, a 2024 WPR/Wisconsin Watch analysis of U.S. Centers for Medicare and Medicaid Services data shows.

Sauk County’s nursing home has a history of high care ratings, but those have recently slipped. Federal inspections between October 2024 and April yielded three “immediate jeopardy” citations related to patient care. Those citations, the most severe type, dropped the facility’s overall rating to “much below average,” CMS data shows. 

Meanwhile, the nursing home has struggled with staffing, losing 10 employees since May 23, including its director of nursing, Thursday’s resolution said. More expensive contractors, many from out of town, are filling in. 

“We need to do everything to make sure that that facility is as successful as it used to be,” said Judy Brey, a leader of the citizen group suing the county. 

Her group filled the board room Thursday night.

By tabling the resolution, the board preserved the status quo. 

“It’ll be county-run until we have more patient care problems out there and the state intervenes, or we’re able to sell it,” said McCumber, who has had family stay at the facility.

While Thursday’s resolution had left room for Aria or another company to buy the home before finalizing its closure, some board members — even proponents of a sale — were not comfortable voting to potentially close it, said Supervisor Terry Spencer.

Spencer, who favors a sale, sits on the Public Works and Infrastructure Committee, one of three committees that met before the full board meeting and took no vote on the resolution.

“If it’s going to fail on its own, we’ll just let it fail on its own, and then we’ll close it,” Spencer said. “But I’d rather see it try than just say we’re closing our doors.”

Resident: Nursing home is ‘one big family’ 

Sauk County has operated a care facility in some form since 1871 — using it to treat diseases ranging from smallpox in the early 1900s to Alzheimer’s in the 1990s, according to the county’s website. Around 50 people live in the facility today, including Robert Leopold, 84, who has been there about a year. He and two other nursing home residents came to the board meeting to speak out against a closure.

“We (nursing home residents) play cards, we have fun, and it’s one big family,” Leopold, a retired teacher and longtime 4-H volunteer locally, said with tears in his eyes. 

“If we have to go someplace else, we’re all going to be a family gone,” he added. “I just hope the board realizes what a beautiful facility they’ve got and be proud of it and do something with it.”

The meeting’s rapid adjournment left no opportunity for Leopold — who was attending his first board meeting during the nursing home debate — or others to publicly voice their perspectives. Brey and others shouted demands that the board allow public comment, pointing out that nursing home residents had traveled 30 minutes to be there.

McCumber responded: “Shame on you for dragging people out of a nursing home.” 

“(Nursing home residents) showed up and they wanted to speak, but nobody gave them the chance,” Brey replied. “That is despicable.”

Sale falls through

While energized by Thursday’s outcome, residents are bracing for a future attempt to sell or close the home.

But McCumber said the county’s best option, Aria, likely won’t buy the facility until what he calls a “frivolous” lawsuit is dropped or dismissed.

Aria received board approval to purchase the facility in September, but the county still needed state approval. The Department of Health Services previously blocked Aria from buying another nursing home, citing past citations that, the department said, “demonstrate a history of noncompliance,” according to the Cap Times.

Aria’s four Wisconsin nursing homes have federal ratings ranging from “much above average” to “much below average.”

The state ultimately approved the Sauk County purchase in May, but the lawsuit prompted Aria to instead seek a leasing agreement with the county.

While the county board approved that arrangement, the state health department required additional approval, according to the resolution. The original state-approved sale plan required Aria to take over the nursing home by July 1. Moving forward with a sale or lease after that deadline would require a new license application, which can take up to 60 days.

Aria told county officials it no longer wished to continue due to misrepresentations of the company online and “unwarranted attacks” that could interfere with business operations and patient care, according to the resolution.

Asked about the potential for a future Aria purchase of the nursing home, resident Mary Camp responded: “You don’t want to know.”

The 79-year-old has lived there for four years and described it as the “best place in the world.”

“I thought it was terrible they were going to sell,” Camp said. “I don’t think (Aria is) going to buy it now. I don’t know. I hope not.”

Her favorite part about her home? The people. At least twice a day someone asks her how she’s doing, and “it’s fantastic,” she said. Her 56-year-old son lives there too.

As they peer into an uncertain future, Brey said she has no plans to slow down her group’s work. As Thursday’s meeting ended, she collected donations for legal fees during a discussion about next steps, including potentially campaigning to recall board members who favored a sale. 

“I feel the power of people being together and united on this,” Brey said. “They know we mean business.”

Sauk County organizers fight off nursing home closure — for now 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.

The U.S. Capitol on June 30, 2025. (Photo by Ashley Murray/States Newsroom)

WASHINGTON — The final “big beautiful bill” approved by Senate Republicans Tuesday included some last-minute changes on hot-button issues such as safety net programs and clean energy tax credits.

Senate Republicans had wrangled for weeks to deliver legislative text to satisfy concerns from lawmakers who objected to cutting Medicaid, the federal-state insurance program for low-income families and some individuals with disabilities.

Other sticking points included threats that the health cuts pose to rural hospitals, and tax revisions that hamper clean energy jobs and investment, most of which are in states that elected President Donald Trump to his second term.

The lawmakers debated amendments for more than 24 hours. Even with final changes, now under consideration in the House, three Republicans held out: Susan Collins of Maine, Thom Tillis of North Carolina and Rand Paul of Kentucky. Vice President JD Vance cast the tie breaking vote.

Here are several rewrites that popped up in the bill’s final minutes and hours:

Rural hospital fund

Senate Republicans doubled the amount for a rural health “transformation program,” or money to compensate rural hospitals for the funds they would lose as a result of the proposed Medicaid cuts.

The latest proposal sets aside $50 billion, up from $25 billion, and moves up the distribution timeline to begin in 2026, up from 2028.

Collins had unsuccessfully introduced an amendment to bump the fund to $50 billion. Despite some support from GOP colleagues, the amendment was blunted by a technical budget point of order.

The Maine Republican still voted “no” Tuesday on the final bill.

SNAP

The lawmakers also made a late change to how and when states would begin to shoulder the responsibility for costs of the Supplemental Nutrition Assistance Program.

According to the new version, if a state’s payment error rate in 2025 multiplied by 1.5 is equal or greater than 20%, then that state would be permitted to wait until 2029, rather than 2028, to begin footing a portion of the bill for food assistance.  A state’s accuracy rate is the annual measurement of over- or underpayments to recipients.

Nine states would hover in the territory of meeting that threshold, according to the Department of Agriculture’s latest error rates published Monday. They are: Alaska, Florida, Georgia, Maryland, Massachusetts, New Jersey, New Mexico, New York and Oregon.

Alaska had the highest payment error rate of all states in both 2023 and 2024. Alaska Sen. Lisa Murkowski’s final decision on the bill was largely unknown until she cast a “yes” vote Tuesday.

A late amendment to strike the language offered by Amy Klobuchar of Minnesota failed 45-55.

Critics say the measure incentivizes states to keep the payment error rates high this year.

Solar energy

GOP senators late Friday added a clean energy excise tax into the bill, taking the industry by surprise. Then it vanished.

The tax that would have been imposed on new solar and wind projects was no longer in the legislation that senators voted on around noon Eastern Tuesday.

Other text loosened a squeeze on tech-neutral tax credits meant to incentivize the installation of energy systems that do not use fossil fuels. Senate Republicans added a year of leeway for new projects to break ground and avoid cutting short two of the tax credits.

Republican Sens. John Barrasso of Wyoming, John Thune of South Dakota, Mike Crapo of Idaho and Lindsey Graham of South Dakota speak to reporters after passage of their sweeping tax break and spending cut bill on Tuesday, July 1, 2025. (Photo by Ashley Murray/States Newsroom)

This report has been updated.

WASHINGTON — U.S. Senate Republicans approved their signature tax break and spending cuts package Tuesday with a tie-breaking vote cast by Vice President JD Vance, following days of tense, closed-door negotiations that went until the few last minutes of a marathon amendment voting session.

The 51-50 mostly party-line vote sends the legislation back to the House, where GOP leaders hope to clear the bill for President Donald Trump’s signature this week. But frustrations throughout the conference over changes made in the Senate could delay or even block final approval. 

Republican Sens. Susan Collins of Maine, Rand Paul of Kentucky and Thom Tillis of North Carolina voted against approving the legislation over concerns it would not benefit the country’s finances or Republican voters.

Changes made in final negotiations were not immediately clear or publicly available.

Majority Leader John Thune said the passage marked “a historic day.”

“We’re very excited to be a part of something that is going to make America stronger, safer and more prosperous, and it really starts with the agenda that President Trump laid out when he was running last year.

“He talked about modernizing our military, securing our borders, restoring energy dominance in this country, bringing tax relief to working families and low income taxpayers in this country, and doing something about the runaway, spiraling spending and debt,” the South Dakota Republican said minutes after the vote.

“So this was an incredible victory for the American people, and we as a team are delighted to be a part of it.”

The bill now heads back to the House. The chamber’s Committee on Rules is expected to meet Tuesday afternoon, which will be the final stop for the bill before it reaches the House floor.

Thune said he believes Senate Republicans have given the House “a really strong product.”

“I think we took what they sent us and strengthened and improved upon it. And so I’m hopeful that now, when it gets sent over there, as they deliberate about how they want to handle it, we’ll find the votes that are necessary to pass it and want to put it on the president’s desk,” he said.

Trump praised the Senate’s passage on his Truth Social media platform, saying “Almost all of our Great Republicans in the United States Senate have passed our ‘ONE, BIG, BEAUTIFUL BILL.’”

He added: “We can have all of this right now, but only if the House GOP UNITES, ignores its occasional “GRANDSTANDERS” (You know who you are!), and does the right thing, which is sending this Bill to my desk. We are on schedule — Let’s keep it going, and be done before you and your family go on a July 4th vacation.”

Several House conservatives have railed against the Senate version, including Reps. Andy Ogles of Tennessee, Ralph Norman of South Carolina and others.

House Speaker Mike Johnson issued a joint statement with House Republican leaders saying the chamber “will work quickly to pass the One Big Beautiful Bill that enacts President Trump’s full America First agenda by the Fourth of July. The American people gave us a clear mandate, and after four years of Democrat failure, we intend to deliver without delay.”

“Republicans were elected to do exactly what this bill achieves: secure the border, make tax cuts permanent, unleash American energy dominance, restore peace through strength, cut wasteful spending, and return to a government that puts Americans first,” the Louisiana Republican said in the statement that included House Majority Leader Steve Scalise of Louisiana, Majority Whip Tom Emmer of Minnesota and conference chair Lisa McClain of Michigan.

Alaska Sen. Lisa Murkowski , whose support had been unclear until the vote, and Majority Whip John Barrasso, of Wyoming, left the chamber to catch an elevator together just after 9:30 a.m. Eastern.

Asked if the bill was in the hands of the parliamentarian, Murkowski quipped, “I think it’s in the hands of the people that operate the coffee machine.”

Barrasso said “Yes” when asked if it would pass this morning.

Murkowski: ‘difficult and agonizing legislative 24-hour period’

Flooded by reporters after the vote, Murkowski said “we do not have a perfect bill by any stretch of the imagination.”

“My hope is that the House is gonna look at this and recognize that we’re not there yet, and I would hope that we would be able to actually do what we used to do around here, which is work back and forth in the two bodies to get a measure that’s gonna be better for the people in this country and more particularly, for the people in Alaska,” she said.

“This is probably the most difficult and agonizing legislative 24-hour period that I have encountered, and I’ve been here quite a while, and you all know I’ve got a few battle scars underneath me,” Murkowski added. “But I think I held my head up and made sure that the people of Alaska are not forgotten in this, but I think that there is more that needs to be done, and I’m not done.”

“I am gonna take a nap, though,” she said.

When asked about Murkowski’s decision to vote for the bill, Thune said, “She, as you know, is a very independent thinker and somebody who studies the issues really, really hard and well. And I’m just grateful that at the end of the day, she included what the rest of us did, or at least most of the rest of us did, and that is that this was the right direction for the future of our country.”

Democrats react

Senate Democrats walking off the floor seemed somber, a sentiment that Senate Leader Chuck Schumer said also extended to Republicans after the bill’s passage.

“On the Republican side, when the bill passed, there was a bit of somberness that I don’t think was expected, and that’s because they knew deep in their hearts how bad this bill is for them, their states and the Republican Party,” Schumer said.

“When people start losing their Medicaid, when they start losing their jobs, when their electric bills go up, when their premiums go up, when kids and parents lose SNAP funding, the people of America will remember this vote,” the New York Democrat continued.

Criticism poured in from others as well, including the nonpartisan Committee for a Responsible Federal Budget, which likened the Senate’s bill passage to jumping “off a budget cliff.”

“The level of blatant disregard we just witnessed for our nation’s fiscal condition and budget process is a failure of responsible governing. These are the very same lawmakers who for years have bemoaned the nation’s massive debt, voting to put another $4 trillion on the credit card,” the organization’s president Maya MacGuineas said in a statement.

CRFB estimates the Senate version of the bill would add $600 billion to the national deficit just in 2027.

The nonpartisan Congressional Budget Office released a calculation Sunday showing the bill would add $3.25 trillion to deficits over 10 years.

Trump weighs in ahead of vote

Trump told reporters on Tuesday morning before leaving for a Florida visit to the “Alligator Alcatraz” immigrant detention site that “it’s very complicated stuff” when asked about Senate Republicans’ debate over spending cuts.

“We’re going to have to see the final version. I don’t want to go too crazy with cuts. I don’t like cuts. There are certain things that have been cut, which is good. I think we’re doing well,” Trump said. “We’re going to have to see, it’s some very complicated stuff. Great enthusiasm as you know. And I think in the end we’re going to have it.”

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.

And it slashes spending on the Medicaid program for low-income people and some people with disabilities as well as shifting significant costs of the federal Supplemental Nutrition Assistance Program, or SNAP, to states for the first time. It also overhauls federal education aid.

It would also bolster spending on border security and defense by hundreds of billions of dollars, including line items for the “golden dome” missile defense system and additional barriers along the southern border.

The measure would provide a substantial funding increase for federal immigration enforcement for detention and removal of people without permanent legal status, aiding the president in carrying out his campaign promise of mass deportations.

The Senate version of the bill also would revive the Radiation Exposure Compensation Act fund, a bipartisan measure championed by Sen. Josh Hawley of Missouri. The fund provides money to victims of certain types of cancer and surviving family members in several states affected by the United States atomic bomb testing program and radioactive waste left behind. 

Uranium miners would also be eligible under the measure. While reviving the fund has received wide bipartisan approval in the Senate, the House has not shown the same support.

The Senate bill would raise the debt limit by $5 trillion, a figure designed to get Congress past next year’s midterm elections before the country would once again bump up against the borrowing limit.

On to the House

House approval is far from guaranteed.

Johnson can only lose four Republicans if all lawmakers in that chamber attend the vote. Several GOP members have voiced frustration with how the Senate has reworked the legislation, signaling an uphill climb for the bill.

House Ways and Means Chair Jason Smith said as he left the Senate cloakroom just after 9:20 a.m. Eastern that lawmakers are “getting closer to a bill signing on July Fourth.”

“If you followed this journey over the last six months, over and over, people said that we could not accomplish a budget (reconciliation bill). We did. They said we would never pass it out of the House. We did. The Senate is going to pass it. The House is going to pass it, and the president’s going to sign it into law,” the Missouri Republican said.

Three amendments succeed

The Senate had adopted three amendments to the bill following an all-night amendment voting session, known as a vote-a-rama.

Tennessee Republican Sen. Marsha Blackburn was able to remove language from the package that would have blocked state and local governments from regulating artificial intelligence for five years if they wanted access to a $500 million fund. That vote was 99-1 with only North Carolina’s Tillis voting to keep the language in the package.

Blackburn said the change was necessary because lawmakers in Congress have “proven that they cannot legislate on emerging technology.”

Senators approved an amendment from Iowa GOP Sen. Joni Ernst by voice vote that would disqualify “anyone making a million dollars or more from being eligible for unemployment income support.”

Louisiana Republican Sen. John Kennedy was able to get an amendment adopted by a voice vote that would move up the date when Medicaid administrators must begin checking the Social Security Administration’s death master file to determine if a new enrollee is alive before adding them to the health program. It was set to begin on Jan. 1, 2028, but will now begin one year earlier.

Senators rejected dozens of amendments offered by both Democrats and Republicans, some of which deadlocked on 50-50 votes. Maine’s Collins and Alaska’s Murkowski broke with their party several times to vote with Democrats.

National private school voucher program

Hawaii Democratic Sen. Mazie Hirono tried to eliminate a sweeping private school voucher program that’s baked into the reconciliation package, but that vote failed 50-50. Collins, Nebraska Republican Sen. Deb Fischer and Murkowski voted in support.

The original proposal called for $4 billion a year in tax credits beginning in 2027 for people donating to organizations that provide private and religious school scholarships.

But the parliamentarian last week deemed the program to not comply with the “Byrd Bath,” a Senate process named for the late Sen. Robert Byrd, forcing senators to rework the program.

Details on the finalized version of the program remain unknown as the final bill text has not been released.   

Safety funding for Virginia airport across from D.C.

Virginia Democratic Sen. Mark Warner tried to add language to the bill that would have increased safety funding for airports near Washington, D.C., and established a memorial for the victims who died in a crash this January. The vote failed on a tied 50-50 vote, with Collins, Kansas GOP Sen. Jerry Moran and Murkowski voting with Democrats in support.

“Colleagues, we all know that on January 29 of this year, 67 individuals lost their lives when a military helicopter and a passenger jet collided near Reagan National Airport. This tragedy underscores the need for more safety improvements at National Airport,” Warner said. “The reconciliation bill increases, actually doubles, the amount of rent that National and Dulles pay the government but doesn’t use any of that money to make those airports and the people who use them any safer.”

He argued there was “no good rationale for increasing those rents and not using them for aviation safety.”

Texas Republican Sen. Ted Cruz spoke against Warner’s amendment, saying the rents for the two airports in Virginia near the nation’s capital haven’t been updated in decades.

“The federal government originally calculated the rent in 1987 at $7.5 million dollars, massively below market rates,” Cruz said. “This bill increases that to $15 million, still dramatically below market rates.”

Cruz — chairman of the Committee on Commerce, Science and Transportation — said the legislation includes $12.5 billion for the Federal Aviation Administration to “transform the air traffic control system” and said his panel is looking into the collision in order to prevent something similar from happening again. 

Trump budget director’s office targeted

Maryland Democratic Sen. Chris Van Hollen also got within one vote of having an amendment adopted when he tried to remove a section from the bill that would increase funding for the White House budget office by $100 million.

“This is at a time when (Federal Emergency Management Agency) grants to many of our states have been canceled, grants for law enforcement have been frozen, grants for victims of crimes are on hold,” Van Hollen said. “That is not efficiency. That is creating chaos and uncertainty. And I ask my colleagues, why in the world would we want to send another $100 million to OMB?”

Wisconsin Republican Sen. Ron Johnson opposed the efforts, saying “the Office of Management and Budget needs to identify budgeting and accounting efficiencies in the executive branch. They need the resources to do it.”

The amendment was not added to the bill following another tied 50-50 vote with Collins, Murkowski and Paul voting with Democrats in favor.

Had GOP leadership wanted either of those proposals added to the package, they could have had Vance break the tie, but they did not.

Collins loses vote on rural hospital fund

Maine’s Collins tried to get an amendment added to the legislation that would have increased “funding for the rural health care provider fund to $50 billion dollars and expand the list of eligible providers to include not only rural hospitals but also community health centers, nursing homes, ambulance services, skilled nursing facilities and others.”

Collins said the additional $25 billion in funding for the fund would be paid for by “a modest increase in the top marginal tax rate, equal to the pre-2017 rate for individuals with income above $25 million and married couples with income above $50 million.”

Collins’ amendment was subject to a Senate procedural limit known as a budget point of order. She was unable to get the votes needed to waive that on a 22-78 vote.

Oregon Democratic Sen. Ron Wyden spoke against Collins’ proposal, calling it “flawed,” and introduced the budget point of order against her amendment.

“The danger Senate Republicans are causing for rural hospitals is so great, Republicans have had to create a rural hospital relief fund so they can look like they are fixing the problem they are causing,” Wyden said. “It is a Band-Aid on an amputation. It provides just a tiny fraction of the nearly $1 trillion in cuts the bill makes to Medicaid. It would be much more logical to simply not cut $1 trillion from Medicaid in the first place.”

Collins received a mix of support from Republicans, including West Virginia Shelley Moore Capito, Louisiana’s Bill Cassidy, Utah’s John Curtis, Nebraska’s Fischer, South Carolina’s Lindsey Graham, Missouri’s Josh Hawley, Ohio’s Jon Husted and Bernie Moreno, Mississippi’s Cindy Hyde-Smith and Roger Wicker, Louisiana’s Kennedy, Kansans Roger Marshall and Moran, Kentucky’s Mitch McConnell, Alaskans Dan Sullivan and Murkowski and Indiana’s Todd Young.

Also voting to waive the point of order and move forward with the amendment were Georgia’s Jon Ossoff and Raphael Warnock and Virginia’s Warner, all Democrats, and independent Maine Sen. Angus King. 

Rachel Castor, a single mom of two and teacher, stands outside her home in Sandpoint, Idaho. Castor’s son could not be admitted to the local hospital during an asthma attack because Bonner General Health lost its pediatrician coverage at the same time it closed the labor and delivery unit in 2023 following the Dobbs decision. (Photo by Erick Doxey for States Newsroom)

Editor’s note: This report examines the impact of the U.S. Supreme Court decision that struck down the federal right to abortion three years ago.

Of all the outcomes Rachel Castor could have predicted from Idaho’s abortion ban, her teenage son being denied hospital admission during an asthma attack wasn’t on the list.

Bonner General Hospital in Sandpoint announced its decision to end obstetric services in March 2023, roughly six months after the near-total ban took effect. Among the stated reasons were the state’s legal and political climates concerning health care, and the loss of pediatrician staffing.

Castor saw the fallout from that decision on a night in early April. Her 17-year-old son spent several hours in the Bonner General emergency room, before the staff informed her if his breathing didn’t improve enough for discharge by the morning, he would need to be transferred an hour south to the hospital in Coeur d’Alene. Bonner General had no pediatricians.

“And I was like, ‘Excuse me?’” Castor said.

Elaine Gloeckle, a 66-year-old Boise resident, said she started having trouble with urinary tract infections and hormonal balances recently and found it hard to get an appointment to see a specialist, even with a referral. It was even more difficult to see a doctor for gynecological care. That wasn’t always the case in the more than 30 years she’s lived in the area — she used to have no trouble seeing doctors.

But now for the gynecology visits, along with care for diabetes management and kidney issues, she has seen physician assistants, who are supervised by the doctors within a practice. While she has had good experiences with the assistants, it’s sometimes difficult to feel confident in their assessments when she isn’t sure how much they are consulting with doctors. And the wait times are still long — at least six weeks, usually, in her experience.

“I have no idea who the doctors are, I’ve never met them,” Gloeckle said. “And I don’t know if that means anything, or if it’s just peace of mind that there is a doctor in the mix.”

It’s been three years since the U.S. Supreme Court issued the Dobbs ruling that ended federal abortion protections and allowed more than a dozen states to implement abortion bans. States that were already struggling with physician shortages say they’re getting worse, especially in rural areas, where many labor and delivery units have also closed their doors. Clinics have closed and resources become more strained with every passing year.

Patients and providers have been left to adjust to barriers accessing abortion care; legal battles that continually redraw access lines; and heartbreak and tragedy as women die from easily treatable conditions like miscarriage and infection.

In places like Florida, Kansas and Louisiana, patients have had to find other providers who will help them with miscarriage complications, often requiring them to travel to a neighboring state with legal access because doctors in states with bans are afraid to see them. Other patients experiencing miscarriage or the threat of miscarriage have reported waiting hours in emergency rooms to be seen while hospital staff consult with attorneys about their legal exposure before taking any action. A Florida Republican lawmaker who opposes abortion said recently that she waited hours to receive treatment for an ectopic pregnancy, which is dangerous and nonviable.

Besides Texas, few states that implemented abortion bans after Dobbs have been as much of a spectacle as Idaho. Between a so-called “abortion trafficking” law that first passed in Idaho, the very public loss of many OB-GYNs and maternal-fetal medicine specialists, and a legal fight with the federal government over whether abortions should be permitted in emergencies — a lawsuit that made its way before the U.S. Supreme Court — the state has been a testing ground of sorts for how a near-total abortion ban can play out for communities.

Many health care providers and advocates warned it wouldn’t just be abortion care, or even pregnancy-related care, that would be affected by the Dobbs decision. Dr. Stacy Seyb, a maternal-fetal medicine specialist in Boise, said in July 2023 that the near-total ban would lead to more consequences as time went on.

“It feels like a step backward in improving the health of women and children in the state,” he told The Guardian. Soon, he warned, the state would “see a collapse in women’s health care.”

‘It makes me wonder what else we’ve lost that we don’t know about’

Bonner General Health’s obstetrics unit was one of many rural hospitals that was already struggling before Dobbs with changing community demographics that meant lower birth rates and difficulty recruiting and retaining physicians. Among its population of about 10,000, the hospital admitted fewer than 10 pediatric patients in 2022 and delivered 265 babies, a decrease from prior years.

It’s a familiar situation nationwide. More than 100 hospitals across 26 states have closed labor and delivery services since 2020. To be sure, the reasons for those closures include many more factors than abortion bans, such as low reimbursement rates from Medicaid programs for obstetrical services and difficulty recruiting and retaining physicians.

In its announcement, Bonner General representatives said they tried to recruit active and retired pediatrics providers in the area, but no long-term sustainable solutions were available.

At that time, it didn’t sink in for Castor that having no pediatrician coverage at the hospital would mean no admission to the hospital for minor children.

Sandy Brower, director of quality and risk management at Bonner General Health, told States Newsroom via email that their staff is well-equipped to see pediatrics patients, who are always seen, treated and stabilized in the emergency department. But she confirmed that the hospital does not admit minors because they have no pediatricians on staff.   

“This approach is not unusual in rural health care,” Brower said. “Around the country, critical access hospitals often rely on stabilization and transfer protocols to ensure that patients …  are seen in the most appropriate setting.”

Faced with the prospect of driving her son to Coeur d’Alene herself or guessing what a 44-mile ambulance ride might cost, Castor — a single mom of two and a teacher — decided to drive to the hospital she’d never been to before. But with little information to go on about the transfer process, she was left wandering around the hospital looking for the right place to go while her son’s condition deteriorated.

“He’d already been away from the hospital for an hour for the drive, and he was starting to not do OK, and it was really stressful because I didn’t know what we were supposed to do,” Castor said. “He had his arms wrapped around himself and he just didn’t look good.”

Once she found her way, Castor said everything went well and they were discharged after one more night. But she was left shaken by the experience and her sense of stability about where she lives. She shares custody with a former partner who lives nearby, so it’s difficult to consider moving.

“I think everyone at the hospital is lovely, but it does seem like we don’t have all the services we need,” Castor said. “It makes me wonder what else we’ve lost that we don’t know about.”

Physician recruitment difficult for pediatrics in populous areas too

Amid the implementation of the abortion ban, Idaho’s population exploded. Between 2020 and 2024, more than 152,000 people moved in and the total number crossed 2 million statewide for the first time in its history. On top of all that, at least three clinics that provided labor and delivery services closed, including two in the Boise area, the most populous portion of the state. The combination created longer wait times and more complicated staffing scenarios.

Christine Myron, spokesperson for Idaho’s largest health care system St. Luke’s, told States Newsroom via email that the time to get an appointment with an OB-GYN has increased over the last two years in all of their service areas, which include every region of the state.

Myron also said in recent weeks, a candidate for a pediatrician position declined their offer because of the restrictive obstetrical care environment in Idaho. She said the difficulties in recruiting extend to every specialty of physicians because young families hesitate to move in.

As of Wednesday, St. Luke’s had 10 pediatric physician vacancies, including specialists for pediatric nephrology, oncology, infectious disease and endocrinology. 

Shifting providers, delays frustrating while trying to conceive

For women like Cynthia Dalsing, who has lived in Sandpoint for more than 30 years, it’s difficult because of her age and location. She is 71, and a recent exam showed a polyp in her uterus that needed to be biopsied and removed. That type of exam and procedure could have been done 3 miles away from her house a few years ago, she said, before Bonner General closed its labor and delivery services.

Instead, she drove back and forth to Coeur d’Alene to complete pre-operative steps, including X-rays, blood work and an EKG, then to have the procedure, then to go back again to talk about the results.

“It’s taken weeks to get care that normally would be pretty routine,” Dalsing said. “It’s a 20-minute procedure.”

The procedure was dilation and curettage, Dalsing said, often referred to as a D&C, which is the same treatment sometimes used for an early abortion or miscarriage where pregnancy tissue needs to be removed from the uterus. When she mentioned the upcoming appointment to a friend, Dalsing said they asked if that was still allowed, given the abortion ban, not knowing it’s a common procedure for many other conditions.

“That’s how clueless and confused people are about all this,” Dalsing said. 

Younger women like 36-year-old Danielle Young, who has lived in Boise since the early 2000s, report issues receiving care as well. Young said since 2016, she has switched providers five times because they kept leaving — three of those were within the past three years.

Young said she had to wait eight months for an annual gynecological wellness appointment with a nurse practitioner, and when the time came, the exam felt rushed and chaotic. After that, she decided to switch practices. Young said it took another six months to be seen by the doctor she chose, but it has been worth the wait.

At the same time, Young said she and her husband are trying to conceive, and he has had difficulties finding a clinic where he can get fertility testing. She said most of the past year has been wasted just trying to reach someone on the phone who can tell them where he should go and when he can get an appointment.

“It’s been frustrating for us, because we would like to have children or a child, and I’m getting older,” Young said.

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!”

American Family Children's Hospital, part of the UW Health complex on Madison's west side. Nurses in the UW Health system have been seeking to restore union representation since 2019. (Photo by Erik Gunn/Wisconsin Examiner)

This report has been updated with reactions from UW Health and SEIU.

Five and a half years after nurses launched a campaign to restore union representation at UW Health, the state’s highest court ruled Friday that the Madison-based hospital system has no obligation to collectively bargain with employees.

Act 10, the 2011 state law that stripped most union rights from public employees, also removed legal guarantees of union representation for University of Wisconsin Hospital and Clinics Authority’s employees, Justice Brian Hagedorn wrote for a unanimous Court.

“When we examine the statutory language along with the statutory history, it is clear that Act 10 ended the collective bargaining requirements formerly placed on the Authority,” Hagedorn wrote.

The Court rejected the argument from Service Employees International Union (SEIU) that with the Act 10 changes, the hospital authority as a corporation fit the definition of “employer” under the Wisconsin Employment Peace Act.

The Peace Act defines an employee as anyone working for hire other than an independent contractor and an employer as a person — including partnerships, corporations and some other legal entities — that engages the services of an employee.

The hospital authority doesn’t automatically meet that definition, however, Hagedorn wrote.

Hospital, nurses union respond

The hospital system affirmed the Court’s ruling “that the Wisconsin Peace Act does not apply to UW Health” in a statement Friday, adding, “UW Health appreciates the court’s deliberate, diligent and final review.”

In a statement, SEIU and the UW Health nurses said they would continue to seek union recognition.

“While we are disappointed by the Wisconsin Supreme Court decision, which found that UW Health nurses are not covered under the Wisconsin Employment Peace Act, we are not deterred,” SEIU and the UW Health nurses seeking union recognition said in a statement.

“Our fight to restore collective bargaining rights doesn’t end in the courtroom,” the union statement added. “We will continue to explore all possible pathways to restoring our full collective bargaining rights, including seeking voluntary recognition and passing legislation, to ensure that all of us, no matter who we are or where we work, have a seat at the table and a voice in our workplace.”

A 2022 agreement between the hospital and the union to discuss issues of concern is continuing, according to the nurses’ union statement.

Over the last three years, “hundreds of nurses have become official union members and have been meeting with top administrators to address critical issues around retention, safe staffing, and quality patient care,” the statement said. “Earlier this year, UW nurses and management mutually agreed to extend this agreement through 2027. All the while, we continue to leverage our collective voice to elect pro-worker leaders at every level of government.”

UW Health has in the past made statements declaring that Act 10 prevented the hospital system from engaging with the union.

“Based upon legal advice received from both internal and external counsel, UW Health is concerned about the lawfulness of engaging in collective bargaining, which is not authorized under any statute,” the hospital system’s press secretary, Emily Greendonner, told the Wisconsin Examiner in an email message Friday.

“While today’s decision provided final clarity that we are not required to collectively bargain, the question of whether we are legally allowed to do so has not been decided by the courts,” Greendonner said.

Ruling relates Act 10, hospital system history

The hospital system was spun off from the University of Wisconsin in 1996 into a new “public body corporate and politic,” the UW Hospital and Clinics Authority. The hospital system’s employees were state employees represented by unions and with collective bargaining rights under Wisconsin’s state employment relations law.

The hospital authority “is not defined as a corporation,” Hagadorn wrote, “it is a ‘public body corporate and politic.’” He cited the Peace Act’s definition of “employer” that states the term does not include “the state or any political subdivision thereof.”

The 1996 law creating the new hospital authority removed its employees from the state employment relations law and added language specifying that the hospital authority was an employer under the Peace Act.

Act 10 changed that, Hagedorn wrote — repealing the hospital authority’s collective bargaining duty that was in the 1996 law as well as all other references to collective bargaining.

“In sum, Act 10 purged references to the Peace Act from the Authority Statute,” Hagedorn wrote.

“When it created the Authority, the legislature added the Authority as an employer under the Peace Act and imposed numerous other collective bargaining provisions. In Act 10, the legislature eliminated the Authority as a covered employer along with other collective bargaining requirements. We therefore hold that the Authority is no longer covered by the Peace Act and is not required to collectively bargain under the Peace Act.”

Friday’s ruling was the final stop for a case that started in September 2022. In an agreement brokered to avert a planned three-day strike by nurses demanding union recognition at UW Health, the hospital system and SEIU agreed to a joint petition to the Wisconsin Employment Relations Commission (WERC).

In the petition, the union argued that the hospital should be considered an employer under the Peace Act, while UW Health argued that Act 10 eliminated collective bargaining at the hospital system. WERC sided with UW Health, and Dane County Circuit Judge Jacob Frost subsequently affirmed the employment commission’s conclusion.

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Group Health Cooperative of South Central Wisconsin's East Side Madison clinic. (Photo by Erik Gunn/Wisconsin Examiner)

A union organizing campaign has turned into a contentious conflict at a Madison-based health care nonprofit.

The organizing drive at Group Health Cooperative of South Central Wisconsin has gotten mired in a mountain of litigation before the National Labor Relations Board.

There have been disputes over who should be included in a union representation vote as well as dozens of unfair labor practice charges that the Service Employees International Union (SEIU) has filed against Group Health management.

Most recently, the NLRB’s regional director has issued an order blocking the election after the union argued that the charges against the co-op would taint the outcome. Group Health is denying the charges, and co-op executives say they want a vote to take place as soon as possible.

The Group Health co-op was founded nearly 50 years ago as a health maintenance organization. Members, who include its employees, say the nonprofit’s focus on primary care and wellness has been central to its appeal. Those who support the union contend that the co-op’s response to the union drive is betraying its progressive roots.

“Everyone involved are gut-wrenched by the animosity that has developed,” said Susan McMurray, a former public employee union lobbyist and Group Health member for nearly 20 years. McMurray spoke at  a union rally outside Group Health’s clinic on Madison’s far East Side on June 20.

“There’s a multitude of reasons many of us chose a cooperative model over a for-profit shareholder model for our health care and insurance over the past almost 50 years,” said retired state employee Ruth Brill, a Group Health member, at a May 13 rally for the union.

“Some of our fellow GHC members have chosen to form a union. A union is like a cooperative in almost every way,” Brill said. “I’m calling on GHC to uphold the cooperative principles that it was founded on.”

In an interview, Marty Anderson, Group Health’s chief strategy and business development officer, rejected the accusation that the co-op has engaged in union-busting.

“GHC is not opposed to a union here at the cooperative,” Anderson said. “I think our position all along has been that we want our employees to have a voice — all of our employees, to have a voice in that choice.”

But Group Health co-op members who support the union see the management’s response — challenging the union’s proposal for who would vote as well as distributing messages to workers criticizing the union — more critically.

Paul Terranova, a community organizer, said he got involved in trying to persuade the co-op’s board to take a different approach earlier this year after a conversation with his Group Health doctor.

Terranova put together a group of members and asked for a board meeting in March.

“They gave us 20 minutes on the agenda to speak,” he told the Wisconsin Examiner. “It was just us making a presentation to them and them saying ‘thank you.’”

Terranova said his group asked the board and the management to “stop the anti-union messaging [and] anti-union activity” and to “get a second opinion” from other nonprofits that work cooperatively with union-represented employees.

“They refused to engage and they denied that there was any anti-union activity or messaging going on,” he said.

Terranova is also part of a member campaign that has endorsed, with the union, four candidates for the Group Health board in elections that concluded this week.

Update: All four were elected to the board. Election results were announced at the co-op’s annual meeting Thursday evening. 

Staffing struggles

The pro-union employees and SEIU filed a petition in December 2024 for a union representing Group Health clinic doctors, physician assistants, nurse practitioners and nursing staff in three departments: primary care, urgent care and dermatology. They also included physical therapists, occupational therapists and health educators.

According to union supporters, nearly 70% of the workers in those jobs and departments had signed cards asking for union representation.

Union supporters say that in those departments, issues including employee turnover and increased workloads prompted the campaign.

“We’re calling for equitable wages, safe provider-to-nurse ratios, meaningful ways to ease the crushing workloads we face and real strategies to improve retention,” said Dr. Ira Segal at the June 20 rally.

“There’s been a lot more turnover in our staffing, and that has increased over the years, which negatively impacts our ability to provide excellent care,” said Dr. Nisha Rajagopalan, a family physician. “The increasing turnover in our staff is unsustainable.”

Staffing crunches in health care have been widespread in the last five years, exacerbated by the COVID-19 pandemic.

“There just aren’t enough care providers and folks that assist those care providers within the [health care] system in total,” said Anderson, the Group Health executive. “We’ve had to flex with the changing health care environment.”

Julie Vander Werff, a physician assistant and union supporter, said she understands the health care workforce challenge. Despite that, she said, she’s experienced a shift in the co-op’s culture that is contributing to the problem.

“They used to be a very respectful employer, and they’ve really gotten off track in terms of how respectful they have been,” Vander Werff said in an interview. “And they’re being really punitive, and we’re losing staff as a result with high, high turnover rates.”

Who’s in, who’s out

The bargaining unit called for in the union’s original petition did not include other Group Health departments: optometry, behavioral health, radiology and pharmacy. It also did not include physical therapist techs, lab techs and interpreters, social workers, receptionists and maintenance staff.

Addressing the June 20 rally, Vander Werff explained that “other departments who are not under primary care leadership are happy with their jobs” and not interested in unionizing. “But primary care is not.”

From the start, Group Health challenged the bargaining unit described in the petition, according to a letter that employees leading the union drive sent to the Group Health board of directors on Feb. 10.

“Federal labor law says that to form a union, workers need petition only for ‘an’ appropriate bargaining unit — not ‘the’ most appropriate bargaining unit (however that would be determined), and certainly not the unit their employers would most prefer,” the employees wrote. “Rather than accepting a unit of GHC workers’ rightful choice, however, administration and counsel have chosen to contest our bargaining unit.”

Still at an impasse after two days of hearings before an NLRB hearing officer, the union amended its election petition to focus on a single Group Health facility, the Capitol Clinic on Madison’s near West Side. The employees wrote in the Feb. 10 letter that the change was made at the NLRB official’s suggestion.

Group Health challenged that, too. After an additional hearing, the Minneapolis-based NLRB regional director rejected the union’s petition for a single-clinic vote. The decision directed an election covering all clinical departments at Group Health — the bargaining unit that the co-op management sought.

Group Health’s position is that the bargaining unit the employees sought “didn’t include classes or employees that do go between our clinics,” Anderson said. “And because we are an integrated care delivery system, we need to make sure that all the appropriate employees are in the bargaining class.”  

While some Group Health members see the response to the union drive as a turn from the co-op’s roots, Anderson defended it. 

“We were formed by a vote of our members, our board is elected by our members, and I think this goes right along with our ethos as a cooperative to allow our employees the opportunity to vote,” he said.

Pro-democracy, or diluting support?

Employees involved in the union campaign and their allies among the co-op’s members argue that the management claim is disingenuous, however.

“While the administration claims they’re fighting us in order to give everyone a voice, this is a union-busting tactic to prevent workers from winning in a fast and fair election of our choosing,” the Group Health workers wrote. “Anti-union organizations do this to flood the unit with people that they hope will vote against our union.”

According to an NLRB report on union representation elections in 2023, 89% of employers didn’t challenge the workers’ proposed bargaining unit. 

Group Health member Paul Terranova rejected the idea that expanding the vote to include people in jobs and departments who weren’t interested in the union was “just trying to be democratic.”

 “If folks in Madison decided we wanted to put something on a referendum, and the state Legislature said ‘No, everyone in the state has to vote on it,’ everyone would know right away what they were doing,” Terranova said. “People would call BS. It’s the same thing here, right?”

“The right of workers to unionize and to decide what our union looks like . . .  doesn’t belong to administration,” Sarah Spolum, a physician assistant, said at the May union rally. “It doesn’t belong to lawyers. It belongs to us, the workers.”

Anderson said Group Health stands by its position. “We have no idea how our employees are going to vote,” he said. “That’s why we want to get to a vote — because we want that certainty and we want to know what our employees are feeling.”

Unfair labor practice charges

Throughout the campaign, the union has filed charges with the NLRB accusing Group Health management of numerous unfair labor practices. The allegations include changes in pay practices due to union organizing, surveillance of employees for union activity, prohibiting employees from displaying union-related materials, firing union supporters and a variety of other actions.

Group Health has denied all the charges.

After the co-op management’s bargaining unit petition was granted, however, the union petitioned the NLRB to block an election. The agency’s regional director granted the petition, ordering the election to be suspended until all the unfair labor practice charges are resolved.

The union, wrote regional director Jennifer Hadsall, “provided sufficient offers of proof which describe evidence that, if proven, would interfere with employee free choice in the election.”

Group Health, through its lawyer, has demanded a hearing on the allegations in the blocking charge, contending that it’s a smokescreen for diminished support.

At the union’s June 20 rally, Susan McMurray read from a letter she sent to Group Health’s CEO.

“Nothing good will come of this decision,” she said of the co-op’s stance during the union campaign. “It will in my view ruin GHC’s reputation in our community, cause irreparable harm to staff, as well as jeopardize patient care.

“And it didn’t and it doesn’t have to be like this,” she added. “In the past few weeks, I have communicated to management repeatedly that we could find a way through the strife and give everyone a graceful way out, a path going forward and something positive to announce at the annual meeting.”

This report was updated Friday, 6/27/2025, with the outcome of board elections at Group Health that were announced Thursday evening.

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Susan Monarez, President Donald Trump’s nominee to be the director of the Centers for Disease Control and Prevention, testifies during her confirmation hearing before the U.S. Senate Committee on Health, Education, Labor, and Pensions on June 25, 2025. (Photo by Kayla Bartkowski/Getty Images)

WASHINGTON — Members of the U.S. Senate Committee on Health, Education, Labor and Pensions pressed President Donald Trump’s nominee to lead the Centers for Disease Control and Prevention about vaccine recommendations Wednesday after the Health and Human Services secretary fired members of a critical vaccine panel this month.

Trump’s pick, former acting CDC Director Susan Monarez, said that she trusted vaccines while defending HHS Secretary Robert F. Kennedy Jr.’s decision this month — widely seen as part of a vaccine-skeptical agenda — to fire all 17 members of the Advisory Committee on Immunization Practices, or ACIP, and recommend eight new members.

“Part of the secretary’s vision in restoring public trust is making sure that the American people can be confident in the way the evidence and science is driving decision-making,” she told senators.

The panel’s seven members — one dropped out this week — will meet Wednesday and Thursday to review data and vote on new vaccine recommendations. The recommendations carry significant weight as insurance providers and federal health programs like Medicaid use them to determine if shots are covered and schools rely on them for immunization mandates.

Cassidy questions

Louisiana Sen. Bill Cassidy, who chairs the committee, said he was concerned about ACIP, especially as a non-CDC staff member is scheduled to give a presentation to the committee about thimerosal, a mercury-based preservative. The panel is expected to vote on approving flu shots that contain the compound.

Lyn Redwood, the former head of Children’s Health Defense, the anti-vaccine group that Kennedy founded, is giving the presentation arguing that thimerosal causes autism. The CDC’s own research shows that thimerosal does not cause autism. 

Cassidy said that while Monarez had no part in this week’s ACIP meeting, or the agenda, he said that “if the ACIP hearing today is being used to sow distrust, I would ask that going forward, that you would make sure that there really was a balanced perspective.”

“Yes, someone can speak as a critic, but there should be someone who is reviewing the overwhelming evidence of the safety of vaccines,” Cassidy, who is a physician, said.

Monarez, who was the agency’s acting director from January to March, said that she trusted vaccines and that immunization was important to save lives.

If Monarez is confirmed by the Senate, she would be the first director of the CDC without a medical degree in nearly 70 years. She has a Ph.D. in microbiology and immunology.

More concerns about vaccine panel

Cassidy was not the only Republican on the panel concerned about the firing of all the members of ACIP.

Alaska Republican Sen. Lisa Murkowski said she was concerned about the backgrounds of the seven new panelists.

“I would hope that one of the things that you would all be looking into is to make sure that these individuals are going to be looking at the science in front of them, (and) leave their political bias at home,” Murkowski said.

Democratic Sens. Patty Murray of Washington state and Angela Alsobrooks of Maryland also pressed Monarez about Kennedy’s actions to fire everyone on the panel.

Murray asked Monarez if the new members of the panel voted to not recommend vaccines, if she would listen to that recommendation.

Monarez sidestepped the question and said the roles at ACIP were difficult to fill and that members needed to pass an ethics process.

“If they have not gone through an ethics approval process they shouldn’t be participating in the meetings,” she said.

Alsobrooks asked Monarez if she believed the 17 members fired from ACIP lacked qualifications.

Monarez did not answer the question, but said Kennedy’s reasoning for “resetting the ACIP to a new cohort was going to be on the path of restoring public trust.”

Grant funding and layoffs

Senators also raised concerns about grants that had been canceled, even though Congress already approved the funds.

Maine GOP Sen. Susan Collins, who is the chairwoman of the Senate Committee on Appropriations, said that her state is suffering from a high level of Lyme disease and as a result a vaccine was in the works at a research institute in Maine.

“This vaccine is very promising and I want to make sure that it is allowed to continue to its conclusion,” Collins said.

Monarez agreed and said if she is confirmed, she will specifically work to make sure funding for that vaccine continues.

“It’s ironic that our dogs can get a vaccine to protect them against tick-borne illnesses like Lyme disease but we humans can’t and I hope we can remedy that,” Collins said.

Sen. Tim Kaine, Democrat of Virginia, pressed Monarez about the elimination of the Office on Smoking and Health at the CDC. He asked if she was involved in laying off all the staff in April, the month after her brief stint as acting director ended.

“I had no participation in (the layoffs) after I left,” she said.

Fluoride in water

Alsobrooks pressed Monarez about Kennedy’s push to have the CDC stop recommending that low levels of fluoride be placed in public drinking water.

Fluoride is added in drinking water to help prevent cavities, tooth decay and other dental health issues.

Alsobrooks asked Monarez, who is her constituent, if the public water supply that contains fluoride in Potomac, Maryland, where Monarez lives, was safe to drink.

“I believe the water in Potomac, Maryland, is safe,” Monarez said. 

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Unauthorized immigrants are not eligible for traditional, federally funded Medicaid, which helps cover medical costs for low-income people.

They have never been eligible. A 1996 welfare reform law signed by Democratic President Bill Clinton also requires most authorized immigrants to wait five years for eligiblity.

Fourteen states, excluding Wisconsin, use state Medicaid funds to cover unauthorized immigrants. 

President Donald Trump has proposed reducing federal Medicaid funds to those states. That would cause 1.4 million people to lose coverage, the nonpartisan Congressional Budget Office estimated. 

Medicaid costs nearly $900 billion annually, two-thirds from the federal government and one-third from the states.

In Wisconsin, Medicaid serves 1.28 million people, more than a third of them children. Among adults, 45% work full time, 28% part time. The annual cost is $12.1 billion, $4.2 billion of it in state spending.

While unauthorized immigrants can’t get Medicaid in Wisconsin, they can apply to receive emergency care covered by state Medicaid.

This fact brief is responsive to conversations such as this one.

Sources

• Georgetown University: The Truth About Medicaid Coverage for Immigrants – and the Looming Threats
• KFF: 5 Key Facts About Immigrants and Medicaid
• Medicaid.gov: Eligibility Policy
• U.S. Health and Human Services Department: What’s the difference between Medicare and Medicaid?
• Civic Media: Trump & Musk Implode While Republicans Gut Your Healthcare | Rep. Mark Pocan Explains the Truth
• Rolling Stone: Mike Johnson and Russ Vought Continue to Lie About Medicaid Cuts
• Truth Social: Donald Trump post
• KFF: Which States Would Be Affected by a House Proposal to Cut Federal Medicaid Funding for States That Cover Undocumented Immigrants?
• ABC News: What will Trump's 'big, beautiful bill' do to Medicaid and SNAP?
• Georgetown University: Factchecking The White House “Mythbuster” on Medicaid Cuts and Immigrants
• Congressional Budget Office: Letter
• Medicaid and CHIP Payment and Access Commission: Medicaid Spending by State, Category, and Source of Funds, FY 2023
• Congress.gov: H.R.3734 – Personal Responsibility and Work Opportunity Reconciliation Act of 1996
• Wisconsin Department of Health Services: Medicaid: Health Care Coverage for Noncitizens
• Wisconsin Watch: Medicaid covers 1.2 million in Wisconsin. The election will determine its future
• KFF: Medicaid in Wisconsin
• Wisconsin Department of Health Services: Medicaid: Health Care Coverage for Noncitizens Frequently Asked Questions
• Congressional Research Service: Unauthorized Immigrants’ Eligibility for Federal and State Benefits: Overview and Resources
• Congress.gov: H.R.3734 – Personal Responsibility and Work Opportunity Reconciliation Act of 1996
• Wisconsin Department of Health Services: ForwardHealth: BadgerCare Plus and Medicaid Emergency Services
• Wisconsin Department of Health Services: Frequently Asked Questions
• National Health Law Program Q and A: The Legal Immigrant Children’s Health Improvement Act
• National Health Law Program Medicaid Coverage of Emergency Medical Conditions: An Update

Are unauthorized immigrants eligible for federal Medicaid coverage? 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.

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.

For elderly residents as well as children and adults with disabilities whose health care is covered by Medicaid, family members who help with their care will also be affected by the proposals coming from Republican members of Congress.

“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.”

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Former Democratic President Joe Biden’s administration added the 2024 rule prohibiting disclosure of protected reproductive health information for criminal, civil or administrative investigations to the Health Insurance Portability and Accountability Act or HIPAA. (Connect Images for Getty Images)

A 2024 federal rule that shielded reproductive health information from disclosure to law enforcement when care was legally obtained, such as in another state with abortion access, was struck down by a federal judge in Texas on Wednesday evening.

U.S. District Judge Matthew Kacsmaryk of Texas’s decision applied nationwide, nullifying the rule immediately. Kacsmaryk had temporarily blocked its enforcement against Dr. Carmen Purl, who sued HHS because she said the rule created a conflict with the laws requiring her to report child abuse.

“Striking down this critical rule is cruel,” said Maddy Gitomer, senior counsel at Democracy Forward, in an emailed statement. “The 2024 HIPAA Privacy Rule has helped protect pregnant people and health care providers from invasive government intrusion into private medical information.’’

The rule did not allow disclosure of protected health information for criminal, civil or administrative investigations against any person for the mere act of seeking, obtaining, or facilitating reproductive health care, to impose criminal or civil liabilities for that conduct, or to identify the person involved in seeking or obtaining that care. It also applied to gender-affirming care.

Two other cases challenging the same rule are still pending in federal courts in Tennessee and Missouri, but it’s unclear what  Kacsmaryk’s decision means for those cases, or another Texas lawsuit led by Attorney General Ken Paxton that also seeks to strike down a broader 2000 privacy rule.

Former Democratic President Joe Biden’s administration added the rule to the Health Insurance Portability and Accountability Act, a 30-year-old federal law meant to protect patient health information, especially when that information travels between providers. The law contains exceptions for when information can be disclosed to investigators, who can subpoena records for a law enforcement matter. After the 2022 Dobbs decision returned abortion regulation to the states, prompting more than a dozen to pass abortion bans, advocates worried that such records could be used by state officials and law enforcement to investigate and prosecute patients seeking an abortion and those who help them.

Lauren Paulk, senior research counsel for If/When/How, a nonprofit that provides legal support for reproductive health care, told States Newsroom on Wednesday evening that people are still protected by the federal HIPAA law, including the foundational 2000 privacy law that requires certain procedural steps to be met before records can be subpoenaed. The 2024 rule was meant to provide reassurance to patients who are afraid to seek abortion or gender-affirming care, even where it is legal, by specifically exempting those records.

Kacsmaryk’s decision, she said, will erode trust between patients and providers and potentially damage that relationship. And it could be a sign of more actions to come.  

“There’s a laundry list of things that I think could start to be added here whenever the courts are saying there really aren’t protections for private reproductive health information,” Paulk said.

Democracy Forward, a nonprofit legal organization, filed a filed a motion to intervene earlier in the case on behalf of the cities of Columbus, Ohio, and Madison, Wisconsin, because attorneys said they no longer had faith that the U.S. U.S. Department of Health and Human Services would adequately defend the law under Republican President Donald Trump’s administration. Kacsmaryk denied that motion to intervene, and Democracy Forward appealed that decision to the 5th U.S. U.S. Circuit Court of Appeals. That appeal is pending.

“Vacating this regulation will be detrimental to the privacy rights of pregnant people across the country, and will interfere with the ability of healthcare providers and patients to communicate confidentially and openly about a patient’s health needs,” Gitomer said.

Gitomer said Democracy Forward will continue to explore all of its options to defend reproductive rights from “political interference and anti-abortion extremists.”

Conservative law firm Alliance Defending Freedom represented doctor in Texas judge’s district

Purl is the sole owner of Dr. Purl’s Fast Care Walk In Clinic in Dumas, Texas. In court documents, she said:

“I consider both a pregnant woman and her unborn child to be human persons, and both are entitled to medical care and deserve the protection of the law. I believe … that elective abortions harm patients’ health and public health.”

The location of Purl’s clinic put her in Kacsmaryk’s district, where he is the only judge. Most federal cases are assigned randomly to a group of judges in a district, but since Kacsmaryk, a Trump appointee, is the sole jurist, some advocates and attorneys have accused law firms like Alliance Defending Freedom, who is representing Purl in the case, of “judge shopping.” That phrase refers to finding a plaintiff in a certain area for the purpose of putting it in front of an ideologically friendly judge.

In an earlier high-profile case, Kacsmaryk attempted to order the U.S. Food and Drug Administration to rescind its decades-old approval of mifepristone, one of two drugs used to terminate early pregnancies and treat miscarriages. That decision was eventually returned  by the U.S. Supreme Court to a lower court for consideration.

Officials in Texas have already attempted to investigate women who left the state, which has a near-total abortion ban and other abortion-related laws, to terminate a pregnancy.

In a 65-page opinion, Kacsmaryk said the U.S. Department of Health and Human Services’ leadership under Biden “invoked HIPAA as a shield against abortion-restrictive states.” He determined the rule unlawfully limited disclosures about abuse and public health to state authorities, and said it exceeded statutory authority because it employed HIPAA to impose special rules for abortion. Such action should only be taken by Congress, he said, especially because the issues at hand are of major political significance.

“People of good faith vehemently disagree on both these issues,” Kacsmaryk wrote, referring to abortion and gender-affirming care. “These issues transcend politics, implicating anthropology, philosophy, and concepts of self. … The 2024 rule creates special rules for information about these politically favored procedures that implicate fundamental and hotly debated questions.”

Sen. Patrick Testin (R-Stevens Point) speaks at a Republican news conference Wednesday before the Senate's floor session. (Photo by Baylor Spears/Wisconsin Examiner)

On unanimous voice votes, lawmakers approved legislation Wednesday that allows nurses with advanced training to practice independently in Wisconsin.

The bill now heads to Gov. Tony Evers, who vetoed similar bills twice before but who is now expected to sign the measure after negotiating changes to address his previous objections.

“I can’t stress what a team effort this was. It was bipartisan,” said Rep. Tony Kurtz (R-Wonewoc), the lead Assembly author on AB 257, before the vote on the Assembly floor. “People put their pettiness aside and they actually got a good product across the finish line.”

The Assembly passed the legislation Wednesday and the Senate concurred later in the day.

“While this legislation had been vetoed in the previous two sessions, I’m proud to say and stand before you that we have an agreement and a deal that when this reaches the governor’s desk, that is going to become law,” said Sen. Patrick Testin (R-Stevens Point).

The bill creates a new formal nursing credential under state law, Advanced Practice Registered Nurse (APRN).

To win Evers’ signature, authors of the bill agreed to increase the amount of training and supervision before an APRN can practice independently, added additional supervision requirements for APRN practitioners who specialize in pain management and included language to restrict the titles APRN practitioners use so patients aren’t confused about their credentials.

Evers previously vetoed APRN measures in 2022 and 2024, specifying in his veto messages that he didn’t sign them because of those issues.

“I wish it didn’t take us nearly a decade to do this,” said Rep. Lisa Subeck (D-Madison) in the Assembly floor session. “But It needed to and I’m glad that we’re getting it done now and I’m glad that we’re getting it done right.”

Under the proposal, the Wisconsin state nursing board would oversee the credentialing of advanced practice nurses. The credential would include certified nurse-midwives, certified registered nurse anesthetists, clinical nurse specialists and nurse practitioners.

“This is a really important bill,” said Sen. Kelda Roys (D-Madison) before the Senate passed the measure. “It is going to increase access to high-quality patient care for people around the state, but especially people in underserved communities.”

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Transgender rights opponents and a supporter rally outside of the U.S. Supreme Court as the justices hear arguments in a case on transgender health rights on December 04, 2024 in Washington, DC. The Supreme Court Wednesday upheld Tennessee's law banning gender-affirming care for minors. (Photo by Kevin Dietsch/Getty Images)

The U.S. Supreme Court upheld Tennessee’s law prohibiting gender affirming care for minors, saying children who seek the treatment don’t qualify as a protected class.

In United States v. Skrmetti, the high court issued a 6-3 ruling Wednesday overturning a lower court’s finding that the restrictions violate the constitutional rights of children seeking puberty blockers and hormones to treat gender dysphoria. The U.S. Court of Appeals overturned the district court’s decision and sent it to the high court.

The court’s three liberal justices dissented, writing that the court had abandoned transgender children and their families to “political whims.”

Tennessee lawmakers passed the legislation in 2023, leading to a lawsuit argued before the Supreme Court last December. The federal government, under the Biden administration, took up the case for the American Civil Liberties Union, Lambda Legal and three transgender teens, their families and a Memphis doctor who challenged the law, but the U.S. Department of Justice under President Donald Trump dropped its opposition.

In its ruling, the court said that the plaintiffs argued that Senate Bill 1 “warrants heightened scrutiny because it relies on sex-based classifications.” But the court found that neither of the classifications considered, those based on age and medical use, are determined on sex.

“Rather, SB1 prohibits healthcare providers from administering puberty blockers or hormones to minors for certain medical uses, regardless of a minor’s sex,” the ruling states.

The ruling says the application of the law “does not turn on sex,” either, because it doesn’t prohibit certain medical treatments for minors of one sex while allowing it for minors of the opposite sex.

The House Republican Caucus issued a statement saying, “This is a proud day for the Volunteer State and for all who believe in protecting the innocence and well-being of America’s children.”

Senate Majority Leader Jack Johnson, who sponsored the bill, said he is grateful the court ruled that states hold the authority to protect children from “irreversible medical procedures.”

“The simple message the Supreme Court has sent the world is ‘enough is enough,’” Johnson said in a statement.

The Tennessee Equality Project, an LGBTQ advocacy group, expressed dismay at the decision: “We are profoundly disappointed by the U.S. Supreme Court’s decision to side with the Tennessee legislature’s anti-transgender ideology and further erode the rights of transgender children and their families and doctors. We are grateful to the plaintiffs, families, and the ACLU for fighting on behalf of more than 1.3 million transgender adults and 300,000 youth across the nation.”

The group said gender-affirming care saves lives and is supported by medical groups such as the American Academy of Pediatrics and the American Medical Association.

The court also rejected plaintiffs’ argument that the law enforces “a government preference that people conform to expectations about their sex.”

The court found that laws that classify people on the basis of sex require closer scrutiny if they involve “impermissible stereotypes.” But if the law’s classifications aren’t covertly or overtly based on sex, heightened review by the court isn’t required unless the law is motivated by “invidious discriminatory purpose.”

“And regardless, the statutory findings on which SB1 is premised do not themselves evince sex-based stereotyping,” the ruling says.

In response to the outcome, Tennessee Attorney General Jonathan Skrmetti said Tennessee voters’ common sense won over “judicial activism” on a law spurred by an increase in treatment for transgender children.

“I commend the Tennessee legislature and Governor Lee for their courage in passing this legislation and supporting our litigation despite withering opposition from the Biden administration, LGBT special interest groups, social justice activists, the American Medical Association, the American Bar Association, and even Hollywood,” Skrmetti said.

U.S. Senate Minority Leader Chuck Schumer, D-N.Y., criticized the ruling just moments after it came out after being asked about it during a press conference.

“This Supreme Court seems to have forgotten that one of their jobs is to protect individual rights and protect individuals from being discriminated against,” Schumer said. “It’s an awful decision.”

Democrats, he said, are “going to explore every solution,” though he didn’t elaborate.

Chief Justice John Roberts wrote in the opinion: “This case carries with it the weight of fierce scientific and policy debates about the safety, efficacy, and propriety of medical treatments in an evolving field. The voices in these debates raise sincere concerns; the implications for all are profound. The Equal Protection Clause does not resolve these disagreements. Nor does it afford us license to decide them as we see best. Our role is not ‘to judge the wisdom, fairness, or logic’ of the law before us, but only to ensure that it does not violate the equal protection guarantee of the Fourteenth Amendment. Having concluded it does not, we leave questions regarding its policy to the people, their elected representatives, and the democratic process.”

The ACLU said in a statement the decision is based on the record and context of the Tennessee case and doesn’t extend to other cases involving transgender status and discrimination.

Chase Strangio, co-director of the ACLU’s LGBTQ & HIV Project, called the ruling “devastating,” but despite the setback said transgender people still have health care options.

“The court left undisturbed Supreme Court and lower court precedent that other examples of discrimination against transgender people are unlawful,” Strangio said in a statement.

Tennessee Lookout is part of States Newsroom, a nonprofit news network supported by grants and a coalition of donors as a 501c(3) public charity. Tennessee Lookout maintains editorial independence. Contact Editor Holly McCall for questions: info@tennesseelookout.com.

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.” 

People protest on June 24, 2022, in front of the U.S. Supreme Court after the release of the ruling in Dobbs v Jackson Women's Health Organization that overturned Roe v Wade case and erased a federal right to an abortion. (Photo by Brandon Bell/Getty Images)

Two years ago Megan Kling and her husband were eagerly looking forward to the birth of their third child. Then at 20 weeks they got devastating news from their doctor.

The infant, upon being born, would have no chance of surviving. He lacked critical internal organs and his brain and heart were both abnormal.

“Our baby would die, either in utero or within hours after birth,” Kling told reporters Monday morning. “We were in a situation with no good outcome.”

To carry him for another four months, knowing that he would not live, “seemed inhumane,” Kling said.

The diagnosis was confirmed at 22 weeks — and by then, Kling said, her doctors were unable to help her because of an 1849 Wisconsin law that at the time was still being interpreted as a near-blanket ban on abortion.

Kling and her husband, residents of western Wisconsin, traveled to neighboring Minnesota. There, doctors at the Mayo Clinic in Rochester confirmed that, if born, their baby would not be viable. At her request, the medical team induced labor at 23 weeks. Kling gave birth and the couple’s son died in their arms an hour later.

Kling told her story Monday at a news conference held by advocates to draw attention to next week’s third anniversary of the U.S. Supreme Court ruling ending a national right to abortion.

Dr. Nike Mourikes of the Committee to Protect Health Care said from the moment the ruling was issued, “I realized how this cruel decision would cause harm to so many lives and undermine the ability of physicians and other health care providers to care for their patients.”

Abortion was a legal right throughout her medical training and practice until the 2022 decision in Dobbs v. Jackson Women’s Health Organization, Mourikes said. 

The Court’s 1973 ruling in Roe v. Wade legalized abortion in the first 20 weeks while placing some limits on the procedure later in pregnancy. Although Mourikes had heard “the horror stories” of what women had experienced before that decision, she said, “I never imagined that we would ever, ever go back to those days again.”  

As a physician, she has cared for many women who sought abortion to end a pregnancy. “Each woman had her own unique history, her own unique reasons and circumstances that led her to make this complex decision,” Mourikes said. “But that choice was her choice, not the government’s, not a politician’s. It was her body and it was her right.”

The 2022 ruling effectively reinstated Wisconsin’s 1849 law, which at the time was widely seen as a near-blanket abortion ban.

A September 2023 Dane County Circuit Court ruling reversed that assumption, with the judge holding that the law applied to feticide, but not to elective abortions. A decision on that ruling is now pending in the Wisconsin Supreme Court.

Nevertheless, the law “casts a shadow over our state,” Morikes said. Republican lawmakers have been unwilling to repeal the law, and even when Roe v Wade was still in effect, enacted laws “that force doctors to practice medicine not for the good of their patients, but to satisfy anti-abortion politicians.”

Those include a requirement for “an invasive, sometimes painful and medically unnecessary ultrasound” before an abortion, she said, as well as “a medically unnecessary 24-hour waiting period” that requires women to visit a health provider two days in a row before having an abortion.

Sydney Andersen, a government relations specialist for Planned Parenthood Advocates of Wisconsin, said Planned Parenthood has succeeded in returning abortion services to Wisconsin since the Dane County ruling.

But the organization faces new challenges, she said. Those include the budget reconciliation bill  that passed the U.S. House last month and is now in the Senate. A provision in the bill prevents Planned Parenthood from accepting Medicaid coverage for low-income patients.

Planned Parenthood at risk of closing hundreds of clinics, drastically limiting abortion access

If the U.S. Senate enacts the provision and it becomes law, “more than 1 million patients across the United States could lose their access to birth control, wellness exams, vaccines, STI [sexually transmitted infection] testing, and cancer screenings, including over 50,000 patients in Wisconsin alone,” Andersen said. Black women, other people of color, rural residents and other low-income families would experience “the most significant impact,” she said.

Kling, who is 34 and described herself as a working mother, said she was telling the story of her third pregnancy to make the point that “abortion restrictions can impact anyone who can become pregnant.”

In an interview, Kling told the Wisconsin Examiner that she had not been politically engaged before the experience.

“I was always pro-choice, but after going through this experience I wanted to utilize my story to help people understand that this can impact anyone,” she said.

Despite the current circuit court ruling, the current state of Wisconsin law is such that hospitals “will always create policy that is more restrictive than what the law allows,” Kling said. “There’s a lot of gray area in our law right now with the politics.”

In the news conference, Kling described the emotions that washed over the couple in the hour that she and her husband held their dying infant.

“Our son only knew love,” she said. “But as parents, those were the most helpless and traumatic moments that we have ever had to endure.”

Kling said she tried to contact her Republican state lawmakers in hopes of raising their awareness about the effect of the current state of abortion restrictions. Her state representative has not responded to her calls or email messages, and her state senator’s aide said he was “too busy to schedule a 10-minute meeting to hear my story,” she said.

“Are they unwilling to understand what real women are going through or do they simply not care?” Kling said. “Is this the reality you want the women of Wisconsin to face? Forcing us to flee our state for care?”

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