Details on the budget bill

The bill, which passed 215-214, comes after days of negotiations between Speaker Mike Johnson (R-La.) and other House Republicans around the ideological spectrum who demanded changes to the bill and refused to support it.

Hours before the vote, Johnson unveiled a series of concessions in an effort to win over different factions within the party, including increasing state and local tax deductions, enacting Medicaid work requirements sooner, and steering more money to reimburse states for immigration enforcement efforts.

Ultimately just two Republicans, Rep. Warren Davidson (R-Ohio) and Rep. Thomas Massie (R-Ky.) voted against the bill. Rep. Andy Harris (R-Md.), chair of the conservative House Freedom Caucus, voted "present" rather than voting for or against the bill. Rep. David Schweikert (R-Ariz.) and Rep. Andrew Garbarino (R-N.Y.) didn't show up to vote, but both later said they would have voted in favor.

The bill includes a variety of healthcare-related provisions, including:

• Requiring people up to age 64 who are without dependents or disabilities to work at least 80 hours a month to maintain Medicaid coverage. They would also need to document twice a year that they're working and could also maintain coverage if they perform community service or are enrolled in educational programs. These work requirements would start in 2026; however, the bill includes a waiver for states that can't implement the work requirements by next year.
• Creating a "money account for growth and advancement," or a "MAGA account," for every child born between Jan. 1, 2025, and Jan. 1, 2029. The government would invest $1,000 on behalf of every baby born during that time into these accounts, which would then be invested on their behalf into financial markets. Once the child has grown up, they could withdraw the proceeds to pay for certain expenses like going to college or buying a house. Parents or other third parties could also contribute to the account, but only post-tax income can be contributed to the account, and the money would be taxed when withdrawn.
• Banning new or increased state provider taxes, and a tightening of standards for what provider taxes are permissible by law.
• Banning states from using state-directed payments to order Medicaid managed care companies to pay providers more than 100% of Medicaid rates. However, states that haven't expanded Medicaid under the ACA can pay up to 110% of Medicare rates.
• Requiring states to maintain updated information on Medicaid enrollees, like verifying addresses and removing deceased people from the rolls.
• Suspending a 2024 CMS regulation aimed at easing enrollment in Medicaid, the Children's Health Insurance Program (CHIP), and the Basic Health Program.
• Requiring eligibility redeterminations every six months for adults covered under ACA Medicaid expansion.
• Mandating cost-sharing up to $35 for services provided to enrollees under Medicaid expansion with incomes above the federal poverty level, which is currently $15,650 for a single person.
• Limiting retroactive reimbursements for newly enrolled Medicaid recipients, reducing it from three months to one.
• Cancelling a regulation that sets staff minimums for nursing homes.
• Eliminating extra federal Medicaid funding under the American Rescue Plan Act that was intended to encourage states to expand Medicaid under the ACA.
• Delaying cuts to Medicaid disproportionate share hospital payments for three years.
• Reducing the federal matching rate for the ACA Medicaid expansion population down from 90% to 80% for any states that provide health coverage or financial assistance to purchase health coverage to individuals who are not a "qualified alien." This provision was ultimately revised to broaden the penalty to states that have expanded coverage for lawfully residing children and/or pregnant people in Medicaid and/or CHIP. Under the Children's Health Insurance Program Reauthorization Act of 2009, states are allowed to provide Medicaid and CHIP coverage to children and pregnant individuals lawfully residing in the United States, including those within their first five years of having certain legal status.
• Increasing Medicare physician reimbursement by 2% in 2026 and a requirement that future payment updates are tied to the Medicare Economic Index.
• Stricter eligibility and income verifications for ACA exchange customers and requirements of new checks for low-income enrollees with zero-premium plans.
• Shortening the enrollment period by one month.
• Ending permanent special enrollment opportunities for people with incomes up to 150% of the federal poverty line and a ban on federal and state exchanges establishing special enrollment periods linked to income.
• Ending automatic enrollment into Silver-level ACA health plans for low-income exchange customers who have Bronze-level plans but quality for cost-sharing reductions that are only applied to Silver plans.
• Restoring cost-sharing reduction payments to health insurance companies covering the lowest-income exchange policyholders.
• Expanding individual coverage health reimbursement arrangements (ICHRAs) by allowing employees offered ICHRAs to buy exchange coverage with pre-tax dollars. Also creates a tax credit for employers offering ICHRAs. The bill would also rebrand ICHRAs as Custom Health Option and Individual Care Expense (CHOICE) arrangements.
• Banning gender-affirming care as an Essential Health Benefit under the ACA as well as Medicaid and CHIP coverage of the service.
• Requiring greater transparency for pharmacy benefit managers in Medicare Advantage and Medicare Part D.

What's next

Now that the bill has passed the House, it will head to the Senate where it is expected to face substantial changes.

Senate Majority Leader John Thune (R-S.D.) and Senate Finance Committee Chair Mike Crapo (R-Idaho) have been working with the House Republicans who drafted the bill but said they still expect to make adjustments.

"When it comes over here, I think [Speaker Johnson] would like to see as little change to the product as possible, because they've cobbled together a delicate balance over there," Thune said. Still, "the Senate will have its imprint on it," Thune added.

Sens. Susan Collins (R-Maine), Lisa Murkowski (R-Alaska), and Josh Hawley (R-Mo.) have all expressed concerns about any cuts to Medicaid, with Hawley specifically vowing to oppose any bill that cuts the program.

While the bill is in the Senate, any senator is allowed to invoke the Byrd Rule and challenge a policy provision's pertinence to the budget. It will then be up to the Senate parliamentarian to advise the presiding officer on what provisions are relevant to the budget. Typically, the presiding officer rules in line with the advice given by the parliamentarian. The full Senate would then vote on whether to uphold the presiding officer's ruling.

If the bill clears the Senate, it will be sent back to the House where House members will either pass the bill as is or try to reconcile their differences with the Senate.

Republicans have set a July 4 deadline for both the House and Senate to pass the bill, work out any differences, and get it to President Donald Trump's desk to sign.

(Edmondson et al., New York Times, 5/22; Weixel, The Hill, 5/21; Wilkerson, STAT+ [subscription required], 5/21; Duehren, New York Times, 5/22; Meyer/Vazquez, Washington Post, 5/22; McAuliff, Modern Healthcare, 5/22; Williams et al, KFF, 5/21; Tong, Fierce Healthcare, 5/21)