May 14, 2025
E&C Republicans advance health care piece of GOP tax bill after marathon markup
Democrats and Republicans clashed throughout the night over the bill’s Medicaid provisions.
By Alice Miranda Ollstein and Ben Leonard, Politico05/14/2025, 4:39pm ET
The House Energy and Commerce Committee, in a 30-to-24 party-line vote, advanced the health care section of the GOP’s sweeping tax bill that would slash Medicaid spending by hundreds of billions of dollars.
Over a 26-and-a-half-hour markup that started Tuesday afternoon and went through the night into Wednesday, Republicans voted down a slew of Democratic amendments, including several that would have stripped out or softened provisions to impose Medicaid work requirements and charge Medicaid recipients copays of up to $35 for health services. But Democrats railed against both GOP policies, arguing they punish the poor to finance tax cuts for the rich.Chair Brett Guthrie (R-Ky.) and committee Republicans defended the provisions as fiscally responsible and politically popular, pointed to exceptions they said would protect vulnerable patients, and argued they have learned from states’ rocky implementation of work requirements when crafting the legislation.Democrats also grilled their GOP counterparts and the committee’s Republican counsel on how the provisions would function in practice — asking how soon patients would be subject to the work requirements after being hospitalized for a mental health crisis; what counts as disability that qualifies someone for an exception; and whether people who can’t navigate the work requirements could still get subsidized Affordable Care Act marketplace plans.
Many Democratic committee members pointed to case studies in Arkansas and Georgia, the only states granted federal permission to enact Medicaid work requirements. Under Arkansas’ rules, thousands of low-income people lost coverage and the state saw no boost in employment. Georgia’s program has also struggled, enrolling a fraction of the anticipated population.
Taking such a policy national, lawmakers argued, would be similarly disastrous, imposing expensive bureaucratic burdens on states to determine eligibility and making millions of people who can’t navigate the red tape uninsured.
“Everyone will suffer,” Ohio Democratic Rep. Greg Landsman said. “The result will be millions and millions of people who won’t get health insurance, and most of them are probably eligible.”
Guthrie and members of House GOP leadership had to tread carefully in crafting this portion of the party-line package central to enacting President Donald Trump’s legislative agenda. Reaching the committee’s $880 billion savings target required making major changes to Medicaid without going so far as to alienate moderate Republicans worried about triggering coverage losses that would spark political blowback in swing districts.
In the end, the draft bill the committee advanced Wednesday didn’t include many of the most controversial changes that had been considered, and Republicans on the committee appeared satisfied. But hard-liners elsewhere in the GOP conference are still demanding even steeper cuts and complain the work requirements don’t kick in until 2029. Republican leaders will have to decide how to handle these disagreements before the full House votes on the legislative package — tentatively scheduled for next week.
The Medicaid portions of the GOP megabill would already lead to 10.3 million people losing coverage under the health safety net program and 7.6 million people going uninsured, according to partial estimates from the CBO released by committee Republicans.
GOP leaders may also struggle to get a provision in the Energy and Commerce draft bill defunding Planned Parenthood over the finish line. Committee Republicans voted down a Democratic amendment that would have stripped out this prohibition, but several centrist Republicans off the committee oppose targeting the organization, which provides contraception, STI testing and other health services in addition to abortion.
Democrats have also noted that the Congressional Budget Office estimated this week that stripping funding from the national network of clinics would cost $300 million over a decade and that the Senate Parliamentarian back in 2017 blocked a similar GOP proposal from moving forward.
Democrats during the marathon markup also pushed back against GOP plans to limit taxes that states levy on providers to help fund their Medicaid programs, which could force states to make major changes to how they finance their programs or cut benefits. The proposal, which the Congressional Budget Office estimated would save about $87 billion, would freeze state provider taxes at their current rates and prohibit them from establishing any new taxes.
Republicans said that states use the taxes to boost their federal share of Medicaid payments without having to use their own revenue, frequently accusing local jurisdictions of “money laundering” by gaming the system to draw down more federal dollars. Some Democrats, including former President Barack Obama, have proposed reining in the taxes.
Robert King contributed to this report.————————–
Right now, this megabill (discussed below) exists in the form of several relatively small bills that various House committees have crafted. However, the House must vote on one bill. Before that can happen, the House Budget Committee must combine the committees’ work products into a single reconciliation package. The Budget Committee markup that will facilitate this step is scheduled for Friday morning.
Next week: Rules Committee sets parameters for floor debate.
Before the full House can vote on the newly-combined package, the Rules Committee must approve a “rule” that sets the terms for a floor debate (e.g., the amount of time for debate, whether amendments are allowed, etc.). Republicans outnumber Democrats on the committee 9-4 so, in theory, the GOP’s signature legislative agenda should advance easily. However, three of House Republicans’ most conservative members are among those nine, and their wing of the GOP isn’t happy with the package as it stands now, namely due to what they deem insufficient Medicaid cuts. If those three oppose the rule, they’ll prevent the bill in its current form from even reaching a vote in the full House.
Later next week: House floor vote.
If the Rules Committee does manage to approve a rule, the bill will move to a vote in the full House of Representatives. The current margin in the House is 220-213, allowing the Speaker just a few GOP defections—assuming all House Democrats oppose the bill, as expected.
In terms of where GOP opposition might emerge, in addition to the conservatives I described above: the Speaker continues to negotiate with Republicans seeking a higher (or eliminated) cap on state and local tax deductions (SALT). Whether those members feel strongly enough to oppose their party’s major legislative priority remains to be seen—but it’s not unheard of. One of the SALT-focused group, Rep. Elise Stefanik (R-NY), opposed President Trump’s 2017 tax package over SALT.
June and July: to the Senate—and back again?
Long story short: even if the House gets this done, there’s virtually no chance the Senate simply passes this bill as-is and sends it to the President to become law.
For one thing, GOP senators are outright saying they’re going to make changes. Some senators oppose the repeal of clean energy tax credits, while others oppose Medicaid cuts, and others still don’t want to see a higher SALT cap. On top of that, some provisions aren’t expected to survive the “Byrd bath,” a procedural scrub to ensure the bill adheres to reconciliation’s strict rules. That could result in provisions like the ban on state AI law enforcement being thrown out.
Remember: the House and Senate must pass the exact same bill. Any Senate changes—no matter how small—will necessitate the bill going back to the House for another vote before the President can sign this package into law.
As for when the Senate could act—and, by extension, force the House to act again? Republicans are aiming to get this package to the President before August, when the U.S. is expected to hit its debt limit. If Republicans raise the debt ceiling as part of this megabill, they can do so without Democrats’ support. If they don’t, they could have to negotiate with Democrats to avoid a debt default. (Source: Congressional Progressive Caucus Center, 5/14)
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Bloomberg News, 5/14New York could lose a billion dollars or more under a Republican proposal that would penalize states for providing health insurance to undocumented immigrants.
The budget bill House Republicans introduced Sunday to cut federal spending by approximately $900 billion, including $715 billion in Medicaid funding, contains a provision that would reduce Medicaid reimbursement rates to states like New York that have extended coverage to undocumented residents who are not eligible for federally-backed insurance programs.While states are already prohibited from using federal dollars to insure undocumented immigrants, the measure being considered would cut funds to states using their own money to pay for it. New York launched a program to do just that last year for undocumented individuals ages 65 and older.
“The intent here is to use the threat of taking federal money away to force states to drop this coverage,” said Bill Hammond, senior health policy fellow at the Empire Center, a conservative think tank based in Albany.
The state’s version of the federal Children’s Health Insurance Program, known as Child Health Plus, which covers kids in low-income families who don’t qualify for Medicaid, could also trigger the penalty, according to Michael Kinnucan, a senior health policy advisor at the left-leaning watchdog group Fiscal Policy Institute.
House Speaker Michael Johnson faces an uphill battle to secure enough votes to pass the reconciliation bill, which was considered in the _House’s energy and commerce committee_ on Tuesday. Republicans have been divided over the spending plan, with representatives in swing districts concerned that Medicaid cuts and other proposals, like a cap on state and local tax deductions, could hurt their chances at the ballot box, while hardline spending hawks push for deeper cuts.
“Undoubtedly, Democrats will use this as an opportunity to engage in fear-mongering and misrepresent our bill as an attack on Medicaid. In reality, it preserves and strengthens Medicaid for children, mothers, people with disabilities and the elderly — for whom the program was designed,” wrote Energy and Commerce Committee Chair Brett Guthrie, a Kentucky Republican, in an op-ed in the Wall Street Journal on Sunday.
The legislation would reduce federal reimbursement rates for the segment of Medicaid recipients covered under the Affordable Care Act’s expansion of the program. Hammond and Kinnucan each estimated the cuts could cost the state between $1 and $2 billion a year based on recent enrollment and reimbursement rates.
“While we won’t speculate about the specific impacts of a draft unfinished proposal, Republicans in Washington have made it clear that any bill they pass will make sweeping cuts to federal programs like Medicaid that millions of New Yorkers rely on,” said Nicolette Simmonds, a spokeswoman for Hochul. “It’s impossible for any individual state to backfill the massive cuts being proposed in Congress, but Governor Hochul is committed to using litigation and other tools to protect New Yorkers.”
The latest threat to federal health funding came days after Albany lawmakers passed a $254 billion state budget that increases Medicaid spending by billions of dollars.
The proposal would force Gov. Kathy Hochul to decide whether to cut coverage for undocumented immigrants to preserve the full slice of the federal match or continue the coverage and supplement the lost funding from state coffers. Hospital leaders and fiscal watchdogs warned that if the administration chooses to revoke health insurance for low-income undocumented residents, tens of thousands of New Yorkers could lose insurance. If the program includes Children’s Health Plus, as Kinnucan believes it will, a majority of those residents will be kids, he said.
“It’s a really disturbing proposal,” he said. “They were talking about doing something about undocumented immigrant health coverage but I’m really stunned by the harshness and overreach here.”
The proposal, if passed, would likely lead to legal challenges based on a 2012 Supreme Court ruling that threatening to withhold federal funding from states that didn’t comply with the Affordable Care Act’s Medicaid expansion was unconstitutional, Kinnucan said.
Immigrants losing coverage would mean more people seeking care in the emergency room, which would strain state and local budgets and push more struggling safety-net hospitals toward the brink, said Kenneth Raske, president and CEO of the Greater New York Hospital Association, an influential trade group representing northeast hospitals.
“In the end, the policy of the energy and commerce people cannot stop people from getting sick. They could stop paying for it, but somebody else will have to pick up the tab,” he said.