May 22, 2025
First, in terms of the House vote that took place several hours ago, the bill passed on a party-line vote by a one-vote margin, so any one and all of our House Majority Reps. in NYS (LaLota, NY-1;Garbarino, NY-2; Malliotakis, NY-11; Lawler, NY-17; Stefanik, NY-21; Langworthy, NY-23; Tenney, NY-24) MUST be held accountable for being among the deciding votes. Only 2 House Majority Reps. voted no – neither were from NY. The bill was jammed strictly for political reasons, with final bill language completed just before the floor debate began. No one had time to read or consider its provisions, and several of the bill’s components. Interesting Note: Speaker Mike Johnson said the two Republican holdouts who skipped the vote did so unintentionally. He said Representative Andrew Garbarino fell asleep, and David Schweikert didn’t get his voting card in on time.
What’s Next for the NYS Council as we continue this fight: Now we must pivot to immediate “rapid response” activities starting right away. Most immediately, we must jam House Majority members’ office phone lines with LOTS of calls that object to and castigate what they have done and the harm it will cause everyday people, families, and communities, including people sharing personal stories with whomever picks up the phone. If you live in a Congressional District represented by any of the lawmakers named (above) please call their office immediately and express your absolute condemnation for the choices your lawmaker has made.
About the Medicaid Work provision:
As I understand it, the House Medicaid Work Requirements provision exempts people with ‘disabilities’ from having to comply with the provision, however the biggest issue with Work Requirements is now and has always been the struggle to keep up with recipient reporting requirements that could impact millions of Americans who do not know or understand the requirements, or those that have trouble keeping up with the paperwork and other requirements associated with maintaining their eligibility for Medicaid benefits. That’s where the rubber meets the road and has (in the past) resulted in eligible Medicaid beneficiaries being thrown off the rolls.
Apparently the provision in the House bill transfers a great deal of the burden for monitoring Medicaid work requirements to individual states (rather than the federal government) making data collection, surveillance and monitoring a major aspect of the proposed change.
Requirements on beneficiaries to report their progress with finding employment, volunteering, etc. have been reduced from what could have been a monthly requirement to twice a year. But for those Medicaid recipients who were granted eligibility as the result of state Medicaid Expansion under the ACA, the terms are different with a 6-month reporting requirement. This provision is clearly aimed at states that expanded Medicaid to undocumented immigrants and other underrepresented populations.
I am still researching what the bill says about certain Medicaid beneficiaries being required to pay
cost share (co-pay) for services.
Remember: The Senate has yet to act. The Senate is eyeing several changes to the bill that are certain to spark ire in the House — including watering down Medicaid changes and making some tax provisions permanent — setting the stage for a chamber-vs-chamber fight and a legislative ping-pong across the Capitol. Senate Majority Leader John Thune (R-S.D.) is already signaling those tweaks.“There are dials and tweaks on some of the tax issues that our members will want to talk about,” Thune said Tuesday.
Medicaid
Establishes work requirements for adult enrollees who don’t have disabilities or dependents that would begin no later than Dec. 31, 2026, and directs the Health and Human Services Department to issue guidance to states on this policy by the end of this year. Beneficiaries would have to document at least 80 hours a month of work or other qualifying activity, such as volunteering. The CBO estimated this would reduce spending by $280 billion based on an earlier iteration that wouldn’t have taken force until 2029.
Bans new or increased state provider taxes and tightens standards for what provider taxes are legally permissible. The bill also bars most states from using state-directed payments to order Medicaid managed care companies to pay providers more than 100% of Medicare rates, but states that haven’t expanded Medicaid under the Affordable Care Act of 2010 would be able to pay up to 110% of Medicare. Combined, these would cut federal spending by $197 billion, although the CBO analysis was based on a previous version of the bill that limited all state-directed payments to 100% of Medicare.
Orders states to maintain updated information on Medicaid enrollees, such as verifying addresses and removing deceased people from the rolls. This would save $17 billion.
Suspends a 2024 Centers for Medicare and Medicaid Services regulation designed to ease enrollment in Medicaid, the Children’s Health Insurance Program and the Basic Health Program. Federal spending would be $82 billion lower under this policy.
Requires eligibility redeterminations every six months for adults covered under the ACA Medicaid expansion. This would cut spending by $53 billion.
Mandates cost-sharing up to $35 for services provided to Medicaid expansion enrollees with incomes above the federal poverty level, which is $15,650 for a single person. That is projected to reduce spending by $13 billion.
Limits retroactive provider reimbursements for newly enrolled Medicaid recipients to one month instead of three. That is projected to save $6 billion.
Reduces federal Medicaid funding to states that use their own money to cover undocumented immigrants through Medicaid. This would cut spending by $11 billion.
Cancels a regulation setting staffing minimums for nursing homes. This would reduce spending by $23 billion.
Eliminates extra federal Medicaid funding from the American Rescue Plan Act of 2021 intended to encourage states to expand Medicaid under the ACA. The provision is estimated to save $881 million.
Delays cuts to Medicaid disproportionate share hospital payments for three years. That would increase spending by $16 billion.
Medicare
Increases Medicare physician reimbursements 2% in 2026 and pegs future payment updates to the Medicare Economic Index. In addition, this provision would eliminate extra payments to physicians participating in alternative payment models. These policies would cost $8 billion.
Triggers Medicare cuts under the Statutory Pay‑As‑You‑Go Act of 2010 that could include reductions in provider reimbursements. Because the bill would increase the budget deficit by $2.3 trillion, the CBO projects the White House Office of Management and Budget would have to curtail Medicare spending by $45 billion in 2026 and $490 billion from 2027 to 2034.
Suspends a rule to facilitate enrollment in Medicare Savings Programs that cater to low-income people eligible for Medicare and Medicaid by pushing back the effective date to 2035. Savings are estimated to be $84 billion.
Expands rural emergency hospitals program. There was no cost estimate for this part of the bill.
Ends Medicare eligibility for some lawfully present foreign nationals who currently qualify by limiting the program to permanent residents who are green card holders, from Micronesia, the Marshall Islands or Palau, or, in certain cases, from Cuba. This would save $132 million.
Health insurance exchanges
Institutes stricter eligibility and income verifications for exchange customers and requires new checks for low-income enrollees with zero-premium plans. This would save $101 billion.
Shortens open enrollment period by one month.
Ends permanent special enrollment opportunity for people with incomes up to 150% of poverty and bars federal and state exchanges from establishing special enrollment periods linked to income.
Allows health insurance companies to demand premium payments before beginning coverage and to remove customers who are in arrears, regardless of income.
Ends automatic enrollment into Silver-level plans for low-income exchange customers with Bronze-level plans who qualify for cost-sharing reductions that can only be applied to Silver plans.
Those provisions combined would reduce spending by $101 billion.
Restores cost-sharing reduction payments to health insurance companies covering the lowest-income exchange policyholders, which Trump cut off in 2017. A CBO analysis from 2018 said that would reduce federal spending by $19 billion, in part because it would enable insurers to reduce premiums, which would decrease spending on premium tax credits. The bill also would withhold cost-sharing reduction payments for insurance plans that cover abortion.
Requires full repayment of excess premium tax credits regardless of enrollee income. Savings are projected to be $2.3 billion.
Expands ICHRAs — individual coverage health reimbursement arrangements — by permitting employees offered these plans to buy exchange coverage with pre-tax dollars. Creates tax credit for small employers that offer ICHRAs. This is projected to cut spending by $514 million.
Limits lawful immigrant access to unsubsidized exchange coverage and makes Deferred Action for Childhood Arrivals recipients ineligible for subsidies. This section would save $63 billion.
Bans gender-affirming care as an Essential Health Benefit under the ACA as well as Medicaid and CHIP coverage of these services. This would reduce spending by $830 million.
Pharmacy benefit managers
Requires greater transparency for PBMs in Medicare Advantage and Medicare Part D.
Orders PBMs to “delink” their compensation from the discounts they negotiate with drugmakers and instead charge set fees under Medicare Part D.
Those provisions combined would reduce spending by $402 million.
Bans spread pricing, a practice under which a PBM charges more for a medicine than the price it secured from the drug company. This would save $3 billion.
Health savings accounts
Relaxes rules governing HSAs, such as raising the annual contribution limit, declaring individual market Bronze and Catastrophic plans compatible with HSAs, and making gym memberships and some other sport and fitness costs HSA-eligible. These policies would result in $25 billion in lost tax revenue.
Here’s parts of an excerpted statement from the National Health Employment Law Project (NHeLP):
Among the incredibly harmful provisions in the “One Big Beautiful Bill” is a national mandate for Medicaid work requirements. These bureaucratic barriers do not promote employment. Instead, they punish people who are already working in low-wage jobs, or who have a disability, chronic condition or caregiving responsibilities. Caps to state Medicaid taxes and other changes to the program will slash billions of more dollars and force states to make difficult decisions on who gets care and what care and services are available.
Additional provisions undermine protections assisting individuals obtain and retain Medicaid and marketplace coverage and prevent states from spending their own funds to provide health insurance to immigrants. We could go on and on about all the ways the bill strips health insurance from low-income individuals to give billionaires huge tax cuts.
The Congressional Budget Office has estimated that the bill’s Medicaid provisions would lead to millions of people losing coverage and billions of dollars in lost federal funding. These cuts would devastate state health programs, undermine rural health care, and harm communities already facing serious health disparities. This bill does not save money. It shifts costs and suffering onto those least able to bear them.
NHeLP urges the Senate to reject this reckless and harmful legislation. Congress should be advancing policies that expand access to care, strengthen Medicaid, and invest in a healthier future for everyone — not ripping health care away from millions of people.