June 24, 2025
As the Senate continues to push aggressively to meet its self-imposed July 4 deadline for passage of its Budget Reconciliation bill, Senate leaders are scrambling to address any proposals or proposed bill language that does not comport with parliamentary rules and other technical elements that could create a problem once the bill goes to a full house vote. A ruling from the Parliamentarian before the bill gets a vote will protect it from facing a filibuster in the Senate.
Here’s more from Politico:
Senate Republicans are scrambling to rewrite major parts of their “big, beautiful bill” in deference to key holdouts and the chamber’s parliamentarian as the clock ticks on a self-imposed deadline.
GOP leaders are aiming to start voting Thursday, but senators emerged from a closed-door briefing on the status of the megabill Monday night saying that some of their biggest sticking points — ranging from key tax decisions to a deal on Medicaid — remain unresolved. The multitude of unresolved issues has left Republicans unsure when the bill will get to the Senate floor, even as leaders project confidence they are on track to pass it and send it back to the House this week — setting up final passage ahead of their July 4 target. Most crucially, it could be Wednesday night or later before Senate Parliamentarian Elizabeth MacDonough finishes ruling on whether major tax provisions, including some measures at the very heart of the domestic policy bill, pass muster under the budget rules GOP lawmakers want to use to pass their bill on party lines.
“I think we’ll eventually pass something, I just can’t tell you when,” said Sen. John Kennedy (R-La.). “We’ve got a lot of stuff to work out, and the bill will be changed on the floor.”
Republicans had initially hoped to have a revised bill ready to be released Monday. Now they aren’t expected to release it while the parliamentarian’s review — the so-called “Byrd bath” — is pending, according to two people granted anonymity to discuss internal thinking.
Majority Leader John Thune (R-S.D.) said that he hoped to be able to hold an initial vote on Thursday, setting up passage over the weekend, but that “part of it right now is the Byrd bath, and it’s taking a little bit longer.”
It’s not just the procedural hoops senators have to jump through. Multiple substantive matters need to be settled, including a high-stakes dispute between the House and Senate GOP over a key tax break.
Sen. Markwayne Mullin (R-Okla.) briefed his colleagues on talks he’s brokering with House Republicans on raising the state-and-local-tax deduction cap, known as SALT. Mullin signaled afterward he thought they were getting close to “acceptance” on what the final proposal would entail.
A $40,000 cap negotiated by the House would not be touched, he suggested, but an income threshold where the deduction starts to phase out could be lowered. But that combination was publicly rejected by SALT-focused House members just days ago, and several GOP senators left the briefing under the impression that Mullin was only laying out potential options and did not have anything resolved.
Beyond the tax fight, Republicans are still working through thorny Medicaid issues. Thune told GOP senators during the closed-door meeting that the Senate would follow the House’s lead in one key respect — it would not change the share of Medicaid costs the federal government pays for those enrolled under the program’s 2010 expansion, according to Missouri Sen. Josh Hawley.
GOP leaders also discussed including a fund to help offset the impact to rural hospitals due to other Medicaid changes in the Senate bill. POLITICO reported Monday that the fund is expected to be included in the bill, but Republicans say they have not yet gotten details on how it would work.
“I am absolutely happy with a rural fund; I think that would be great,” Hawley said. “Will that solve the issue? I don’t know.”
Senate Republicans included language in their bill to curtail provider taxes, which most states use to fund their Medicaid programs and garner larger federal reimbursements. House GOP leaders, who chose only to freeze those taxes, are increasingly worried that they’ll have to spend weeks more negotiating the megabill if the Senate doesn’t quickly retreat from some of its proposed changes.
Hawley said that he has been talking to House leaders who are warning that the language can’t pass their chamber, necessitating a time-consuming “conference” with the Senate. Speaker Mike Johnson has urged senators to keep their changes to the House-passed bill to a minimum but senators have eyed major changes to the tax package while sanding down some of the proposed spending cuts.
At Monday’s briefing, Sen. Thom Tillis of North Carolina handed out a paper that estimated how much Medicaid funding several states, including his and Hawley’s, would lose under the Senate provider tax proposal.
Republicans are also getting heartburn as MacDonough warns that several key provisions do not comply with the strict rules governing what can be included under reconciliation, which lets them skirt a 60-vote filibuster.
For instance, a plan to shift some food-aid costs to states, generating tens of billions of dollars in savings, is in flux after MacDonough ruled over the weekend that the scheme, which penalized states for their payment error rate, did not comply. Senate Agriculture Committee Republicans are hoping they can salvage the plan with relatively small changes.
Losing the cost-sharing proposal would be a setback for leadership, which is already facing pushback from House and Senate conservatives who believe the bill doesn’t go far enough on cutting spending. Rep. Andy Harris (R-Md.), chair of the hard-right House Freedom Caucus, warned Monday that if the bill “should pass the Senate in its current rumored form, it probably would have trouble in the House.”
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Although our current focus is on the Senate, at the end of the day the two houses must reconcile their Reconciliation bills and the Senate appears to be working overtime to ensure its more conservative Republicans will be a ‘yes’ vote as the bill goes to the floor – whenever that may be. So it is useful to continue to focus on the House bill given that Senate leaders are actively pursuing provisions and language that will ultimately make it through the House.
How many deaths are acceptable to pay for rich people’s tax breaks?
June 23, 2025
The House has passed a budget reconciliation bill, and now the Senate is taking up its version, which it hopes to pass before leaving for the July 4th recess. Health economists at the University of Pennsylvania have estimated that a bill like the House bill would lead to 51,000 preventable deaths each year. We have to ask Senators if they believe thousands of deaths is an acceptable price to offset some of the cost of the trillions in tax breaks in this bill.
As more of what the bill does becomes clear, the public opposes it by an almost two to one margin. The public overwhelmingly supports Medicaid and SNAP/food and nutrition assistance – three-quarters or even more oppose cuts in these basic needs programs. Despite this, the House and Senate Republican leadership are pushing hard for this bill. What do they most want? Trillions of dollars in tax breaks that overwhelmingly benefit people with the highest incomes, and more funding to detain and remove immigrants, without due process and even when they are here legally. That’s not what voters want. Please, right away, tell your Senators to defend SNAP and Medicaid, and to reject a bill that will lead to 51,000 preventable deaths a year.
House bill consequences include:
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51,000 |
More than 51,000 people will die each year because of the cuts to Medicaid, Medicare, the Affordable Care Act, and the lowered requirements for nursing home staffing in the House-passed Brutal Budget Bill.
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16 million |
That’s how many will lose health insurance if the House bill passes, according to the Congressional Budget Office. 10.9 million will lose Medicaid, Medicare, or Affordable Care Act (ACA) coverage because of cutbacks in the bill. Another 5.1 million will lose ACA insurance mostly because of the failure to extend the current expanded Premium Tax Credit.
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20.4% down to 11% |
From 2013 to 2023, the number of uninsured working age people declined from 20.4% to 11%, because of the ACA and its expansion of Medicaid. But with 16 million people expected to lose health insurance, those gains are likely to be reversed. You can find your state’s perhaps temporary reduction in the number of uninsured here.
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8 million; |
About 8 million people live in households that would lose some or all of their SNAP food assistance, including about 2.5 million children and over half a million adults who are aged 65 or older or have a disability, because someone in the household is subject to the newly expanded work reporting requirement. That’s roughly 1 in 5 SNAP participants. (See state data on the number of people at risk here.)
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120,000 – 250,000 |
CBO estimates between 120,000 – 250,000 immigrants here lawfully and now eligible for SNAP benefits would lose them if the Big Brutal Bill is enacted, including 50,000 children. These include people here for humanitarian reasons. See state data here.
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53% – 27% |
By an almost two to one margin, voters polled by Quinnepiac oppose the bill in Congress misnamed the “One Big Beautiful Bill Act” (OBBB).
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87%; 75% |
The public overwhelmingly supports Medicaid and food aid. 87% of voters polled think Medicaid funding should increase or stay the same. 75% say the U.S. is spending either too little or the right amount on nutrition assistance.
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$400 |
Expected annual increase in an average family’s household energy bill because of the budget bill’s elimination of federal tax credits for low-carbon sources of electricity like wind, solar, batteries and geothermal power.
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1%; 69%; 44% |
The poorest fifth of Americans would receive 1 percent of the bill’s net tax cuts in 2026 while the richest fifth would receive 69 percent and the richest 5 percent alone would get nearly half (44 percent) of the net tax cuts that year, according to the Institute on Taxation and Economic Policy (ITEP).
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-$820; |
If the Big Brutal Budget Bill passes, taking into account the loss of services like Medicaid and SNAP plus the impact of the tax cuts: in 2026, the lowest 10th, with incomes up to $17,000/yr, would lose $820; while the richest one-tenth of 1%, with incomes above $4.3 million, would gain $390,070, according to the Penn-Wharton Budget Model.
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Following Up:
As we expected, yesterday’s press conference hosted by Dr. Memhet Oz (CMS Administrator) and Robert Kennedy (head of HHS) was (in my opinion) nothing more than window dressing on the topic of health insurance prior authorization tactics and promises for reform. Oz began the press event by talking about the millions of Americans that have had problems with with ‘pre-authorization’ tactics used by insurers and then went on to announce (and take credit for) a group of insurers across the country that has (once more) made a commitment (non-binding) to do better by scaling back use of AI and ‘moving the process along quicker”.
Modern Healthcare published an article this morning confirming what we already know – that these types of window dressing changes do not hit the plans hard financially at all, and many experts believe this is the health plans taking one for the team and just the cost of doing business.
While there is talk of inserting language into a final budget reconciliation bill that would curb some of these tactics it is unclear whether the language will pass as part of budget reconciliation, and CMS oversight remains anemic at best.
Oz also emphasized that the pledge is not a bill or a regulation.
“This is an opportunity for the industry to show itself. Participation is voluntary, but by the fact that three-quarters of the patients in the country are already covered by participants in this pledge, it’s a good start, and the response has been overwhelming, gratifyingly so,” Oz said.
Early Monday morning, insurers revealed the key elements of the pledge, which include commitments to reduce the number of codes that are subject to prior auth and to establish a framework that significantly increases how many authorizations are adjudicated electronically and in real time.
The insurers also said that as part of the pledge they will increase accountability and transparency around denials.
About 50 insurers have signed on to the pledge including all six of the largest, publicly traded health plans: Elevance Health, Centene, Cigna, CVS Health’s Aetna, Humana and UnitedHealthcare. A slew of Blue Cross Blue Shield plans are also leading the charge, and the initiative is backed by both AHIP and the Blue Cross Blue Shield Association.
Here’s more from Modern Healthcare article, 6/24/25:
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Federal regulators said they will hold health insurance companies accountable to their promises to ease the prior authorization process. |
The insurance groups AHIP and the Blue Cross and Blue Shield Association and 48 companies announced a plan Monday to ease the prior authorization burden amid negative publicity and scrutiny from Congress, federal regulators and state legislatures.
Over the course of 2026 and 2027, insurers including UnitedHealth Group subsidiary UnitedHealthcare, CVS Health subsidiary Aetna and Cigna
Although the industry groups unveiled the initiative Monday, the Wall Street Journal first reported on it Friday and Bloomberg News confirmed the plan the following day.
When the New York Stock Exchange opened Monday, shares for publicly traded insurers were up a collective 0.1% from Friday’s closing prices.
The plan represents a nice headline for an industry that has faced fury over claims denials since the fatal shooting of UnitedHealthcare CEO Brian Thompson in December — and for President Donald Trump’s administration, said Robert Blendon, professor emeritus at the Harvard University School of Public Health.
“Given the backlash over denials, it’s in the interest of the administration to find some way to deal with this issue so they can move on. It will relieve the need of the administration to have some sort of legislation,” Blendon said.
“It will have very little financial impact. It’s an operational change. Hopefully, it makes things go faster and it’s easier for providers. But this hardly sounds transformational to the practice of medicine in America,” said Ari Gottlieb, an independent healthcare consultant.
The insurance groups AHIP and the Blue Cross and Blue Shield Association and 48 companies announced a plan Monday to ease the prior authorization burden amid negative publicity and scrutiny from Congress, federal regulators and state legislatures.
Over the course of 2026 and 2027, insurers including UnitedHealth Group subsidiary UnitedHealthcare, CVS Health subsidiary Aetna and Cigna
Although the industry groups unveiled the initiative Monday, the Wall Street Journal first reported on it Friday and Bloomberg News confirmed the plan the following day.
When the New York Stock Exchange opened Monday, shares for publicly traded insurers were up a collective 0.1% from Friday’s closing prices.
‘Violence in the streets’
Health and Human Services Secretary Robert F. Kennedy Jr. and Centers for Medicare and Medicaid Services Administrator Dr. Mehmet Oz touted the announcement at a news conference Monday, where they highlighted their work with insurance and provider groups to secure the agreement.
“There’s violence in the streets over these issues,” Oz said. “Americans are upset about it.”
Prior authorization is often referred to as a necessary evil that insurance companies use to constrain costs and ensure patients receive appropriate care.
Providers and policyholders are inclined to view prior authorization as insurance companies second-guessing clinical decisions and patient preferences.
The bureaucratic nature of the practice has always frustrated providers, who contend insurers have introduced more and more friction into the system in recent years to boost profit margins. Watchdogs such as the Health and Human Services Office of the Inspector General have conducted investigations that support this notion.
These complaints appear to conflict with financial conditions in the health insurance sector, where narrow margins are the norm, said Brad Ellis, a senior director at Fitch Ratings.
“It’s not like these insurance companies are just stacking up profits. They’re just trying to hold down costs, and therefore the premiums of insured people,” Ellis said.
Consequently, Ellis said, any additional spending arising from health plans approving more care would simply be passed on to members in the form of higher premiums.
Upgrading technology
The technological elements of the insurance industry plan may prove the most meaningful.
By 2027, insurers say they will adopt Fast Healthcare Interoperability Resources, or FHIR, for processing transactions. This builds on broader efforts to promote interoperability in the sector.
Health insurance companies often use different workflows for exchanging patient health information and processing billing requests, said Wes Sanders, founder of Evensun Consulting, which advises insurers on technology.
“As long as there’s not a standard, it’s really hard to do consistent electronic prior auth,” Sanders said.
Just 35% of insurers processed prior authorization requests electronically in 2024, according to survey findings the industry-backed Council for Affordable Quality Healthcare published last year. Shifting to fully electronic processes would save at least $515 million annually, the group estimates.
Providers can find it difficult to keep track of a mixture of electronic processes, telephone calls and faxes, which contributes to errors in prior authorization requests that delay care, Sanders said.
“Most carriers have some kind of portal. But that becomes a real pain if you’re a provider because you’re having to go into 10 different portals, all with different login rules,” Sanders said.
The health insurance sector was already moving toward interoperable electronic prior authorizations, in part because of a CMS rule finalized last year. Under that regulation, insurers participating in programs such as Medicare and Medicaid must implement FHIR by 2027.
CMS oversight
Although the prior authorizations agreement is mostly voluntary, some current and pending CMS regulations apply similar limits to the process, and Congress may include legislation restricting prior authorizations in the One Big Beautiful Bill Act of 2025.
Moreover, Oz said the agency and AHIP will create a public dashboard to track insurance company compliance with their promises. The tool will include information on what billing codes no longer require preapproval, how timely responses are and whether companies are using standardized technology, he said.
“If the insurance industry cannot address the needs of preauthorization by themselves, there are government opportunities to get involved. They might not be as nimble, but they will be used if we are forced to use them,” Oz said.
Oz acknowledged that insurers have not always followed through on similar pledges in the past.
In 2018, for example, AHIP, the Blue Cross Blue Shield Association, the American Hospital Association, the American Medical Association, the Medical Group Management Association and the American Pharmacists Association produced a “consensus statement” on how to make the process less burdensome. Providers weren’t satisfied with the results.
And in the past several years, insurers attempted to appease providers and members by reducing prior authorizations and automating more approvals. Providers say improvement has been minimal.
This time will be different, Oz said, because of the number of insurers participating, the prevailing negative public sentiment and the commitment to interoperability.